# NTSB LAX94LA136: Piper PA-28-140, N20BS, Santa Rosa, CA, February 23, 1994 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: February 23, 1994, 10:50 local (18:50 UTC) - Place: Santa Rosa, CA - Coordinates: 38.499523, -122.759933 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.4995&lon=-122.7599&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 1 uninjured - Status: Completed, report November 14, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 28675 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX94LA136 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28675/pdf - Page: https://openairdocs.org/ntsb/LAX94LA136 ## Probable cause A failure of the pilot-in-command to ensure that the powerplant controls were configured properly before moving the aircraft propeller. Inadequate planning/decision making was a factor in this accident. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Propeller/rotor contact to person, standing - engine(s) not operating - powerplant controls - improper, pilot in command(cfi) (cause) - planning/decision - inadequate, pilot in command(cfi) (contributing factor) ## Analysis PRIOR TO DEPARTING ON A TRAINING FLIGHT, THE FLIGHT INSTRUCTOR AND A STUDENT WERE SEATED IN THE AIRPLANE ATTEMPTING TO START THE ENGINE. THE ENGINE TURNED OVER SLOWLY, BUT FAILED TO START. THE FLIGHT INSTRUCTOR BELIEVED THE PROBLEM TO BE WITH THE STARTER. SHE DECIDED TO EXIT THE AIRPLANE TO REPOSITION THE PROPELLER IN ORDER TO FREE THE STARTER. IN THE PROCESS, THE PROPELLER ROTATED AND STRUCK THE HEAD AND SHOULDER OF THE FLIGHT INSTRUCTOR. THE STUDENT INSIDE THE AIRPLANE DID NOT MANIPULATE THE CONTROLS WHILE THE INSTRUCTOR WAS OUTSIDE. EXAMINATION OF THE COCKPIT CONTROLS REVEALED THAT THE MASTER SWITCH WAS OFF, MIXTURE AND THROTTLE CONTROLS AT IDLE, AND THE MAGNETO SWITCH WAS ON. ## Factual narrative On February 23, 1994, about 1050 hours Pacific standard time, the instructor pilot of a Piper PA-28-140, N20BS, was struck by the propeller of the airplane at the Sonoma County Airport, Santa Rosa, California. The airplane was to be operated as a visual flight rules (VFR) instructional flight to Sacramento, California. The airplane, registered to the pilot and operated by Redwood Aviation Enterprises, Santa Rosa, was not damaged. The certificated commercial pilot/certified flight instructor received serious injuries. A student pilot seated in the airplane was not injured. Visual meteorological conditions prevailed. A Federal Aviation Administration (FAA) operations inspector, Oakland Flight Standards District Office, reported that the pilot and student were preparing to depart on their flight. The student attempted to start the airplane; however, the engine was cranking too slowly to start. The instructor exited the airplane to arrange for an electrical "jump" start. The student inside the airplane did not manipulate the controls while the instructor was outside. The instructor turned the propeller to position it for the start. The engine caught and rotated the propeller, striking the instructor in the head and shoulder. Examination of the cockpit controls revealed that the master switch was OFF, mixture and throttle controls at idle, and the magneto switch was ON. The pilot reported that she was unsure whether the propeller was stopped at the top of a compression stroke causing it to rotate suddenly when it was moved, or whether the engine actually fired. ## Aircraft - Registration: [N20BS](https://openairdocs.org/deregistered/N20BS-2020-02-28), registration cancelled 2020-02-28, S/N 28-22373, built 1966 (OpenAirDocs) - Reported make and model: PIPER PA-28-140 - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-22373 - Airframe hours: 4298 - Engines: LYCOMING O-320 150 horsepower reciprocating - Damage: No damage - Flight: Instructional, Part 91 - Operator: Redwood Aviation Enterprises - Registered owner: Lindholm, Berit - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 4, 1993, 59 hours before - Destination: SMF, SACRAMENTO, CA - Airport: STS, Sonoma County Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 26; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; seat: left; flight hours: 780 total, 600 in this make and model, 685 as pilot in command, 82 in the last 90 days, 22 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 320° at 10 knots - Visibility: 25 statute miles - Lowest ceiling: none - Temperature: 50 °F, dew point 36 °F - Altimeter: 30.00 inHg - Observed at: STS ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19940223010579A](https://openairdocs.org/incident/19940223010579A), Feb 23, 1994: Piper PA28140, Santa Rosa, CA. Unable engage starter. CFI got out to reposition prop. Was hit in head by live prop. Mag switch was still on. From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.