# NTSB WPR10LA091: Beech A23-24, N973WP, Camas, WA, December 22, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: December 22, 2009, 12:15 local (20:15 UTC) - Place: Camas, WA - Coordinates: 45.627777, -122.404167 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=45.6278&lon=-122.4042&mi=10 - Phase of flight: [Prior to flight](https://openairdocs.org/ntsb-phases/100) (OpenAirDocs' grouping) - Defining event: [Prior to flight: Electrical system malf/failure](https://openairdocs.org/ntsb-events/332) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report October 21, 2010 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 75195 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR10LA091 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/75195/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=75195 - Page: https://openairdocs.org/ntsb/WPR10LA091 ## Probable cause The left magneto's broken p-lead, which led to the engine inadvertently starting while the pilot was turning the propeller by hand. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Ignition system: magneto/distributor](https://openairdocs.org/ntsb-findings/01057414): Aircraft › Aircraft power plant · Damaged/degraded (probable cause); cases with it: [Beech A23-24, 1 case](https://openairdocs.org/ntsb-findings/01057414/cases.md?model=1151226), [All aircraft, 101 cases](https://openairdocs.org/ntsb-findings/01057414/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Electrical system malf/failure](https://openairdocs.org/ntsb-events/332) (defining event); cases with it: [Beech A23-24, 1 case](https://openairdocs.org/ntsb-events/332/sequence.md?model=1151226), [All aircraft, 182 cases](https://openairdocs.org/ntsb-events/332/sequence.md) - [Prior to flight: Ground handling event](https://openairdocs.org/ntsb-events/080); cases with it: [Beech A23-24, 1 case](https://openairdocs.org/ntsb-events/080/sequence.md?model=1151226), [All aircraft, 108 cases](https://openairdocs.org/ntsb-events/080/sequence.md) ## Analysis The pilot reported that due to low overnight temperatures the engine would not start. As a part of his normal procedure for cold weather operations, he turned off the master and ignition switches, removed the key, and exited the airplane. The pilot was rotating the propeller counterclockwise by hand when the engine suddenly started. The airplane began moving down the taxiway and struck an unoccupied, parked airplane. The engine immediately stopped and the airplane turned approximately 90 degrees to the left, substantially damaging the airplane's left wing. Postaccident examination of the engine revealed a broken p-lead on the left magneto of the airplane. The pilot stated that he could have prevented this accident from occurring by placing the mixture at idle cutoff, placing the throttle at idle, chocking the wheels, and turning the propeller in a clockwise direction. ## Factual narrative On December 22, 2009, about 1215 Pacific standard time, a Beech A23-24, N973WP, collided with parked airplanes after inadvertently starting at the Grove Field Airport, Camas, Washington. The pilot, who was the owner, was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. The private pilot and passenger were not injured; the airplane sustained substantial damage. The pilot had planned to conduct a personal local area flight. Visual meteorological conditions prevailed, and a flight plan was not filed. During a telephone conversation with a Safety Board investigator, the pilot reported that he and the passenger boarded the airplane for a local flight. Due to low overnight temperatures, when he attempted to start the engine, the starter could not turn the propeller through the entire compression cycle. As part of his normal procedure for cold weather operations, the pilot exited the airplane and rotated the propeller counterclockwise in an attempt to circulate the oil through the engine. While beginning to rotate the propeller, the engine inadvertently started. The airplane, with the passenger still on board, lurched forward and traversed across the ramp. The airplane collided with a parked airplane; the accident airplane's left wing was damaged. He noted that the master switch was off and that he had not engaged the ignition switch. A post-accident examination of the airframe and engine by a Federal Aviation Administration (FAA) inspector and certificated airframe and powerplant mechanic revealed that there was a broken p-lead on the left magneto of the airplane. According to the pilot, the airplane last underwent an annual inspection on April 22, 2009, 41 flight hours prior to the accident. The S4LN-1227 magneto (p/n BL349365-03, s/n H139905 FR), was originally installed on the engine at time of manufacture and had amassed about 3,300 hours of time in service. The airplane was equipped with a Textron Lycoming IO-360-A2B, which rotates the propeller counterclockwise during operation (as viewed from the front). In the section titled "RECOMMENDATION" in the NTSB Pilot/Operator Report, Form 6120.1, the pilot stated if he conducts this procedure again he will place the mixture and throttle in the idle position, chock the wheels, and turn propeller in a clockwise direction. ## Aircraft - Registration: [N973WP](https://openairdocs.org/deregistered/N973WP-2012-01-20), registration cancelled 2012-01-20, S/N MA-274, built 1967 (OpenAirDocs) - Reported make and model: BEECH A23-24 - Registry model: [Beech A23-24](https://openairdocs.org/model/beech-a23-24) (registry code 1151226) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: MA-274 - Airframe hours: 3303 - Engines: LYCOMING IO-360 SER 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Woodruff Barry W - Registered owner: Woodruff Barry W - Airworthiness certificate: Standard, Normal; Standard, Utility - Last inspection: Annual, April 22, 2009, 41 hours before - Departed: 1W1, Camas, WA - Destination: 1W1, Camas, WA - Airport: 1W1, Grove Field Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review May 6, 2008; flight hours: 1,602 total, 1,104 in this make and model, 1,571 as pilot in command, 10 in the last 90 days, 5 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: 3,400 ft overcast - Temperature: 41 °F, dew point 36 °F - Altimeter: 30.17 inHg - Observed at: TTD, 5 nm away ## 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 20091222052741A](https://openairdocs.org/incident/20091222052741A), Dec 22, 2009: Beech A23-24, Camas, WA, Substantial damage. Pulling prop through prior to starting, keys out and master off, eighth of a turn-engine started with non-pilot passenger on board. Aircraft traveled approx.… ## Docket (1 files) The files NTSB released with the investigation on July 22, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=75195. 515 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 515 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323684&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF 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.