WPR12LA085

NTSB accident investigation · Piper PA-28R-200 · San Diego, CA · January 30, 2012

Accident · FatalLimited investigationFinal report
Date
January 30, 2012, 08:30 local (16:30 UTC)
Place
San Diego, CA
Injuries
1 fatal
Damage
No damage
Phase of flight
Standing
Aircraft
N746RPiper PA-28R-200
Defining event
Standing-engine(s) start-up: AC/prop/rotor contact w person
Weather
Visual (VMC) · Day
Status
Completed · report June 19, 2013
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
FAA FSDO
FAA report
20120130002379A
Case key
82772

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's failure to turn the magneto switch to the off position before moving the propeller to start the engine by hand.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Ignition system: switchingAircraft › Aircraft power plant · Incorrect use/operationAll aircraft: 9 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotAll aircraft: 1,391 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

AC/prop/rotor contact w personStanding-engine(s) start-upAll aircraft: 61 casesDefining event

Analysis

The passenger reported that he and the pilot were both seated in the airplane when the pilot made three unsuccessful attempts to start the engine. The pilot told the passenger to “get out, I need to jump it.” The passenger got out of the airplane and was walking away when he heard a noise. When he looked back toward the front of the airplane, he saw the pilot lying on the ground below the propeller. The airplane’s engine was not running. Postaccident examination revealed that the magneto switch was in the both position. It is likely that the pilot moved the propeller, and because the magnetos were in a ready-to-start condition, this resulted in a spark plug firing, which caused the propeller to turn rapidly and strike the pilot.

Factual narrative

On January 30, 2012, about 0830 Pacific standard time, the pilot of Piper PA-28R-200, N746R, was struck by the airplane’s propeller during engine start at Gillespie Field Airport, San Diego, California. He was fatally injured, and his passenger was not injured. There was no damage to the airplane. The airplane was registered to, and operated by, the private pilot under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the planned personal cross-country flight, which was originating at the time of the accident. The pilot was preparing for a flight to Bermuda Dunes, California. The passenger stated that they were seated in the airplane when the pilot made three unsuccessful attempts to start the engine. He told the passenger “get out, I need to jump it.” The passenger got out of the airplane and was walking away when he heard a noise. When he looked back towards the front of the airplane, he saw the pilot lying on the ground below the propeller. The airplane’s engine was not running. Federal Aviation Administration inspectors responded to the scene of the accident and reported that photographs of the cockpit taken immediately after the accident by a local law enforcement officer showed that the magneto switch was in the both position, the mixture control was full forward (rich), the propeller control was full forward, the throttle control was about 1/4 travel forward, and the master switch was off.

Aircraft

Registration
N746R
Reported as
Piper PA-28R-200
Category
Airplane
Serial number
28R-7535075
Engine
Lycoming IO-360 SER, 180 horsepower, reciprocating
Damage
No damage
Flight
Personal · Part 91
Operator
Woodard Gordon
Registered owner
Woodard Gordon
Airworthiness certificate
Standard, Normal
Departed
SEE · San Diego, CA
Destination
SEE · San Diego, CA
Flight plan
Unknown
Airport
SEE · Gillespie Field Airport

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
41
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine sea
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Toxicology
Performed

Weather

Conditions
Visual (VMC) · Day
Visibility
10 statute miles
Lowest ceiling
None
Temperature
61 °F, dew point 27 °F
Altimeter
30.04 inHg
Observed at
SAN, 12 nm away

Docket · 1

The files NTSB released with the investigation on April 23, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 66 KB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.