# NTSB WPR12LA085: Piper PA-28R-200, N746R, San Diego, CA, January 30, 2012 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: January 30, 2012, 08:30 local (16:30 UTC) - Place: San Diego, CA - Coordinates: 32.82611, -116.972221 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.8261&lon=-116.9722&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Defining event: [Standing-engine(s) start-up: AC/prop/rotor contact w person](https://openairdocs.org/ntsb-events/081) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report June 19, 2013 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: FAA FSDO - NTSB case key (mKey): 82772 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR12LA085 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/82772/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=82772 - Page: https://openairdocs.org/ntsb/WPR12LA085 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Ignition system: switching](https://openairdocs.org/ntsb-findings/01057430): Aircraft › Aircraft power plant · Incorrect use/operation (probable cause); cases with it: [All aircraft, 9 cases](https://openairdocs.org/ntsb-findings/01057430/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Standing-engine(s) start-up: AC/prop/rotor contact w person](https://openairdocs.org/ntsb-events/081) (defining event); cases with it: [All aircraft, 61 cases](https://openairdocs.org/ntsb-events/081/sequence.md) ## 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 (not matched to a registry record) - Reported make and model: PIPER PA-28R-200 - Category: Airplane - Serial number: 28R-7535075 - Engines: 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. - Pilot; age 41; injuries: fatal; 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 ## 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 20120130002379A](https://openairdocs.org/incident/20120130002379A), Jan 30, 2012: Piper PA-28R-200, El Cajon, CA, No damage, 1 fatal. On 01-30-2012 at Gillespie Field (ksee) in El Cajon, California; private pilot [privacy data omitted] was preparing his Piper arrow N746R for a flight to… ## Docket (1 files) The files NTSB released with the investigation on April 23, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=82772. 66 KB in all. - Passenger Statement (item 1, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391362&FileExtension=.PDF&FileName=Passenger%20Statement-Master.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.