Pilot Debrief

PIPER PA-28-161 near Beverly, MA — 2010-08-27

Final reportERA10LA446
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Date
2010-08-27
Location
Beverly, MA, USA
Airport
BVY
Aircraft
PIPER PA-28-161
Registration
N9184Y
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Ground

Probable cause

The flight instructor's decision to exit the airplane on the taxiway with the engine still operating, and his failure to avoid the rotating propeller.

NTSB narrative

The flight instructor and the private pilot receiving instrument instruction noticed that the pilots of another airplane ahead of them were having difficulty latching the canopy. The flight instructor opened his door, exited the airplane to try to help them, and either jumped or stumbled off the leading edge of the right wing and came into contact with the airplane’s moving propeller. The airplane was equipped with a walkway which led aft from the cockpit and was used to enter and exit the airplane. The cabin door was hinged at the front, and was equipped with a door holder which prevented over travel of the door and would hold the door in an open position, blocking an occupant from going forward, instead of aft, down the walkway. Additionally, the door was equipped with a secondary door stop mounted on the upper surface of the right wing almost directly in line with the lower outer edge of the door. Examination of the secondary stop revealed that it exhibited compression buckling and was bent forward and to the right from its usual mounted position, indicating the flight instructor may have tripped on the stop, causing it to buckle. However, interviews with the operator revealed the flight instructor would often jump off the front of the airplane wing to put on propeller locks when securing them for the night, indicating that he would sometimes not use the walkway for exiting the airplane.

Analysis

Primary failure mode
Human factors
First missed decision gate
Instructor should not have exited the aircraft with the engine running.

NTSB coding

Evidence available

  • Photos
  • 12 docket documents
View NTSB final reportView NTSB docket

Docket documents12

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