Pilot Debrief

AERO COMMANDER 100 near San Antonio, TX — 2015-07-23

Final reportCEN15CA324
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Date
2015-07-23
Location
San Antonio, TX, USA
Airport
SSF
Aircraft
AERO COMMANDER 100
Registration
N5542M
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Ground

Probable cause

The pilot's improper decision to attempt flight with an unairworthy airplane and improper starting procedure that resulted in an uncontrolled takeoff without the pilot aboard. Contributing was the inoperative airplane battery/engine starter.

NTSB narrative

The pilot attempted to start the airplane engine by hand propping it because the engine could not be started using the starter because the battery was dead. The airplane had a chock under the left main landing gear wheel, and the pilot side door was propped open with a passenger aboard for the engine start. Upon engine start, the airplane jumped the chock and began to accelerate along the ground. The pilot ran along side of the airplane attempting to open the pilot side door, which had closed. When the airplane speed became too fast for the pilot to run alongside of the airplane, he stood on the main landing gear, holding the strut, and continued to attempt entry into the airplane while telling the passenger to pull the brake, throttle, mixture, or turn off the ignition key switch. The airplane impacted a 10-inch barrier, knocking the pilots legs off the main landing gear, and the airplane ran over the pilot's leg. The pilot pulled up onto the wing strut, still giving instruction to the passenger while attempting to enter the pilot side door, but the prop-wash was making this "feat impossible". About 59 mph, the airplane departed the airfield, becoming airborne, and at 6 feet above ground level, the pilot let go of the wing strut and fell to the ground. The airplane climbed, nosed forward, touched down on the nose landing gear, and impacted a construction dirt pilot before it nosed-over. The airplane sustained substantial damage that included damage to each wing spar and a bent empennage. The pilot sustained minor injuries, and the passenger sustained serious injuries. The airplane was not equipped with shoulder harnesses and was not required to be equipped with shoulder harnesses. The pilot's experience in hand-propping airplanes and the injuries of the passenger were unknown at the time this report was written.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot should not have attempted to start the engine with a passenger aboard.

NTSB coding

Evidence available

  • 1 docket document
View NTSB final reportView NTSB docket

Docket documents1

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