NTSB Factual Report

HISTORY OF FLIGHT

On August 27, 2010, about 1226 eastern daylight time, a flight instructor giving instrument instruction in a Piper PA-28-161, N9184Y, operated by Beverly Flight Center Incorporated, was fatally injured at Beverly Municipal Airport (BVY), Beverly Massachusetts, when he exited the airplane with the engine operating, and made contact with the rotating propeller. The airplane received minor damage. Visual meteorological conditions prevailed, and no flight plan was filed for the Title 14 Code of Federal Regulations Part 91 local instructional flight.

According to the pilot and flight instructor in a PiperSport (N602PS) who witnessed the accident, they were in the run-up area adjacent to the departure end of runway 34 at BVY. They were trying to close and lock the canopy on their airplane prior to takeoff but were unable to get the canopy to lock correctly. The accident airplane with the flight instructor and private pilot receiving instrument instruction was holding short of the active runway behind and to the right of them. They then observed the flight instructor in the accident airplane open the door of the accident airplane, exit, and then either jump, or stumble off, the leading edge of the right wing and come in contact with the moving propeller.

According to the private pilot who was receiving instruction from the flight instructor in the accident airplane. He and the instructor had started out with a prebrief in the classroom of what they were going to do on the lesson that day. The private pilot stated that he and the instructor would socialize with each other and that on the day of the accident the flight instructor seemed to be distracted. The private pilot knew that the instructor was interested in a female student at the flight center but could not date her but; she was going for her commercial check ride that day which meant that he would then be able to date her as he would no longer be her instructor.

The instructor told the private pilot that he felt terrible since the female student was leaving the following Tuesday to join the military. The private pilot also stated that the flight instructor was also a dive instructor, and he had a couple of lessons that afternoon and then he was going to go out with her.

The flight center had recently purchased the PiperSport and they were having problems with the canopy latching all of the time. The flight instructor had flown it from New York one time and he was frustrated with it.

When they pulled up parallel to the Piper Sport in the runway 34 run-up area, the flight instructor in the PiperSport was making motions that the canopy would not latch. The private pilot's flight instructor then exclaimed "I can't believe this stupid plane" and "Go around these guys". The flight instructor then stated "My flight controls", and maneuvered so that they were behind and to the right of the PiperSport.

A little while later, the flight instructor stated "I am going to help these clowns out", and got out of the airplane. The private pilot at this point had just glanced down at his checklist when he heard a "thud". He looked out of the windscreen and saw the flight instructor's sunglasses lying on the ground and knew something had happened. He then shutdown the airplane and called the tower.

The private pilot advised the NTSB that he had never seen the flight instructor jump off the front of the wing before. During interviews with company personnel it was discovered however, that the flight instructor had been observed to jump off the front of the flight center's airplanes when he would secure them for the night by getting the propeller lock out of the baggage compartment, and climbing up and over the right wing instead of walking around it to put the prop lock on.

PERSONNEL INFORMATION

According to Federal Aviation Administration (FAA) and pilot records, the flight instructor held an airline transport pilot certificate with multiple ratings including airplane single and multi-engine land. His most recent FAA first-class medical certificate was issued on March 17, 2010. He reported 3,400 total hours of flight experience on that date.

According to FAA and pilot records, the private pilot held a rating for airplane single-engine land. His most recent FAA third-class medical certificate was issued on October 23, 2007. He reported 130 hours of flight experience.

AIRCRAFT INFORMATION

The accident airplane was a low wing, unpressurized, four seat, single engine monoplane of conventional stressed skin construction. It was equipped tricycle landing gear. It had one cabin entrance door which was located next to the right side of the flight instructor's seat. It was powered by a 160 horsepower Lycoming O-320-D3G engine which was equipped with a Sensenich 74DM6-0-60, fixed pitch, 74 inch diameter, two bladed propeller.

According to Federal Aviation Administration (FAA) and airplane maintenance records, the accident airplane was manufactured in 1985. The airplane’s most recent 100 hour inspection was completed on August 25, 2010. At the time of the inspection, the airplane had accrued 16,466 total hours of operation.

METEOROLOGICAL INFORMATION

The reported weather at BVY, at 1253, approximately 27 minutes after the accident included: wind, 310 at 12 knots, gusting to 16 knots, visibility 10 miles, scattered clouds at 5,000 feet, temperature 24 degrees Celsius, dew point 11 degrees Celsius, and an altimeter setting of 30.03 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

Examination of the airplane by an FAA inspector revealed that one blade of the propeller was bent forward, approximately 10 degrees at the 3/4 span position. No other visible damage was observed.

MEDICAL AND PATHOLOGICAL INFORMATION

A post mortem examination of the flight instructor was performed on the pilot by the Commonwealth of Massachusetts, Office of the Chief Medical Examiner.

Toxicological testing of the flight instructor was conducted at the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The specimens were negative for carbon monoxide, cyanide, basic, acidic, and neutral drugs.

TESTS AND RESEARCH

Review of the Piper Cherokee Warrior II Information Manual, and Piper PA-28-151/161 Warrior Airplane Parts Catalog revealed that in order to enter the airplane, occupants would first grab a handhold on the right upper side of the fuselage and place a foot on a step that was mounted on the right side of the airplane aft of the wing. They would then step up onto a non-skid walkway that started on the aft inboard portion of the wing, and proceed forward on the walkway. The occupant would then unlatch both the lower and upper latches of the cabin entrance door which was hinged at the front and enter the cabin. In order to exit the cabin the sequence of events would be reversed.

Further review also revealed that no provision was made for occupants to either enter or exit the airplane from the front of the right wing. In addition to the door being hinged at the front, it also 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.

Review of Photographic Evidence revealed that the accident airplane conformed to the manufacturer's description with one exception, which was the inclusion of an aftermarket secondary door stop which was added to the airplane under an FAA approved supplemental type certificate, and was mounted on the upper leading edge surface of the right wing at wing station 57.00 on the inboard side of the fuel cell.

Further review revealed that the secondary stop exhibited signs of compression buckling, and was bent forward and to the right from its usual mounted position.

ADDITIONAL INFORMATION

In order to increase safety Beverly Flight Center took the following actions:

1. Conducted a safety briefing for flight instructors, students, and rental pilots regarding the factual information and circumstances surrounding the accident stressing propeller safety.

2. Issued a memorandum to their personnel titled "Reducing the Dangers of Propellers" which states:

- When maneuvering the aircraft into a parking position without the aid of the engine, tow bars should be used in lieu of pulling/pushing on the propellers.

- When entering or exiting the aircraft, always enter from behind the aircraft.

- When the engine is running, no person is permitted to enter, exit or approach the aircraft under any circumstances. If exiting, entering or approaching the aircraft required, proper procedures will be taken for shutting down the aircraft prior to any such actions.

- Hand-propping will not be permitted regardless of the situation.

- When walking with students within the vicinity of the ramp, one will make sure to keep the student close by and forewarn them of the dangers associated with the ramp area.

- One will ensure that no other personnel are within the vicinity of the propeller when starting the engine and will always announce clearing the area before starting.

NTSB 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.