Narrative:

After preflting the aircraft, the pilot climbed in the plane and was pushed out of the hangar by a co-worker. The ramp adjoining the hangar is sloped, and pilots typically start their engines as they roll away from the hangar. The pilot did not do this, instead he stopped the plane 50 ft from the hangar, pushed mixture rich, pumped the engine primer 3 times, set the parking brake, and exited the plane. The plane normally required 6 or 7 turns of the propeller with the starter to start, and the pilot was attempting to prime the engine so it would start easier, as he had done 2 or 3 times, successfully in the past week. The pilot pulled the propeller through by hand 3 times, and the engine started on the third pull. The pilot attempted to get into the cockpit, but was unable, as the plane was accelerating rapidly. The plane crossed the ramp and flipped over in a ditch. The magnetos were found on 'both,' and the throttle was found open. The pilot did not remember turning on the magnetos or opening the throttle, but it is likely that he did so in an automatic fashion as was his habit. He did not use a checklist for engine start. Contributing human factors included: complacency about checklists, disbelief that the pilot would make serious, costly mistakes, a daily routine that changed little for weeks at a time which included several tasks that became automatic.

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Original NASA ASRS Text

Title: AFTER THE ENG STARTED DURING HAND PROPPING TO THE PRIME THE ENG FOR STARTING, IT RAN INTO A DITCH AND OVERTURNED.

Narrative: AFTER PREFLTING THE ACFT, THE PLT CLBED IN THE PLANE AND WAS PUSHED OUT OF THE HANGAR BY A CO-WORKER. THE RAMP ADJOINING THE HANGAR IS SLOPED, AND PLTS TYPICALLY START THEIR ENGS AS THEY ROLL AWAY FROM THE HANGAR. THE PLT DID NOT DO THIS, INSTEAD HE STOPPED THE PLANE 50 FT FROM THE HANGAR, PUSHED MIXTURE RICH, PUMPED THE ENG PRIMER 3 TIMES, SET THE PARKING BRAKE, AND EXITED THE PLANE. THE PLANE NORMALLY REQUIRED 6 OR 7 TURNS OF THE PROP WITH THE STARTER TO START, AND THE PLT WAS ATTEMPTING TO PRIME THE ENG SO IT WOULD START EASIER, AS HE HAD DONE 2 OR 3 TIMES, SUCCESSFULLY IN THE PAST WK. THE PLT PULLED THE PROP THROUGH BY HAND 3 TIMES, AND THE ENG STARTED ON THE THIRD PULL. THE PLT ATTEMPTED TO GET INTO THE COCKPIT, BUT WAS UNABLE, AS THE PLANE WAS ACCELERATING RAPIDLY. THE PLANE CROSSED THE RAMP AND FLIPPED OVER IN A DITCH. THE MAGNETOS WERE FOUND ON 'BOTH,' AND THE THROTTLE WAS FOUND OPEN. THE PLT DID NOT REMEMBER TURNING ON THE MAGNETOS OR OPENING THE THROTTLE, BUT IT IS LIKELY THAT HE DID SO IN AN AUTOMATIC FASHION AS WAS HIS HABIT. HE DID NOT USE A CHKLIST FOR ENG START. CONTRIBUTING HUMAN FACTORS INCLUDED: COMPLACENCY ABOUT CHKLISTS, DISBELIEF THAT THE PLT WOULD MAKE SERIOUS, COSTLY MISTAKES, A DAILY ROUTINE THAT CHANGED LITTLE FOR WKS AT A TIME WHICH INCLUDED SEVERAL TASKS THAT BECAME AUTOMATIC.

Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.