Woman Backs Into Propeller, Kansas, fatal, 10/27

Everyone in a small aircraft should shout clear (or the variations given here) prior to engaging the starter. Every time.

Just last week, I was unhappy over another pilot in the tie down across from me. I was mindful that he was about to start his engine. Was in “my area”, doing preflight. But what if i had a lapse of attention, or forgot?
That verbal warning (not given) might have reninded me.
I’m quite confident a clear prop call has saved multiple people. Likely many.
 
Last edited:
I'm a big fan of "clear" followed by a 5 to 10 second pause while looking at the area that's supposedly clear. The fact is that in the overwhelming majority of human prop strikes involve an engine that has been running for much longer than the few seconds allowed after yelling ''Clear. Nothing wrong with redundancy, however
 
I’ve not posted on here in a coons age and foolishly bought a second plane, one with two engines, no room in the hangar, did it anyway……foolish??? Ok anyway to the topic, pulled the Mooney out in front of the hangar, preflight complete, got in head down with the interior/ before starting engine portion of the checklist in front of me. Narrow walkways between hangars. Master switch on, fingers on the key, “clear prop!” Out of the corner of my eye I see movement so I pause. A small dog runs from between hangars towards the front and close behind was a small little boy maybe 4 yrs old. 28 years of yelling “Clear Prop” for nothing until this point. Did the boy or the dog stop? No sir. Did my taking the split second to yell Clear Prop have any impact on what did or possibly could have happened? Who knows but what I do know is, doing so did cause a split second delay in my engaging the starter so in my opinion it was worth the 28 yrs of doing it for nothing for possibly preventing what could’ve been something I could never unsee nor ever undo.

Just my thoughts,

Plane Crazy
 
Margy was the originator of the Smithsonian Udvar-Hazy fly-in. They made anybody who wanted to go out on the ramp go through a safety briefing about not going near props even though there were no engines running during this event (we swept all the visitors off the ramp before the planes taxied out).
 
Iflydogs said:
Any pilots from the UK here? At GA fields there I have noticed everyone is required to wear hi-viz vests, to the point they are not even allowed to disembark until someone walks up to the plane and hands them out.
Click to expand...
That’s our Young Eagle policy, too. Our vests tend to disappear during the year, so every December I usually order another dozen. We run 20-30 people on our ground team, of course 12-18 show up at any time. The advantage or disadvantage of running at 2 airports all year.
 
asicer said:
I wish more CFI's would teach that "clear prop" isn't just something you say but also something you do.
Click to expand...

kind of like the rest of the checklist... don't just blather the words, actually check for three green, etc etc etc
 
“Clear!”
Look around 360 degrees (or as much as your windows allow).
“Clear - left, right, front, back.”
Listen.
All quiet, still clear?
Hit it.

There is no rush, and I’d have a bit of a time coming up with a reason for a GA pilot to hurry the start.
 
Last edited:
Hengelo said:
Assigning blame is not the same as understand causality. I absolutely support a disciplined inquiry to understanding the accident chain and putting in place measures that will prevent further similar tragedies.

Beginning that process with "who is to blame?" both limits your ability to successfully do that and it announces that you are looking for heads to put on a spike which encourages people to participate in as minimalist and as defensive a manner possible.
Click to expand...
Oh yes, let's not "offend" anyone by saying who made a mistake in a simple "Cause and Effect" case. We can say it was an "accident" because "accident" means nobody is at fault, right??? Somebody did something which caused a death. We investigate who, when, what, where and why to find out exactly what went on. Somebody was walking around and not observing SITUATIONAL AWARENESS. That "somebody" was the final line of defense against something bad happening. That somebody wasn't paying attention. This fatal injury was not the fault of the aircraft or anything else other than somebody's lack of situational awareness. If that person had been observing awareness, this would not have happened. Sounds cold but people make mistakes all the time. Most of our mistakes don't have this type of horrendous end result. Anybody and everybody who has business on a ramp can and should learn from this.
 
There is no doubt that this was a horrible and tragic thing that happened. From the article: "37-year-old Amanda Gallagher was taking photos at the Air Capital Drop Zone of people getting on and off of planes when she backed into an active airplane propeller."

It appears they may have been hot loading skydivers when this occurred. If so, there seems to be some responsibility to be had by the ramp safety crew and/or the pilot making a decision to load/unload people with the props turning. Regardless of who is to blame it won't change the outcome. But it is also clear that lessons should be learned from an event like this with such a great cost i.e. the loss of a life.
 
Bob Noel said:
kind of like the rest of the checklist... don't just blather the words, actually check for three green, etc etc etc
Click to expand...
Its called a "CHECK LIST" for a reason..."CHECK AND OBSERVE THE ITEMS ON THE LIST"!
 
kmacht said:
Well on my sonex I can see the whole prop. I need to lean a little bit but it’s doable. I generally start the engine very soon after entering the aircraft so unless someone comes running across the ramp and hides underneath my cowel as I’m climbing not the cockpit, yelling clear prop isn’t going to prevent any safety related issues.

If people really think it’s an issue then why have no manufacturers put warning sirens or alarms that go off outside the airplane right before you go to start it? That to me would be more useful than hoping someone hears you yell clear prop from inside the cockpit.
Click to expand...
It is for the ones that you didn't think of, never saw, and absolutely came out of nowhere. It costs you nothing at all, so why not just do it?
 
Jim_R said:
I do it even if it's 3am and the only other creatures around are jackrabbits. Just like I use my blinkers every single time. Because it's easier than worrying about whether or not someone's out there who might benefit. If there's no one to hear, then there's no harm yelling your fool head off. And if there is someone who can hear, then there's potentially someone who could benefit from being alerted, even if it's for no other benefit than becoming aware they're about to get blasted by propwash.
Click to expand...
This.
 
DC8PIC said:
That "somebody" was the final line of defense against something bad happening. That somebody wasn't paying attention. This fatal injury was not the fault of the aircraft or anything else other than somebody's lack of situational awareness. If that person had been observing awareness, this would not have happened.
Click to expand...

That presumes there is always one single root cause. Unless a thorough incident investigation is done, we can’t say that the person that was killed was the only cause. What you suggest is correct as one preventative (corrective) measure, but it presumes things and draws conclusions. I get what you’re trying to say however.
 
455 Bravo Uniform said:
That presumes there is always one single root cause. Unless a thorough incident investigation is done, we can’t say that the person that was killed was the only cause. What you suggest is correct as one preventative (corrective) measure, but it presumes things and draws conclusions. I get what you’re trying to say however.
Click to expand...
Sometimes there is a single cause for a mishap. The insistence that a "Swiss cheese" collection of contributing events to a mishap always occurs can be incorrect.

If a person walks into the propeller of an aircraft before the pilot can react (and pulling the mixture isn't an instantaneous remedy), then that's quite cut and dried. In this case, saying hot loading is a factor isn't accurate in my mind, because that's a reality of some jump operations, and the decedent was experienced in those operations.

She chose to be in close proximity to the airplane, and the most obvious factor appears to be inattention on her part. Is that harsh? Perhaps. But a convoluted explanation for the event may not be accurate. Bad things happen when people do inexplicable things around danger.
 
As referenced earlier, I did a presentation for a trauma society meeting years ago (reviewed over 200 cases at the NTSB of propeller injuries). I don't have the raw data any more but my recollection was that there were few, if any, cases involving start up. In almost all of the cases the deaths and injuries occurred when the victim simply walked into a spinning prop.

Clearing the prop area before engaging the starter is always a good step, but rarely would have prevented the propeller injury.
 
3393RP said:
Sometimes there is a single cause for a mishap. The insistence that a "Swiss cheese" collection of contributing events to a mishap always occurs can be incorrect.
Click to expand...
Sometimes there is a single, isolated cause for a mishap that's just pure bad luck, but rarely. I've investigated a fair number of mishaps and the reality is that there are almost always multiple causal and contributory factors which lend themselves to using Reason's Swiss Cheese model as a way of helping the general pilot population to understand the incident.

I'm not privy to the details of the case beyond what has been discussed in this thread, but off the top of my head the potential Swiss Cheese holes I would be considering as possibilities are:

* PIC's decision to keep engine running while embarking/disembarking passengers
* Allowing non-participant personnel near the aircraft during operation (photographer)
* Insufficient safety supervision by ground personnel
* Insufficient safety procedures for embarkation/debarkation
* Insufficient safety training of personnel permitted near the aircraft
* Loss of situational awareness by photographer
* Existence of hazardous attitude of photographer (i.e. rule existed regarding proximity to prop, but was disregarded?)

All speculative, of course, and subject to refinement or exclusion as the evidence is gathered. But my point is that while the primary causal factor at face value appears to be someone losing SA and moving into the arc of a spinning prop, there are numerous points along the mishap chain where this could have potentially been prevented.
 
3393RP said:
Sometimes there is a single cause for a mishap. The insistence that a "Swiss cheese" collection of contributing events to a mishap always occurs can be incorrect.

If a person walks into the propeller of an aircraft before the pilot can react (and pulling the mixture isn't an instantaneous remedy), then that's quite cut and dried. In this case, saying hot loading is a factor isn't accurate in my mind, because that's a reality of some jump operations, and the decedent was experienced in those operations.

She chose to be in close proximity to the airplane, and the most obvious factor appears to be inattention on her part. Is that harsh? Perhaps. But a convoluted explanation for the event may not be accurate. Bad things happen when people do inexplicable things around danger.
Click to expand...

A basic principle of operational risk management is that nobody is 100% attentive. People get distracted, make mistakes, or lack knowledge. Layers of redundant safety measures prevent errors from becoming fatal.

I have hot loaded many aircraft. I've been on landing zones where hundreds of soldiers loaded dozens of running helicopters at once. At night. So it is not inherently unsafe. But it does take planning and controls.

In this case, it is easy to see a photographer getting distracted by peering through her viewfinder, and backing up to get a wider FOV. It would have been smart to have a line person keep an eye on things. But hindsight is 20/20 and many skydiving ops are shoestring ops.
 
I won't hot load even on planes where it is legal (it's not in mine). The starter works just fine in my plane. Time to swap passengers isn't enough to heat soak the thing to the point of vapor locking being a probem.
 
My experience in the Wild West of the formerly-fat-ultralight environment is that there are two parts to the camera's contribution to accident chains. The first, as has already been discussed here is the distraction/limited-view situational awareness contribution. The second, and far more nefarious component is one that I jokingly refer to as the camera reducing the photographer's and the subject's IQ by 50 points each. People often make stupid decisions when motivated by the presence of a camera. There appears to be some of that second element present in this case as is evidenced by the photographer willingly getting close enough to the turning prop that the subsequent loss of SA could then do its thing to finish the chain.
 
DC8PIC said:
Oh yes, let's not "offend" anyone by saying who made a mistake in a simple "Cause and Effect" case. We can say it was an "accident" because "accident" means nobody is at fault, right??? Somebody did something which caused a death. We investigate who, when, what, where and why to find out exactly what went on. Somebody was walking around and not observing SITUATIONAL AWARENESS. That "somebody" was the final line of defense against something bad happening. That somebody wasn't paying attention. This fatal injury was not the fault of the aircraft or anything else other than somebody's lack of situational awareness. If that person had been observing awareness, this would not have happened. Sounds cold but people make mistakes all the time. Most of our mistakes don't have this type of horrendous end result. Anybody and everybody who has business on a ramp can and should learn from this.
Click to expand...
This has nothing to do with "offending" anyone. It's about getting to the right answer and making the rest of us safer.
3393RP said:
Sometimes there is a single cause for a mishap. The insistence that a "Swiss cheese" collection of contributing events to a mishap always occurs can be incorrect.
Click to expand...
Others here have qualified it, but I'm going to flat out say it: There is never just one cause.
3393RP said:
If a person walks into the propeller of an aircraft before the pilot can react (and pulling the mixture isn't an instantaneous remedy), then that's quite cut and dried.
Click to expand...
Not at all. Why was that person there? Why was the prop turning in the first place? Were any procedures in effect to attempt to protect against this type of accident? Were the people present properly trained in those procedures? Were they following the procedures? If they were following the procedure, what is missing from the procedure such that it didn't prevent the accident? If they weren't following the procedure, why not? Is there any recurrent training in the procedure, is it often enough, and did it happen?
3393RP said:
In this case, saying hot loading is a factor isn't accurate in my mind, because that's a reality of some jump operations, and the decedent was experienced in those operations.
Click to expand...
The fact that it happens frequently, and even happens frequently without incident, doesn't mean it wasn't a factor. This is pretty much the basis of normalization of deviance. "We've hot loaded a thousand times without anyone getting hurt, so it's perfectly safe." Nope, not so.
 
flyingcheesehead said:
The fact that it happens frequently, and even happens frequently without incident, doesn't mean it wasn't a factor. This is pretty much the basis of normalization of deviance. "We've hot loaded a thousand times without anyone getting hurt, so it's perfectly safe." Nope, not so.
Click to expand...
And just to be clear, “we’ve hot loaded a thousand times without anyone getting hurt” is a data point. Using that data point doesn’t make it normalization of deviance. Using ONLY that data point to determine that “it’s perfectly safe” is normalization of deviance. Where the actual crossing of a line occurs where not having and/or using proper procedures makes it a normalization of deviance is a little harder to pin down.
 
MauleSkinner said:
And just to be clear, “we’ve hot loaded a thousand times without anyone getting hurt” is a data point. Using that data point doesn’t make it normalization of deviance. Using ONLY that data point to determine that “it’s perfectly safe” is normalization of deviance.
Click to expand...
Exactly.
MauleSkinner said:
Where the actual crossing of a line occurs where not having and/or using proper procedures makes it a normalization of deviance is a little harder to pin down.
Click to expand...
Probably at the point where someone justifies not having procedures because nothing has happened yet. The part that's harder to pin down is, what if nobody ever suggests that there should be a procedure in place to mitigate the added risk of hot loading? "We've always done it that way" can be a real killer.
 
Humans are remarkably adept at making mistakes. We’re not perfect.

@flyingcheesehead makes the point better than I could. Procedure #1 can reduce the chance of someone having a bad day. Procedure #2 can reduce the already reduced chance. It’s like always going halfway to your destination, mathematically you’ll never get there. And eventually the procedures reach a point where it’s “good enough”, but it’s never zero.
 
flyingcheesehead said:
This has nothing to do with "offending" anyone. It's about getting to the right answer and making the rest of us safer.

Others here have qualified it, but I'm going to flat out say it: There is never just one cause.

Not at all. Why was that person there? Why was the prop turning in the first place? Were any procedures in effect to attempt to protect against this type of accident? Were the people present properly trained in those procedures? Were they following the procedures? If they were following the procedure, what is missing from the procedure such that it didn't prevent the accident? If they weren't following the procedure, why not? Is there any recurrent training in the procedure, is it often enough, and did it happen?

The fact that it happens frequently, and even happens frequently without incident, doesn't mean it wasn't a factor. This is pretty much the basis of normalization of deviance. "We've hot loaded a thousand times without anyone getting hurt, so it's perfectly safe." Nope, not so.
Click to expand...
Deviance from what? If it's their normal operating procedure, they aren't deviating from anything.
 
Matthew said:
@flyingcheesehead makes the point better than I could. Procedure #1 can reduce the chance of someone having a bad day. Procedure #2 can reduce the already reduced chance. It’s like always going halfway to your destination, mathematically you’ll never get there. And eventually the procedures reach a point where it’s “good enough”, but it’s never zero.
Click to expand...
Reminds me of the joke about the mathematician, the engineer, and the beautiful woman.
dmspilot said:
Deviance from what? If it's their normal operating procedure, they aren't deviating from anything.
Click to expand...
Hey, I didn't name it. ;)

But, hot loading is an additional risk. Reasonable steps should be taken to mitigate that risk, and reasonable steps should be taken to ensure that those mitigations are reasonably effective.

I learned a lot from working in aviation safety. The GA community tends to think that more safety = less fun, and that does not need to be true... And we do not need to react to safety proposals with the backlash that we tend to react with.
 
455 Bravo Uniform said:
I’ve led and been involved in numerous major incident investigations and have never had a case where there was only one root cause. My mileage may vary…
Click to expand...
Similar experience here regarding investigations, but one time I saw a material failure one might consider a gray area exception. The doomed crew was doing everything right. It's just the part was not built properly by the OEM and failed inflight. More like one exceptionally weak link in the chain of events.
 
Daleandee said:
There is no doubt that this was a horrible and tragic thing that happened. From the article: "37-year-old Amanda Gallagher was taking photos at the Air Capital Drop Zone of people getting on and off of planes when she backed into an active airplane propeller."

It appears they may have been hot loading skydivers when this occurred. If so, there seems to be some responsibility to be had by the ramp safety crew and/or the pilot making a decision to load/unload people with the props turning. Regardless of who is to blame it won't change the outcome. But it is also clear that lessons should be learned from an event like this with such a great cost i.e. the loss of a life.
Click to expand...
Right....including FIRST AND FOREMOST anybody walking on the ramp!
 
You must log in or register to reply here.
Back
Top