History of Flight
On July 26, 2018, about 1648 eastern daylight time, a private pilot was fatally injured when struck by the propeller of a Cessna 182P (registration N1311S) during a preflight inspection at Cleveland Regional Jetport (RZR) in Cleveland, Tennessee. The airplane, owned by NCFL Ltd. and operated under 14 CFR Part 91, was not damaged. Visual meteorological conditions prevailed for an intended personal flight to Blairsville Airport, Georgia.
The pilot's wife reported that they had flown to RZR earlier that day, and her husband performed a normal engine shutdown using the mixture control. After running errands, they returned to the airport. While outside the airplane near the passenger door, her husband was conducting a preflight inspection with the ignition key in his pocket. She heard the "propeller move" and the engine attempting to start. She looked up and saw her husband fall to the ground. She went to him, thought the propeller stopped, then sought help inside the fixed-base operator.
According to FAA and airport personnel, airport security video did not capture the sequence of events.
Aircraft Information
The four-place, high-wing airplane, serial number 18264876, was manufactured in 1976. It was powered by a 230-hp Continental O-470-S engine with two magnetos controlled by a five-position rotary ignition switch. The pilot purchased the airplane in April 2007, and his wife stated there had been no previous instances of the ignition key being removable in any position other than off.
Cessna Service Bulletin SEB91-5 Revision 1 called for inspection and lubrication of the ignition switch but did not require checking key removal in non-off positions. Airworthiness Directive 93-05-06 required an internal inspection for corrosion and lubrication but similarly did not specify key-to-switch integrity checks. The mechanic who performed the annual inspection in January 2018 complied with the AD and reported checking the ignition key in all positions except off, finding no discrepancies. While the engine was running, he slightly pulled aft on the key and found it could not be removed from any position other than off.
Postaccident Examination
Postaccident examination of the cockpit revealed the mixture control in idle-cutoff, throttle full out, battery and alternator switches off. The ignition switch appeared to be in the off position but was closer to the right magneto position. With the key installed, the switch could be turned counterclockwise to off. The ignition key was easily removable from the switch in the right and left positions. Subsequent testing showed that in the as-found position (between off and right), the right magneto was hot (ungrounded), and the key could be fully removed. In the off position, the switch did not align with the panel placard. The ignition switch and key were removed and sent to the manufacturer for operational testing.
Examination at ACS Products Company revealed that the key was removable in every position (left, right, both, start, and off). The key tumbler showed wear consistent with use, and the key was made of brass alloy c377. Company personnel could not determine why the key could be removed from non-off positions. The switch was manufactured in April 1976, with no record of return since then.
Medical and Pathological
An autopsy was not requested by NTSB or FAA, nor performed by the medical examiner. Forensic toxicology detected no ethanol or tested drugs. Testing for cyanide was not performed, and specimens were insufficient for carbon monoxide analysis.
Previous Incidents
A review of the NTSB database revealed three previous investigations involving loss of ignition switch-to-key integrity leading to unintended engine startup, resulting in injury or uncommanded movement.