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.