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Accidents · NTSB ERA18LA199 · Final report

Cessna 182 accident near Cleveland, Tennessee, July 26, 2018

On July 26, 2018 at about 8:48 pm local time, a 1976 Cessna 182, registered N1311S, was involved in an accident during standing (engine(s) start-up) near Cleveland, Tennessee (Cleveland Regional Jetport airport). It was a personal flight under general aviation rules (Part 91). 1 person was killed. The weather was visual conditions (good weather).

The NTSB's probable cause their words, unchanged

The undetected wear of the ignition switch and key, which allowed removal of the key from an intermediate position and subsequently led to an unintended engine start-up. Contributing to the undetected wear of the 42-year-old ignition switch was the lack of guidance by the switch manufacturer and airframe manufacturer for procedures to detect lack of integrity between the ignition key and switch.

Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.

What the record shows

Date
July 26, 2018 · about 8:48 pm local time
Place
Cleveland, Tennessee · Cleveland Regional Jetport · map
Type
Accident
Injuries
1 person was killed.
Weather
visual conditions (good weather)
Aircraft
Cessna 182 P, built 1976 · all 182s on the register
Registration
N1311S · registry record · serial 18264876
Damage
Not recorded
Flight
Personal flight · general aviation rules (Part 91)

The NTSB's narrative final · quoted from the NTSB record

After completing a personal flight with his wife, the private pilot secured the engine by placing the mixture control in the idle cut-off position. Based on physical evidence observed after the accident, he likely moved the ignition switch toward the off position and removed the key. The pilot's wife indicated that, after they performed local errands and returned to the airport, the pilot was performing his preflight inspection of the airplane with the ignition key in his pocket. Although airport security video did not capture the accident sequence and the pilot's wife, who was by the airplane's right cabin door, did not see her husband move the propeller, she heard the propeller move and the engine starting or trying to start. The pilot likely slightly moved the propeller and the engine briefly started; the propeller then rotated and fatally injured the pilot. The engine did not sustain operation, and the propeller ceased rotating. Postaccident examination of the 42-year-old ignition switch revealed that it appeared to be in the off position when observed visually from the pilot's seat, but its actual selected position was more toward the right magneto position. The switch and key were determined to be slightly misaligned with the instrument panel placard markings. On- and off-airframe operational testing of the ignition switch in the as-found position revealed the right magneto was hot, or not grounded. In addition, examination of the cut surfaces of the key notches revealed relatively smooth and reflective surface features consistent with a worn surface on the flank of the notch adjacent to the key retention ridge and on the tip end of the shank opposite the notched side. Examination of the key cylinder revealed an area with a smooth and reflective surface consistent with wear on the lower side of the key slot. The location and shape of the worn area was consistent with wear contact with the tip of the key as it was inserted and removed. The key could be removed from the switch in any of the five positions due to the wear of the switch's internal components, contrary to its intended function that would retain the key in any position except the off position. Although the switch manufacturer tested all new switches to ensure this functionality when new, that test is not specified to be performed at any time as part of any inspection or checklist by the switch manufacturer, airframe manufacturer, or Title 14 Code of Federal Regulations Part 43 Appendix D. Although the mechanic who performed the last annual inspection reported the key-to-switch integrity was satisfactory with no discrepancies, the worn condition of the ignition switch likely existed at the time of the annual inspection, which was about 31 flight hours before the accident flight (excluding the pilot's previous flight the day of the accident). Additionally, during the annual inspection when the mechanic installed the ignition switch after repairs, he failed to properly align the switch positions with the marks on the instrument panel placard.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.

The factual record from the NTSB's investigation tables, in plain English

What happened, in order

  1. Preflight or dispatch event during standing
  2. AC/prop/rotor contact w person during standing (engine(s) start-up) defining event

The NTSB's findings

  • cause Aircraft › Aircraft power plant › Ignition system › Switching › Fatigue/wear/corrosion
  • factor Organizational issues › Management › Policy/procedure › Availability of policy/proc › Manufacturer
  • factor Organizational issues › Management › Policy/procedure › Availability of policy/proc › Equipment supplier

Pilot

  • Certificate: private
  • Ratings: single-engine land
  • Flight time: 1,500 hours in all; 811 in this make and model; 15 in the last 90 days; 12 in the last 30 days; 1,453 as pilot in command
  • Last flight review: July 10, 2017
  • Medical certificate: BasicMed (with waivers/limitations)
  • Seat: none
  • Injury: fatal

The aircraft

  • Airframe total time: 4,895 hours
  • Last inspection: annual inspection, January 10, 2018; 31 hours since
  • Maximum gross weight: 2,950 lb
  • Seats: 4
  • Landing gear: fixed
  • Engine: Continental O-470-S (piston); 2,300 hours total

The flight

  • Departed from: RZR Cleveland TN at 8:48 pm
  • Destination: DZJ Blairsville GA
  • Flight plan: not recorded

Weather at the time

  • Light: daylight
  • Visibility: 10 statute miles
  • Sky: a few clouds at 6,000 ft
  • Temperature: 88°F (31°C), dew point 61°F (16°C)
  • Altimeter: 29.97 inHg
  • Observation at 8:55 pm from KRZR

Injuries

FatalSeriousMinorNone
Flight crew1

Documents from the investigation the NTSB's docket: the evidence folder behind the report

12 documents, released by the NTSB on July 8, 2019. View them here, or download them; the NTSB redacts some personal details before release, and this site shows the NTSB's own titles rather than its file names.

The same docket at the NTSB · documents without a copy here are fetched from the NTSB when you open them.

Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.