Piper PA-28-140 accident near Santa Rosa, California, February 23, 1994
On February 23, 1994 at about 6:50 pm local time, a Piper PA-28-140, registered N20BS, was involved in an accident near Santa Rosa, California (Sonoma County Airport). It was an instructional flight under general aviation rules (Part 91). 1 person was seriously injured; 1 other was unhurt. The weather was visual conditions (good weather).
The NTSB's probable cause their words, unchanged
A failure of the pilot-in-command to ensure that the powerplant controls were configured properly before moving the aircraft propeller. Inadequate planning/decision making was a factor in this accident.
Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.
What the record shows
- Date
- February 23, 1994 · about 6:50 pm local time
- Place
- Santa Rosa, California · Sonoma County Airport · map
- Type
- Accident
- Injuries
- 1 person was seriously injured; 1 other was unhurt.
- Weather
- visual conditions (good weather)
- Aircraft
- Piper PA-28-140 · all PA-28-140s on the register
- Registration
- N20BS · no longer on the register · serial 28-22373
- Damage
- Not recorded
- Flight
- Instructional flight · general aviation rules (Part 91)
The NTSB's narrative final · quoted from the NTSB record
PRIOR TO DEPARTING ON A TRAINING FLIGHT, THE FLIGHT INSTRUCTOR AND A STUDENT WERE SEATED IN THE AIRPLANE ATTEMPTING TO START THE ENGINE. THE ENGINE TURNED OVER SLOWLY, BUT FAILED TO START. THE FLIGHT INSTRUCTOR BELIEVED THE PROBLEM TO BE WITH THE STARTER. SHE DECIDED TO EXIT THE AIRPLANE TO REPOSITION THE PROPELLER IN ORDER TO FREE THE STARTER. IN THE PROCESS, THE PROPELLER ROTATED AND STRUCK THE HEAD AND SHOULDER OF THE FLIGHT INSTRUCTOR. THE STUDENT INSIDE THE AIRPLANE DID NOT MANIPULATE THE CONTROLS WHILE THE INSTRUCTOR WAS OUTSIDE. EXAMINATION OF THE COCKPIT CONTROLS REVEALED THAT THE MASTER SWITCH WAS OFF, MIXTURE AND THROTTLE CONTROLS AT IDLE, AND THE MAGNETO SWITCH WAS ON.
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
Pilot
- Certificate: commercial pilot
- Ratings: multi-engine land; single-engine land; instructor: airplane single-engine; instrument: airplane
- Flight time: 780 hours in all; 600 in this make and model; 82 in the last 90 days; 22 in the last 30 days; 685 as pilot in command; 270 on instruments
- Medical certificate: Class 2 (valid medical--no waivers/lim.)
- Seat: left
The aircraft
- Airframe total time: 4,298 hours
- Last inspection: annual inspection, August 4, 1993; 59 hours since
- Maximum gross weight: 2,150 lb
- Seats: 2
- Landing gear: fixed
- Engine: Lycoming O-320 (piston); 0 hours total
- Operator: Redwood Aviation Enterprises
The flight
- Destination: SMF Sacramento CA
- Flight plan: none
- Runway 0
Weather at the time
- Light: daylight
- Wind: from 320° at 10 knots
- Visibility: 25 statute miles
- Sky: clear
- Temperature: 50°F (10°C), dew point 36°F (2°C)
- Altimeter: 30.00 inHg
- Observation at 6:45 pm from STS
Injuries
| Fatal | Serious | Minor | None | |
|---|---|---|---|---|
| Crew | 1 | 1 |
Documents from the investigation the NTSB's docket: the evidence folder behind the report
The docket, the folder of records gathered during an investigation (maintenance records, photographs, witness statements, examinations), has not been read from the NTSB for this case yet; the list appears here once it has. Open the docket at the NTSB.
Other NTSB records under N20BS the same tail number, which may have belonged to a different aircraft at the time
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.