# NTSB CEN09LA525: Cessna 182, N2364G, Caddo Mills, TX, August 15, 2009

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: August 15, 2009, 11:38 local (16:38 UTC)
- Place: Caddo Mills, TX
- Coordinates: 33.04111, -96.241111 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=33.0411&lon=-96.2411&mi=10
- Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping)
- Defining event: [Standing-engine(s) operating: AC/prop/rotor contact w person](https://openairdocs.org/ntsb-events/081)
- Highest injury: Serious injuries
- Injuries: 1 serious, 4 uninjured
- Status: Completed, report April 28, 2011
- Report: Approved by Office Director
- NTSB office: Central Region
- Parties: United States Parachute Association, FAA Dallas FSDO
- NTSB case key (mKey): 74531
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN09LA525
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74531/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74531
- Page: https://openairdocs.org/ntsb/CEN09LA525

## Probable cause

The failure of the operator to ensure that the airplane engine was shutdown during passenger unloading and the lack of adequate supervision of the passenger by the pilot and ground crewmember.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Culture: standard operating practices](https://openairdocs.org/ntsb-findings/04024015): Organizational issues › Management · Operator (probable cause); cases with it: [Cessna 182B, 1 case](https://openairdocs.org/ntsb-findings/04024015/cases.md?model=2072706), [All aircraft, 10 cases](https://openairdocs.org/ntsb-findings/04024015/cases.md)
- [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 182B, 2 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=2072706), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md)
- [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Ground crew (probable cause); cases with it: [Cessna 182B, 2 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=2072706), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md)
- [Environmental issues](https://openairdocs.org/ntsb-findings/03010000): Environmental issues › Operating environment · Effect on operation; cases with it: [Cessna 182B, 1 case](https://openairdocs.org/ntsb-findings/03010000/cases.md?model=2072706), [All aircraft, 14 cases](https://openairdocs.org/ntsb-findings/03010000/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Taxi-from runway: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Cessna 182B, 4 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=2072706), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md)
- [Standing-engine(s) operating: Cabin safety event](https://openairdocs.org/ntsb-events/110); cases with it: [Cessna 182B, 2 cases](https://openairdocs.org/ntsb-events/110/sequence.md?model=2072706), [All aircraft, 151 cases](https://openairdocs.org/ntsb-events/110/sequence.md)
- [Standing-engine(s) operating: Aircraft loading event](https://openairdocs.org/ntsb-events/010); cases with it: [Cessna 182B, 1 case](https://openairdocs.org/ntsb-events/010/sequence.md?model=2072706), [All aircraft, 84 cases](https://openairdocs.org/ntsb-events/010/sequence.md)
- [Standing-engine(s) operating: AC/prop/rotor contact w person](https://openairdocs.org/ntsb-events/081) (defining event); cases with it: [Cessna 182B, 1 case](https://openairdocs.org/ntsb-events/081/sequence.md?model=2072706), [All aircraft, 61 cases](https://openairdocs.org/ntsb-events/081/sequence.md)

## Analysis

The airplane landed from a skydiving flight with a remaining passenger after three parachutists had jumped from the airplane. The engine was not shut down and the airplane was pointed toward the vehicle waiting for the passenger to deplane. When the passenger exited the airplane, a ground crewmember leaned toward the airplane to talk to the pilot while the passenger went around the right side of the airplane. The passenger walked forward into the rotating propeller. Federal Aviation Administration guidance information states that stopping the engine is the most effective way to ensure passengers arrive and depart the vicinity of an airplane safely. When necessary to discharge a passenger from an aircraft on which an engine is running, it advises that the pilot should never stop the aircraft with the propeller in the path of the passenger’s route from the aircraft.

## Factual narrative

On August 15, 2009, about 11380 central daylight time, the rotating propeller of a Cessna 182B, N2364G, struck a deplaning passenger at the Caddo Mills Municipal Airport (7F3), Caddo Mills, Texas. The airplane was registered to an individual and was operated by North Texas Skydiving Center LLC under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan had been filed. The passenger was seriously injured and the pilot, who was the only other person remaining on board, was not injured. The flight had originated from 7F3 and had been conducting multiple flights to drop sport parachutists. According to the pilot, he had just landed after three parachutists had jumped from the airplane with one passenger remaining aboard. He stopped the airplane with its nose pointed toward a parked vehicle where the next group of parachutists was waiting to board. A ground crewmember arrived at the right cabin door and assisted the exit of the passenger while the engine and propeller were still operating. As the ground crewmember leaned in to speak to the pilot, the passenger went around the outboard side of the right wing strut and walked toward the group of persons waiting to board for the next flight. The passenger provided a written statement that she was on-board this flight to observe a group of parachutists and that she intended to later that day go up with an instructor for her first tandem jump. After the three parachutists had jumped, the airplane landed on the runway and taxied back toward the place where the next group of parachutists was waiting. The passenger was sitting aft-facing on the forward right side cabin floor when the airplane came to a stop. A ground crewmember came to the open right cabin door, tapped the passenger’s foot, and told her she was “good to go.” As she was exiting the airplane, the ground crewmember leaned in to talk to the pilot. The passenger then exited the right door of the airplane and walked forward toward the waiting vehicle when she was struck by the operating propeller. Several witnesses said the passenger did not appear to see the propeller as she slowly walked toward the parked vehicle. Inspectors from the Federal Aviation Administration (FAA) examined the airplane and found damage to two of the propeller blades and damage to the parachute worn by the passenger at the time of the accident. According to FAA Advisory Circular 91-42D "Hazards of Rotating Propeller and Helicopter Rotor Blade” A review of propeller accidents indicates that most were preventable. A propeller under power, even at slow idling speed, has sufficient force to inflict fatal injuries. On page 4 it cautions that the engine “should be shut down before boarding or deplaning passengers”...”when it is necessary to discharge a passenger from an aircraft on which an engine is running, never stop the aircraft with the propeller in the path of the passenger’s route from the aircraft.”

## Aircraft

- Registration: [N2364G](https://openairdocs.org/aircraft/N2364G), registered now, S/N 51664, built 1958 (OpenAirDocs)
- Reported make and model: CESSNA 182 (B)
- Registry model: [Cessna 182B](https://openairdocs.org/model/cessna-182b) (registry code 2072706) (OpenAirDocs)
- Registry engine: [Continental O-470 series](https://openairdocs.org/engine/continental-o-470-series) (registry code 17026, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 51664
- Airframe hours: 9031
- Engines: CONTINENTAL O470 235 horsepower reciprocating
- Damage: Minor damage
- Flight: Skydiving, Part 91
- Operator: North Texas Skydiving Center, LLC
- Registered owner: Larry Portman DBA First Flight
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, August 3, 2000, 1,799 hours before
- Departed: 7F3, Caddo Mills, TX
- Destination: 7F3, Caddo Mills, TX
- Airport: 7F3, Caddo Mills Municipal Airport, runway 17R, 4,000 × 75 ft, concrete

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 83; injuries: none; commercial; airplane ratings: multi-engine land, single-engine sea; medical: class 2, with waivers/limitations; last flight review September 28, 2002; seat: left; flight hours: 6,000 total, 4,000 in this make and model, 30 in the last 90 days, 10 in the last 30 days, 30 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 180° at 9 knots, gusting 18
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 88 °F, dew point 70 °F
- Altimeter: 29.96 inHg
- Observed at: KTKI, 19 nm away

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 20090815017759A](https://openairdocs.org/incident/20090815017759A), Aug 15, 2009: Cessna 182B, Caddo Mills, TX, Minor damage. (-23) On August 15, 2009 at approximately 1130 CST the rotating propeller of a Cessna 182B, N2364G, struck and injured a deplaning passenger at the Caddo mill…

## Docket (10 files)

The files NTSB released with the investigation on February 9, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74531. 5.6 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 500 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342915&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Operations - Pilot Interview Notes (item 2, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342916&FileExtension=.PDF&FileName=Operations%20-%20Pilot%20Interview%20Notes-Master.PDF
- Accident Report Photos (with 4 embedded photos) (item 3, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342920&FileExtension=.PDF&FileName=Accident%20Report%20Photos%20%20(with%204%20embedded%20photos)-Master.PDF
- Passenger Statement (item 4, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342917&FileExtension=.PDF&FileName=Passenger%20Statement-Redacted.PDF
- Witness Statements (item 5, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342918&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF
- Maps and Drawings of Accident Site (item 6, .PDF, 149 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342919&FileExtension=.PDF&FileName=Maps%20and%20Drawings%20of%20Accident%20Site-Master.PDF
- Emergency 9-1-1 Call Center Log (showing initial call time at 1138 hours) (item 7, .PDF, 17 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342921&FileExtension=.PDF&FileName=Emergency%209-1-1%20Call%20Center%20Log%20%20(showing%20initial%20call%20time%20at%201138%20hours)-Redacted.PDF
- USPA Skydiving Operations Manual (USPA website document) (item 8, .PDF, 189 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342922&FileExtension=.PDF&FileName=USPA%20Skydiving%20Operations%20Manual%20%20(USPA%20website%20document)-Master.PDF
- Pilot Safety and Warning Supplements - Potential Hazards (Cessna Aircraft Company publication) (item 9, .PDF, 242 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342923&FileExtension=.PDF&FileName=Pilot%20Safety%20and%20Warning%20Supplements%20-%20Potential%20Hazards%20%20(Cessna%20Aircraft%20Company%20publication)-Master.PDF
- Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342931&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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