# NTSB CEN11LA368: Cessna 152, N222UM, Ann Arbor, MI, May 25, 2011 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: May 25, 2011, 10:30 local (14:30 UTC) - Place: Ann Arbor, MI - Coordinates: 42.223056, -83.745552 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.2231&lon=-83.7456&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, 1 uninjured; on the ground: 1 serious - Status: Completed, report November 7, 2012 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 79288 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN11LA368 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/79288/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=79288 - Page: https://openairdocs.org/ntsb/CEN11LA368 ## Probable cause The flight instructor’s failure to maintain clearance from the propeller when exiting the airplane. Contributing to the accident were the instructor’s decision not to shut down the engine before exiting the airplane and the operator’s lack of a policy prohibiting any person from entering or exiting an airplane with its engine operating. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Cessna 152, 11 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=2071835), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Aircraft](https://openairdocs.org/ntsb-findings/01040000): Aircraft › Aircraft propeller/rotor · Not specified (probable cause); cases with it: [Cessna 152, 1 case](https://openairdocs.org/ntsb-findings/01040000/cases.md?model=2071835), [All aircraft, 11 cases](https://openairdocs.org/ntsb-findings/01040000/cases.md) - [Policy/procedure: availability of policy/proc](https://openairdocs.org/ntsb-findings/04021010): Organizational issues › Management · Operator (probable cause); cases with it: [Cessna 152, 1 case](https://openairdocs.org/ntsb-findings/04021010/cases.md?model=2071835), [All aircraft, 28 cases](https://openairdocs.org/ntsb-findings/04021010/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Cessna 152, 33 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2071835), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Standing-engine(s) operating: AC/prop/rotor contact w person](https://openairdocs.org/ntsb-events/081) (defining event); cases with it: [Cessna 152, 2 cases](https://openairdocs.org/ntsb-events/081/sequence.md?model=2071835), [All aircraft, 61 cases](https://openairdocs.org/ntsb-events/081/sequence.md) ## Analysis The flight instructor exited the airplane with the engine operating in preparation for a student pilot to perform his second solo flight. The flight instructor was struck by the rotating propeller as she walked toward the front of the airplane. The flight instructor stated that the operator's flight instructors would typically exit and walk toward the back of an airplane when they were going to have student pilots perform their solo flights. However, instead of walking toward the rear, she walked toward the front where her car was parked. After the accident, the operator adopted a policy prohibiting anyone from entering or exiting an airplane with the engine operating. ## Factual narrative On May 25, 2011, about 1030 eastern daylight time, a Cessna 152, N222UM, was standing with the engine operating when the flight instructor exited the airplane with a student pilot at the controls. The flight instructor was struck by the propeller and sustained serious injuries. The airplane was registered to and operated by University of Michigan Flyers Inc. under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed at the time of the accident. The instructional flight began about 0800 and was to remain in the traffic pattern of Ann Arbor Regional Airport, Ann Arbor, Michigan. The flight instructor stated she had four hours of sleep before arriving at the airport at 0620 to begin providing flight instruction for the student pilot's second supervised solo flight. She provided ground instruction to the student pilot while waiting for rain showers to clear the area. Once the weather cleared, they began the flight and performed takeoff and landings at the airport. Upon completion of the takeoffs and landings, they taxied to the ramp where the flight instructor exited the airplane with the engine operating. The flight instructor stated that instead of walking toward the rear of the airplane, as would normally be done to allow a student pilot to solo, the flight instructor walked toward her car, which was toward the front of the airplane. The flight instructor held her headset with its cords dangling in her left hand with her jacket and flight bag in her right hand. The headset cord was caught by the moving propeller, turning her into the propeller. The flight instructor stated that the operator's flight instructors would typically have the airplane pointed in the direction that it was going to taxi in for a solo flight. Flight instructors would then exit toward the rear of the airplane with the engine operating. The flight instructor stated that the operator's post accident policy/procedure is to not allow passengers/personnel to enter and/or exit from aircraft with the engine operating. Advisory Circular 91-42D, Hazards of Rotating Propeller and Helicopter Rotor Blades, section 8. Flight Personnel and Flight Instructors, states: a. The engine of a fixed-wing aircraft or a helicopter should be shut down before boarding or deplaning passengers. This is the simplest method of avoiding accidents. Cessna Pilot Safety and Warning Supplement, Potential Hazards, Propellers, states: Pilots can be most effective in ensuring that his or her passengers arrive and depart the vicinity of the airplane safely by stopping the engine(s) completely at the time of loading and unloading, or by providing a definite means of keeping them clear of the propeller if it is left in motion. ## Aircraft - Registration: [N222UM](https://openairdocs.org/deregistered/N222UM-2023-05-29), registration cancelled 2023-05-29, S/N 15281063, built 1977 (OpenAirDocs) - Reported make and model: CESSNA 152 (NO SERIES) - Registry model: [Cessna 152](https://openairdocs.org/model/cessna-152) (registry code 2071835) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 15281063 - Airframe hours: 18014 - Engines: Lycoming O-235-L2C 110 horsepower reciprocating - Damage: No damage - Flight: Instructional, Part 91 - Operator: University of Michigan Flyers Inc - Registered owner: University of Michigan Flyers Inc - Airworthiness certificate: Standard, Utility - Last inspection: 100 hour, March 26, 2011 - Departed: ARB, Ann Arbor, MI - Destination: ARB, Ann Arbor, MI - Airport: ARB, Ann Arbor Municipal Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 65; injuries: serious; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land, single-engine sea; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review November 17, 2010; seat: right; flight hours: 5,600 total, 3,000 in this make and model, 5,400 as pilot in command, 109 in the last 90 days, 66 in the last 30 days, 5 in the last 24 hours - Student pilot; age 27; injuries: none; student; medical: class 3, with waivers/limitations; seat: left; flight hours: 29 total, 29 in this make and model, 0 as pilot in command, 29 in the last 90 days, 8 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 60° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: 1,000 ft broken - Temperature: 55 °F, dew point 52 °F - Altimeter: 29.87 inHg - Observed at: KARB ## 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 20110525030159A](https://openairdocs.org/incident/20110525030159A), May 25, 2011: Cessna 152, Ann Arbor, MI, Minor damage. CFI exited aircraft on the ramp to solo student, upon exiting aircraft she ducked under the wing strut and walked forward into turning propeller. ## Other investigations on N222UM (1) 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. - [NTSB CEN23LA036](https://openairdocs.org/ntsb/CEN23LA036), Nov 13, 2022: Cessna 152 (N222UM), Manchester, MI, substantial damage. Probable cause: A partial loss of engine power as a result of carburetor ice. ## Docket (7 files) The files NTSB released with the investigation on August 1, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=79288. 2.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - Student Pilot (item 1, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370374&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20Student%20Pilot-Redacted.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - Flight Instructor (item 2, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370377&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20Flight%20Instructor-Redacted.PDF - Written Statement - Flight Instructor (item 3, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370379&FileExtension=.PDF&FileName=Written%20Statement%20-%20Flight%20Instructor-Redacted.PDF - Record of Conversation - Flight Instructor (item 4, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370380&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Flight%20Instructor-Master.PDF - Weather Reports and Records - ARB (item 5, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370381&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records%20-%20ARB-Master.PDF - Advisory Circular 91-42D (item 6, .PDF, 351 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370385&FileExtension=.PDF&FileName=Advisory%20Circular%2091-42D-Master.PDF - Cessna Pilot Safety and Warning Supplements - Excerpt (item 7, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370386&FileExtension=.PDF&FileName=Cessna%20Pilot%20Safety%20and%20Warning%20Supplements%20-%20Excerpt-Master.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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.