# NTSB CEN21LA295: Flight Design Ctls, N920SS, Ray, MI, June 28, 2021 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 4 · Limited · Final report - Date: June 28, 2021, 19:30 local (23:30 UTC) - Place: Ray, MI - Coordinates: 42.738367, -82.889726 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.7384&lon=-82.8897&mi=10 - Phase of flight: [Other](https://openairdocs.org/ntsb-phases/800) (OpenAirDocs' grouping) - Defining event: [Other: AC/prop/rotor contact w person](https://openairdocs.org/ntsb-events/081) - Highest injury: Serious injuries - Injuries: 1 serious, 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 4 - Basic report with no Prelim publish - NTSB office: Central Region - Parties: FAA FSDO - NTSB case key (mKey): 103380 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21LA295 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103380/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103380 - Page: https://openairdocs.org/ntsb/CEN21LA295 ## Probable cause The flight instructor’s improper decision to direct the student pilot to exit the airplane with the engine running, which resulted in serious injury when the student walked into the propeller arc. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Flight Design CTLS, 4 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=060005B), [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. - [Other: AC/prop/rotor contact w person](https://openairdocs.org/ntsb-events/081) (defining event); cases with it: [Flight Design CTLS, 1 case](https://openairdocs.org/ntsb-events/081/sequence.md?model=060005B), [All aircraft, 61 cases](https://openairdocs.org/ntsb-events/081/sequence.md) ## Analysis The flight instructor was conducting the 16-year-old student pilot’s first instructional flight. After completing several takeoffs and landings, they “taxied around the airport multiple times,” during which they experienced “light to sometimes moderate” rain. At the conclusion of the lesson, the rain became heavy enough that visibility was reduced, and the instructor decided to taxi the airplane into its open hangar to avoid getting wet. As they approached the hangar, the instructor noted a set of wheel chocks on the ground, and with the engine still running, he instructed the student to exit the airplane, walk around the propeller arc, and move the chocks so that he, “could taxi the airplane nose-first into the hangar…then turn it around once inside and shut down.” He stated that he repeated the instructions to ensure that the student understood. The student subsequently exited the airplane and walked forward into the spinning propeller, resulting in serious injury. The instructor reported that there were no preaccident mechanical malfunctions or failures of the airplane that would have precluded normal operation. ## Aircraft - Registration: [N920SS](https://openairdocs.org/aircraft/N920SS), registered now, S/N F-10-02-05 (OpenAirDocs) - Reported make and model: FLIGHT DESIGN GMBH CTLS - Registry model: [Flight Design CTLS](https://openairdocs.org/model/flight-design-ctls) (registry code 060005B) (OpenAirDocs) - Registry engine: [Rotax 912ULS series](https://openairdocs.org/engine/rotax-912uls-series) (registry code 55572, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: F-10-02-05 - Year built: 2010 - Airframe hours: 2315 - Engines: Rotax 912ULS 100 horsepower reciprocating - Damage: Minor damage - Flight: Instructional, Part 91 - Registered owner: Dodger Aircraft LLC - Airworthiness certificate: Special, Special light-sport (Special) - Last inspection: Condition, March 2, 2021, 45.5 hours before - Destination: Same as departure - Airport: 57D, Ray Community - Equipment: Auto-pilot, Airframe parachute, ADS-B, Stall warning system, Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 37; injuries: none; commercial, flight instructor; airplane ratings: multi-engine land, single-engine land, single-engine sea; instrument ratings: airplane; medical: class 2, unknown; last flight review April 14, 2021; seat: right; restraint: 3-point; flight hours: 571 total, 4.2 in this make and model, 46.6 as pilot in command, 1,080.9 in the last 90 days, 27 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: 5,000 ft broken - Temperature: 79 °F, dew point 79 °F - Altimeter: 30.11 inHg - Observed at: KMTC, 8 nm away - METAR: METAR KMTC 282256Z 00000KT 10SM -SHRA SCT040 BKN050 BKN250 26/26 A3011 RMK AO2A LTG DSNT NW SHRAB24 CB 12NW MOV NE SLP197 P0011 T02600260 $= ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Incident 20210628011059I](https://openairdocs.org/incident/20210628011059I), Jun 28, 2021: Flight Design Gmbh CTLS, Ray, MI, Minor damage. CFI took student pilot for first instructional flights. After second Flight student was not feeling well. CFI switched to ground work, it began to rain,… ## Docket (3 files) The files NTSB released with the investigation on February 9, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103380. 10.8 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 10.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13199876&FileExtension=pdf&FileName=NTSB%206120_1_Redacted-Rel.pdf - CFI additional statement (item 2, PDF, 2 pages, 239 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13200148&FileExtension=pdf&FileName=Final%20Statement%20of%20Facts-Rel.pdf - Statement from club president (item 3, PDF, 2 pages, 257 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13200126&FileExtension=pdf&FileName=Statement%20from%20Club%20President_Redacted-Rel.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.