ERA22LA362

NTSB accident investigation · Diamond DA-40 · Bardstown, KY · August 7, 2022

Accident · FatalClass 3 · LimitedFinal report
Date
August 7, 2022, 14:25 local (18:25 UTC)
Place
Bardstown, KY · Ramp
Injuries
1 fatal, 2 uninjured
Damage
Minor damage
Phase of flight
Standing
Aircraft
N723AGDiamond DA-40
Defining event
Standing-engine(s) operating: AC/prop/rotor contact w person
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
Transportation Safety Board of Canada, Diamond Aircraft Industries Inc., FAA/FSDO
FAA report
20220807020229A
Case key
105676

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot’s failure to provide adequate instructions to remain seated until the engine was shut down, which resulted in the passenger’s decision to exit the cockpit while the engine was operating and subsequently being struck by the rotating propeller.

Findings · 1

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Action: lack of actionPersonnel issues › Action/decision · PilotDiamond Aircraft Ind DA 40: 2 casesAll aircraft: 792 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot decided to land during the personal sightseeing flight so the two passengers could switch seats. The pilot stated they were going to quickly change seats due to rain in the area, and his desire to keep the rain out of the cockpit. He stated he also briefed the passengers that, after exiting the airplane, they should walk aft and meet at the tail before coming back around and to watch out for the propeller. After parking, the pilot opened the canopy while the engine was still operating, and he proceeded to start the engine shutdown procedures per the checklist. During this time the front seat passenger exited the cockpit onto the right wing and proceeded to step off the front of the wing towards the propeller. While the pilot was completing the engine shutdown checklist, the passenger walked into the rotating propeller, resulting in a fatal injury. According to the rear seat passenger, the sequence of events transpired very quickly, and the pilot did not provide any briefing information regarding exiting the airplane after they landed. The airplane flight manual’s engine shutdown/starting procedures stated that the canopy must be closed and latched (or in an intermittent position to allow for cooling) during engine operation and that no persons should enter or exit the airplane while the engine was running. Given the pilot’s desire to keep the cockpit from getting wet due to the rain, the front seat passenger may have had the impression that she needed to quickly exit. It is likely that had the pilot provided more assertive commands to remain seated until advised to exit the airplane until after the engine had been shut down, consistent with the guidance in the airplane’s flight manual, the accident would have been avoided.

Factual narrative

On August 7, 2022, about 1425 eastern daylight time a Diamond Aircraft DA-40, N723AG, sustained minor damage when it was involved in an accident at Samuels Field Airport (BRY), Bardstown, Kentucky. A passenger was fatally injured and the private pilot and additional passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, after about a one-hour pleasure flight with a passenger in the front seat and in the back seat, they decided to land at BRY so the two passengers could switch seats. As they approached the airport, light rain was developing. The pilot stated they were quickly going to change seats because of the rain and the large canopy style door: he wanted to keep the rain out of the cockpit. During the taxi to the ramp, the front seat passenger handed the rear seat passenger her purse and phone and asked her to place it on the rear seat in preparations for switching seats. The pilot stated that before starting the shutdown checklist he briefed both passengers that when they exited the airplane, they would walk around the back of the airplane and meet at the tail then come back around and to watch out for the propeller. The pilot turned the airplane around to face the taxiway then came to a stop. Shortly after parking, the pilot opened the canopy as the engine was still operating but commenced the shutdown procedures per the checklist. As he was shutting down the engine, the front passenger exited the cockpit. The front seat passenger got out of the cockpit onto the right wing and stepped off the front step where she proceeded to walk into the operating propeller before the engine could be shut off and was fatally injured. According to the rear seat passenger, it all transpired “so fast” and the pilot did not provide any briefing information regarding exiting the airplane after they landed. The airplane was a four-seat, low-wing cantilever monoplane made from composite materials. It had fixed tricycle landing gear and a T-tail. The front canopy opened forward and up with the hinge on the front and the aft seat door was in a gullwing configuration only on the left side. The right wing, which was designed to be entered and exited off the front had a fuselage-mounted step forward of the leading edge wing root that was about 5 ft from the propeller arc. According to Diamond Aircraft, a temporary revision to the airplane flight manual was generated in 2014. Under the Temporary Revision, Entering and Exiting the Airplane; Chapter 4A.3 Checklists for Normal Operating Procedures. It stated the following: CAUTION Before starting the engine and until the engine is shut down, the canopy must be closed and latched in position 1 or 2 (‘cooling gap’) and the door must be closed and latched. During engine operation it is prohibited to enter or exit the airplane.

Aircraft

Registration
N723AG
Reported as
Diamond DA-40
Category
Airplane
Serial number
40.427
Built
2004
Airframe hours
2,431
Engine
Lycoming IO-360, 180 horsepower, reciprocating
Damage
Minor damage
Flight
Personal · Part 91
Operator
Bccm Aircraft Holdings LLC
Registered owner
Bccm Aircraft Holdings LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 7, 2022
Destination
Same as departure
Airport
BRY · Samuels Fld, runway 03/21, 5,003 × 75 ft, asphalt
Equipment
Stall warning system, ADS-B, Electronic multifunction display, Electronic primary flight display

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
23
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
July 12, 2022
Seat
Left
Restraint
None
Flight hours
120 total · 15 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
350° at 5 knots
Visibility
4 statute miles
Lowest ceiling
1,400 ft broken
Temperature
81 °F, dew point 77 °F
Altimeter
30.15 inHg
Observed at
BRY
METAR
KBRY 071855Z AUTO 35005KT 4SM SCT005 SCT009 BKN014 27/25 A3015 RMK AO1

Docket · 6

The files NTSB released with the investigation on April 10, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.6 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.