- 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.
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.