# NTSB GAA19CA582: Diamond DA 40, N4119S, Mesa, AZ, September 28, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: September 27, 2019, 17:22 local (Sep 28, 2019, 00:22 UTC) - Place: Mesa, AZ - Coordinates: 33.460834, -111.728332 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.4608&lon=-111.7283&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report March 17, 2020 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 100370 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA582 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100370/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100370 - Page: https://openairdocs.org/ntsb/GAA19CA582 ## Probable cause The pilot's decision to abort a go-around with insufficient runway remaining to safely stop the airplane, which resulted in a loss of control, runway excursion and impact with a concrete barrier. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Diamond Aircraft Ind DA 40, 11 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=2990002), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Diamond Aircraft Ind DA 40, 20 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2990002), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Diamond Aircraft Ind DA 40, 5 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2990002), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Communication (personnel): accuracy of communication](https://openairdocs.org/ntsb-findings/02063515): Personnel issues › Task performance · Pilot; cases with it: [Diamond Aircraft Ind DA 40, 1 case](https://openairdocs.org/ntsb-findings/02063515/cases.md?model=2990002), [All aircraft, 25 cases](https://openairdocs.org/ntsb-findings/02063515/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [Diamond Aircraft Ind DA 40, 9 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=2990002), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Diamond Aircraft Ind DA 40, 12 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2990002), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Diamond Aircraft Ind DA 40, 12 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2990002), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that, he intended to do touch-and-goes in the local traffic pattern. While on the downwind leg, the air traffic controller cleared him to land. During the landing roll, past the halfway point on the runway, he increased the engine power to full to takeoff and told the controller that he was doing a "go-around". The controller immediately instructed him to exit the runway on to the last taxiway so the pilot "cut the entire power", applied brakes and full right rudder, but the airplane skidded, exited the runway and impacted a concrete barrier. The airplane sustained substantial damage to the forward, lower fuselage. The flight safety officer reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The pilot added that he wanted to do touch and goes but did not accurately communicate his intentions to the air traffic controller. ## Factual narrative The pilot reported that, he intended to do touch-and-goes in the local traffic pattern. While on the downwind leg, the air traffic controller cleared him to land. During the landing roll, past the halfway point on the runway, he increased the engine power to full to takeoff and told the controller that he was doing a "go-around". The controller immediately instructed him to exit the runway on to the last taxiway so the pilot "cut the entire power", applied brakes and full right rudder, but the airplane skidded, exited the runway and impacted a concrete barrier. The airplane sustained substantial damage to the forward, lower fuselage. The flight safety officer reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The pilot added that he wanted to do touch and goes but did not accurately communicate his intentions to the air traffic controller. ## Aircraft - Registration: [N4119S](https://openairdocs.org/deregistered/N4119S-2021-06-01), registration cancelled 2021-06-01, S/N 40.804, built 2010 (OpenAirDocs) - Reported make and model: Diamond DA 40 (Undesignat) - Registry model: [Diamond Aircraft Ind DA 40](https://openairdocs.org/model/diamond-aircraft-ind-da-40) (registry code 2990002) (OpenAirDocs) - Registry engine: [Lycoming IO-360-M1A+](https://openairdocs.org/engine/lycoming-io-360-m1a-plus) (registry code 41869, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 40.804 - Year built: 2010 - Airframe hours: 9565.5 - Engines: Lycoming IO-360-MIA 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Cae Oxford Aviation Academy Phoenix Inc - Registered owner: Cae Oxford Aviation Academy Phoenix Inc - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, September 21, 2019 - Departed: FFZ, Mesa, AZ - Destination: FFZ, Mesa, AZ - Airport: FFZ, Falcon Fld, runway 22R, 3,799 × 75 ft, asphalt - Equipment: Data recorder, Electronic multifunction display, Electronic primary flight display, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 27; injuries: none; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review April 18, 2019; seat: left; restraint: 3-point; flight hours: 187 total, 187 in this make and model, 98 as pilot in command, 44 in the last 90 days, 16 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 290° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 57 °F - Altimeter: 29.75 inHg - Observed at: KFFZ ## 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 20190927014439A](https://openairdocs.org/incident/20190927014439A), Sep 27, 2019: Diamond Aircraft Ind Inc DA 40, Mesa, AZ, Substantial damage. Airman ran off end of runway: The following information was obtained by interviewing the airman and was later confirmed upon review of audio recordings: The… ## Docket (3 files) The files NTSB released with the investigation on December 31, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100370. 1.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479511&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Accident Photo (item 2, .PDF, 245 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479512&FileExtension=.PDF&FileName=Accident%20Photo-Master.PDF - Record of Conversation - Pilot (item 3, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479513&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilot-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.