WPR22FA164

NTSB accident investigation · Diamond Aircraft Ind DA 40 · Cedar City, UT · April 24, 2022

Accident · FatalClass 3 · FieldFinal report
Date
April 23, 2022, 18:48 local (Apr 24, 2022, 00:48 UTC)
Place
Cedar City, UT · uneven mountainous terrain
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N321PFDiamond Aircraft Ind DA 40
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Transportation Safety Board of Canada, Lycoming Engines, Federal Aviation Administration, Diamond Aircraft
FAA report
20220423005739A
Case key
104989

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 maintain obstacle clearance, which resulted in controlled flight into terrain. Contributing to the accident was the pilot’s decision to operate the airplane above its maximum gross weight.

Findings · 3

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.

Aircraft capability: climb capabilityAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleDiamond Aircraft Ind DA 40: 1 caseAll aircraft: 183 cases
Terrain: mountainous/hilly terrainEnvironmental issues › Physical environment · Effect on equipmentDiamond Aircraft Ind DA 40: 1 caseAll aircraft: 329 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

Witnesses traveling near the accident site reported that they observed the accident airplane flying on an easterly heading about 200 to 300 ft above ground level. The airplane did not appear to be in distress. After the airplane passed over the witnesses’ positions, the airplane maneuvered as if the pilot were trying to turn it around. One witness stated that the airplane’s wings were almost completely vertical at that point. The airplane subsequently impacted mountainous terrain about 7 miles southeast of the departure airport. A postcrash fire ensued. Postaccident examination of the airplane revealed no evidence of a pre-existing mechanical malfunction that would have precluded normal operation. A review of the airplane’s weight and balance information showed that, at the time of departure, the airplane was about 128 pounds over the airplane’s maximum gross weight of 2,646 pounds. The airplane was also outside the approved center-of-gravity envelope. The calculated density altitude at the time of departure was about 6,022 ft. The calculated fuel use from the departure airport to the accident location was about 5 gallons. Thus, at the time of the accident, the airplane was likely about 98 pounds over the maximum gross weight. The calculated density altitude at the accident location and the time of the accident was about 7,203 ft. The calculated climb performance for the airplane, at its assumed altitude and air density conditions, would have about 300 ft per minute. The excessive airplane weight likely limited the airplane’s ability to climb in mountainous terrain.

Factual narrative

The weight of the airplane at the time of departure from CDC was estimated to be about 128 pounds over the maximum gross weight (2,646 pounds). Based on the airplane’s most recent weight and balance information, full fuel level (40 gallons), the reported or measured occupant weights, and no baggage. The airplane’s center of gravity (CG) was calculated using the passenger and seat locations in the most favorable position and was found to be outside of the manufacturer’s approved CG envelope. According to the performance information in the DA-40 Airplane Flight Manual and the assumed altitude and air density conditions, the airplane’s climb performance would have been about 300 ft per minute. On April 23, 2022, about 1848 mountain daylight time, a Diamond Aircraft DA 40, N321PF, was destroyed when it was involved in an accident near Cedar City Regional Airport (CDC), Cedar City, Utah. The pilot and three passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The operator reported that the pilot rented the airplane with the intent to fly a multileg cross-county flight from his home base of Spanish Fork Municipal Airport/Woodhouse Field (SPK), Spanish Fork, Utah. The planned route of flight comprised stops at CDC and four other airports before returning to SPK. The operator stated that the airplane departed SPK on the first leg with about 40 gallons of fuel. Recorded airport surveillance video at CDC showed that the accident airplane landed at 1615 and taxied to the self-serve fuel pumps. The pilot and passengers disembarked, and the pilot refueled the airplane, adding about 14 gallons of fuel. The pilot and passengers subsequently boarded the airplane for the next destination, Bryce Canyon Airport (BCE), Bryce Canyon City, Utah, and taxied toward the runway. A pilot-rated witness, who was driving westbound down Cedar Canyon, reported that he observed the accident airplane flying up the canyon and over the river at an altitude of about 300 ft above ground level (agl). The witness stated that. as the airplane was about to pass over his position, the airplane turned left and then right, and its maneuvers were “quick” and “like a rocking motion.” The witness added that the propeller appeared to be under power and not windmilling. Another witness, who was traveling near the accident site, reported that he observed the accident airplane flying on an easterly heading over the highway at an altitude of about 200 to 300 ft (agl). The witness stated that, other than being low, the airplane did not appear to be in distress. The witness also stated that that his vehicle’s windows were up, so he could not hear the airplane’s engine. After the airplane passed over the witness’ position, he looked in the mirror and saw the airplane “bank really hard to the south, back across the highway” as if the airplane “were trying to turn around in the narrow canyon.” The witness added that, at thatpoint, the airplane’s wings were “almost completely vertical” and that the airplane “didn’t look like it had enough speed to pull off that maneuver.” The airplane impacted mountainous terrain along the southern edge of the canyon about 7 miles southeast of CDC. A postcrash fire ensued. The Utah Department of Health, Office of the Medical Examiner, Taylorsville, Utah, performed an autopsy of the pilot. His cause of death was blunt force injuries. Toxicology testing performed at the Federal Aviation Administration Forensic Sciences Laboratory found no ethanol or drugs of abuse in the pilot’s specimens. The calculated density altitude at the time of departure was about 6,022 ft. The calculated density altitude at the accident location and the time of the accident was 7,203 ft. During his last Federal Aviation Administration medical examination, the pilot reported that he was 74 inches tall and weighed 215 pounds. Examination of the accident site revealed that the airplane impacted mountainous terrain along the southern edge of a canyon about 7 miles southeast of CDC. The airplane came to rest inverted on a magnetic heading of about 289° and at an elevation of 6,583 ft mean sea level. The first identified point of contact (FIPC) was a tall tree with damaged limbs near the top of the tree. The debris path was oriented on a magnetic heading of about 294° and was about 150 ft in length from the FIPC to the main wreckage. All major structural components of the airplane were located in the debris path. The figure below shows the wreckage at the accident site. Figure. Accident site diagram. Flight control continuity was established from the cockpit to all primary flight controls. Numerous separations were noted within the flight control system with signatures consistent with overload separation or due to the recovery process. Postaccident examination of the airframe and engine revealed no evidence of mechanical anomalies that would have precluded normal operation.

Aircraft

Registration
N321PF
Reported as
Diamond Aircraft Ind DA 40
Category
Airplane
Serial number
40.375
Built
2004
Airframe hours
5,900
Engine
Lycoming IO-360-MIA, 180 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Platinum Aviation
Registered owner
Rrsf LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · April 4, 2022 · 22 hours before
Departed
CDC · Cedar City, UT
Destination
BCE · Bryce Canyon, UT
Airport
CDC · Cedar City Rgnl
Equipment
Satellite tracking device, Stall warning system, ADS-B, Auto-pilot, 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
37
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 1, Without waivers/limitations
Last flight review
September 6, 2021
Seat
Front
Toxicology
Performed
Flight hours
91 total

Weather

Conditions
Visual (VMC) · Day
Wind
20° at 8 knots
Visibility
10 statute miles
Temperature
48 °F, dew point 18 °F
Altimeter
30.10 inHg
Observed at
KCDC, 7 nm away
METAR
KCDC 240053Z AUTO 02008KT 10SM FEW095 09/M08 A3010 RMK AO2 SLP177 T00941083

Docket · 15

The files NTSB released with the investigation on August 23, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 11.5 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.

Other investigations on N321PF · 1

Matched to the same aircraft by N-number and date.