WPR22FA227

The accident flight was intended to teach the flight instructor candidate how to enter, recognize, and recover from an aggravated stall wherein the airplane follows a corkscrew path. Before the accident maneuver, automatic dependent surveillance - broadcast (ADS-B) data revealed that several training maneuvers were performed with extraordinary directional changes greater than 180° or rapid descents in altitude. The rapid changes in altitude and recovery were consistent with stall or spin recovery maneuvers. Although there were no witnesses to the accident, surveillance video footage captured the airplane descending rapidly in a developed spin. Postaccident examination of the airframe and engine revealed that the airplane impacted terrain in a 45° nose-down attitude, with no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. The operator’s training guidance stated that the minimum altitude to perform spin training was 9,500 ft mean sea level (msl). According to ADS-B data, the accident maneuver was entered about 9,100 ft msl, and the elevation at the wreckage site was 4,590 ft. According to the operator’s flight experience logs, the flight instructor accumulated 2 hours of flight experience learning how to spin the accident airplane. The fight instructors personal flight logs were not provided, and his total flight experience was not determined. According to the operator’s flight experience logs, the flight instructor candidate had no actual flight experience in the accident airplane make and model. The pilot under instruction's toxicology testing detected codeine and morphine in urine at low levels. These results could be explained by codeine use alone, although other potential explanations exist. Regardless, the pilot under instruction had no detectable codeine or morphine in his blood, which makes it unlikely that codeine or morphine effects contributed to the accident.

The operator’s spin recovery training parameters are illustrated below: The Spin recovery needs to be briefed from the Airplane Flight Manual (AFM). Here are the parameters that will be briefed- • Minimum altitude to do the flight is 9,500-10,000 MSL. o 6,000 AGL is listed in the AFM for a 6-turn spin. o We will only do a 3-turn spin o After every spin you will climb back to the minimum altitude o 1,500 AGL is listed in the AFM as the lowest recovery altitude, we should never get this close during spins. • CFI will only do a power-off stall into a Spin as per the AC circular and CFI PTS. • CFI will do stall to the incipient phase and then the recovery. • Student will do stall to the incipient phase and then the recovery. • CFI will demonstrate the first 3-rotation spin and recovery • Student will perform the requisite 3-rotation spins to both directions and a total of 3 separate spins and recoveries. • If safety is ever in question, you will stop the training flight. The airplane manufacturer’s pilot operating handbook and approved AFM, provided the recovery method for spins within its normal procedures (see Figure 2). Figure 2. POH/AFM spin recovery training According to the AFM, for planning purposes at least 1,000 ft of altitude loss should be allowed for a 1-turn spin and recovery. Additionally, the AFM identified that spins are to be completed before reaching at minimum 1,500 ft agl. On June 24, 2022, about 0903 Mountain daylight time, a Cessna 152, N934JH, sustained substantial damage when it was involved in an accident in Mendon, Utah. The flight instructor and pilot receiving instruction sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the flight school’s Chief Flight Instructor, the purpose of the accident flight was for the flight instructor to conduct spin training with the pilot receiving instruction, who was a flight instructor candidate. The accident airplane departed Logan-Cache Airport, in Logan, Utah, and traveled to Utah State University’s designated aviation practice area, about 10 nm southwest of the airport. According to ADS-B data, several training maneuvers were performed, with the duration of flight lasting nearly thirty minutes. Three maneuvers were performed with directional changes greater than 180° or rapid descents in altitude, consistent with spin training. ADS-B data indicated that the accident maneuver was entered about 9,100 ft msl (~4,510 ft agl). The elevation at the wreckage site was 4,590 ft. A review of surveillance footage showed the airplane in a fully developed left spin. When the airplane entered the surveillance video’s field of view, the airplane subsequently completed three rotations to the left, in a nose-down attitude, within a time span of about seven seconds, before disappearing from the camera view and impacting terrain. Figure 1: N934JH spin maneuver initiated An autopsy of the flight instructor was performedby the Utah Department of Health Office of the Medical Examiner, Taylorsville, Utah. According to the autopsy report, the cause of death was blunt force injuries and the manner of death was an accident. Toxicology testing performed on the flight instructor candidate by the FAA Forensic Sciences Laboratory found 206 µg/ml codeine and 71 µg/ml morphine in the urine. The pilot under instruction had no detectable codeine or morphine in his blood at the time of the crash. A review of the operator’s pilot logs for the flight instructor and flight instructor candidate receiving instruction revealed that most of their actual flight experience was acquired in a low-wing, four-seat, technically advanced airplane. The accident airplane was a high-wing, two-seat, analogue-gauge airplane. A review of the flight instructor’s pilot log provided by the operator indicated that he had acquired 348.9 hours of flight experience, with 2.4 hours of flight experience in the accident airplane. The pilot’s log revealed that he had acquired 1.1 hours of flight experience nine days before the accident flight, 0.9 hours three days before the accident flight, and 0.4 hours in the accident airplane, which was acquired on the ground before terminating the planned flight due to inclement weather. A review of the flight instructor candidate’s pilot log provided by the operator revealed that he had acquired 252.8 hours of flight experience, with 0.4 hours in the accident airplane, which was acquired on the ground before terminating the planned flight due to inclement weather. The personal flight logs for the flight instructor and the pilot receiving instruction were not provided. According to a fuel invoice provided by the operator, the accident airplane was refueled with just over 6 gallons of 100LL aviation gasoline on June 23, 2022. The wreckage was in a tall grass field located in an agricultural area. The aircraft impacted terrain about a 45° nose-down attitude. The cockpit was compressed upward and aft, decreasing cockpit volume. The wings remained connected to their respective wing attachment fittings. Both lift struts remained attached to the fuselage and the wings. The left- and right-wing root skins exhibited compression damage. Neither wing’s leading edge exhibited signs of impact compression damage, although the left-wing tip sustained impact damage. The aluminum fuel tanks remained intact. The right wing was bent upward approximately 10° outboard of the lift strut. The upper-wing skins exhibited wrinkles consistent with compression. The lower wing skins in the same area exhibited wrinkles consistent with tension. The empennage remained intact. The left horizontal stabilizer was bent downward approximately 10° about midspan. The manufacturer of the accident airplane issued a mandatory rudder stop modification identified as Single Engine Bulletin (SEB) 01-1. The service bulletin was mandated by Federal Aviation Administration Airworthiness Directive (AD) 2009-10-09and was complied with on the accident airplane and postaccident inspection revealed no anomalies. The purpose as stated in the bulletin was as follows: To provide an enhanced rudder stop, bumper, doubler and attachment hardware designed to assist in preventing the possibility of the rudder overriding the stop bolt during full left and/or right operation of the rudder. According to weight and balance calculations conducted by the flight instructor and validated by the investigator-in-charge, the airplane was operated within center-of-gravity limitations and within weight and balances tolerances. An examination of the airframe revealed no indications of flight control cable or control surface obstructions that would have prevented or restricted the normal operation of the flight controls. There was no evidence of preimpact mechanical malfunctions observed during examination of the engine.