Pilot Debrief

CESSNA 152 near Mendon, UT — 2022-06-24

Final reportWPR22FA227
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Date
2022-06-24
Location
Mendon, UT, USA
Aircraft
CESSNA 152
Registration
N934JH
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Maneuvering

Probable cause

The flight instructor’s failure to recover from a developed spin, which resulted in impact with terrain. Contributing to the accident was the flight instructor’s decision to enter the maneuver below the operator’s altitude limitation.

Contributing factors

Contributing to the accident was the flight instructor’s decision to enter the maneuver below the operator’s altitude limitation.

NTSB narrative

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.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Conducting spin training below the minimum safe altitude of 1,500 ft agl.

NTSB coding

Evidence available

  • CVR
  • Video
  • ADS-B / radar
  • Photos
  • 19 docket documents
View NTSB final reportView NTSB docket

Docket documents19

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