Pilot Debrief

Diamond Aircraft DA-40 near Bardstown, KY — 2022-08-07

Final reportERA22LA362
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Date
2022-08-07
Location
Bardstown, KY, USA
Airport
BRY
Aircraft
Diamond Aircraft DA-40
Registration
N723AG
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Ground

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.

NTSB narrative

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.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot should have ensured passengers exited only after engine shutdown.

NTSB coding

Evidence available

  • 6 docket documents
View NTSB final reportView NTSB docket

Docket documents6

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