WPR11FA050
WPR11FA050

HISTORY OF THE FLIGHT

On November 17, 2010, at 1306 mountain standard time, a Diamond DA20-C1, N978CT, descended vertically in a spin or spiral and impacted terrain in Payson, Utah. The airplane was operated by Utah Valley University (UVU) Aviation Science Department under the provisions of Title 14 Code of Federal Regulations Part 91. The commercial pilot/certified flight instructor and a student pilot were killed, and the airplane was substantially damaged. Visual meteorological conditions prevailed, and a company flight plan had been filed. The instructional flight originated at Provo Municipal Airport, Provo, Utah, at 1245.

Witnesses reported hearing and seeing the airplane descend vertically in a spiral or spin making numerous rotations before impacting the driveway of a residence. Sounds consistent with engine operation during the descent were also reported. The airplane was operating below the radar coverage area. No radio distress call was received by local air traffic control agencies or the dispatcher monitoring the Utah Valley University base frequency at Provo Airport.

The certified flight instructor (CFI) had flown 28 flights with the student since January 27, 2009. The student pilot was preparing for his final (end of course) private pilot check flight. Maneuvers being practiced on this flight were stalls, slow flight, and landing pattern. The aircraft wreckage was located directly under a designated practice area (practice area D). The aircrew had called on the common base frequency and coordinated the use of high altitude practice area D. The floor of the working area is 7,000 feet mean sea level (msl), and the upper altitude limit is 10,000 feet msl. The terrain elevation is approximately 4,530 feet msl. According to the flight school Director of Operations, typical work done in the high altitude working areas are stalls, slow flight, and steep turns.

PERSONNEL INFORMATION

The certified flight instructor, age 34, held a commercial pilot certificate for airplane single-engine land, airplane multiengine land, instrument airplane, and a flight instructor certificate for airplane single-engine, and instrument airplane. She was issued a first-class medical certificate on August 8, 2008, with no limitations. Examination of copies of the CFI’s logbook showed that she had accumulated 869.8 hours of flight time with 512.7 hours of that as dual instruction given. During the 30 days prior to the accident she had accumulated 9.2 hours of flight time, with 8.4 of those hours as dual instruction. Within the previous 90 days the CFI had flown 4 times with the student she was instructing. She had flown 6 flights in 2003 where spins were noted as having been performed, and she had a logbook endorsement for instructional proficiency for stall awareness, spin entry, spins, and spin recovery, dated August 5, 2003. There were no other logbook entries noting that spins had been performed or practiced after August 5, 2003. The CFI had received her flight review on September 10, 2010, and flew a night currency flight on October 21, 2010; both flights were flown with the flight school's chief instructor for the private pilot curriculum.

The CFI’s husband was interviewed in order to establish what her stress and fatigue levels were the day of the accident. The CFI’s husband stated that his wife had a full time job working for the City of Lindon as the finance director, was taking night classes in pursuit of a Masters Degree in Public Administration, and they had two children. During the week day she would usually flight instruct in off hours, which included lunch breaks. She attended night classes on Tuesday nights from 1800-2200. An extended family member had been helping to take care of the children and cook some of the family meals. Her regular sleep routine was to be in bed around 2230 and up around 0615. The night before the accident she was in bed at 2245, and she was up at 0615 the day of the accident. Her eating patterns were unchanged the few days prior to the accident, diet was normal, and her sleep pattern had been undisturbed. She had not complained of fatigue or any physical ailments, and she was not under any unusual stresses.

The student pilot, age 25, held a second-class medical certificate and student pilot certificate dated January 5, 2009. The certificate had an instructor’s solo endorsement dated April 21, 2009, in the DA20-C1, and an instructor's cross-country endorsement dated September 4, 2009, in the DA20-C1. Examination of the student pilot’s logbook revealed that he had a total 63.7 hours of flight time (53.6 hours dual, and 10.1 hours solo). The student had flown four flights (4.8 hours) over the previous 90 days; August 27, October 2, October 12, and November 11. All four flights were with the accident CFI. Remarks in the student’s logbook state that during all four flights slow flight was practiced, and stalls were practiced on all except for the November 11 flight. Review of the student's training records indicated that the student was preparing for his final (end of stage) private pilot check flight. Training records showed that tasks on all training flights were marked with an “S”, indicating satisfactory performance of that task; however, in the remarks section of the last four flights the instructor stated that the lesson was reviewed for student proficiency. The training records did not have any additional remarks or comments by any CFI about the student’s flying performance, and none were required by the UVU Aviation Science Department.

AIRCRAFT INFORMATION

The two-seat, low wing, fixed gear, single-engine airplane, serial number C0078, was manufactured in 1999. It was powered by a Teledyne Continental Motors IO-240-B, 125-hp engine, and equipped with a Sensenich fixed pitch propeller. Review of the maintenance records showed that a 50-hour inspection was performed on November 1, 2010; engine time since overhaul (TSO) was 1,437.9 hours, and total airframe hours were 6,148.4 hours. The most recent maintenance was the replacement of the left and right tires on November 10, 2010, at total aircraft time of 6,167.2 hours.

In a written statement the CFI who flew N978CT from 1000 to 1200 on the day of the accident said that the airplane operated normally throughout the flight. The flight lasted 1.2 hours, consisted of four stop-and-go’s, and the controls felt normal and moved freely.

The UVU dispatch records, fueling log, and Invoice Out Report for N978CT indicate that the accident airplane flew twice on November 17 before the accident flight for a total of 2.6 hours, and that the airplane was fueled with 11.6 gallons of avgas just before the accident flight. The cockpit and baggage area items that were located with the airplane wreckage were inventoried and weighed; total weight in the baggage compartment was 23.9 pounds. The autopsies documented the CFI’s weight as 140 lbs, and the student’s weight as 170 lbs. The airplane’s weight and balance documents dated May 5, 2010, shows the airplane empty weight was 1,224 lbs. The calculated weight of the airplane at takeoff was 1,705 lbs, and the center of gravity (CG) was 10.93 inches aft of datum. The airplane's weight and balance was within the normal operating range as specified in the Diamond DA20-C1 Flight Manual, Supplement 4. The maximum allowed gross weight of the DA20-C1 is 1,764 lbs, and the furthest aft cg allowed is 12.49 inches.

The DA20-C1 flight manual states in Section 2.9 Approved Maneuvers, that the airplane is certified in the UTILITY Category in accordance with Canadian Airworthiness Manual Chapter 523-VLA. Permissible Utility Category Maneuvers include all normal flight maneuvers and spinning. Section 4.4.16 Spinning, includes two CAUTION notes stating, “Intentional spinning is only permitted with flaps in cruise position,” and “Depending on CG and spin entry technique attempts to enter spins may develop into spiral dives. Monitor the airspeed during the first turn and recover immediately if it increases to 65 KIAS.” Another NOTE states, “Spins with aft CG may oscillate in yaw rate and pitch attitude. This has no effect on recovery procedure or recovery time.”

The Flight Test Report concerning spins in the DA20 (FTR-DA20-C1-014) was provided by Diamond Aircraft. The report documents a series of 150 spin entries performed with the DA20-C1 to include full aft CG with flaps at cruise, takeoff, and landing position. The specific conclusions of the report state, “It has been shown by test that the DA20-C1 Katana is able to recover from a 6-turn or 3-second spin, whichever takes longer, with flaps retracted, or from a 1-turn or 3-second spin, whichever take longer, with flaps extended, within an additional 1 1/2 turns. For both the flaps retracted and flaps extended conditions, the positive limit maneuvering load factor and the airspeed limit are not exceeded during spin recovery when the flaps are retracted during the spin recovery. Note that the DA20-C1 contains a placard stating ‘All aerobatic maneuvers, except for intentional spinning which is permitted with flaps UP only, are prohibited.’ It is Impossible to obtain an unrecoverable spin with any use of controls at the entry to or during the spin, as showed by over 150 successful spins completed during this test program.”

The Flight Test Report stated that the utility category aircraft exhibited a very smooth conventional spin with yaw rates of 125 degrees per second and height loss of 250 feet per turn at full aft CG. These parameters relate to a 5,200 feet per minute rate of descent.

The DA20-C1 Flight Manual, section 3.3.6, Recovery from Unintentional Spins, states the following:

1. Throttle Idle
2. Rudder Fully applied to the opposite direction of spin
3. Control Stick Ease forward
4. Rudder Neutral after rotation has stopped
5. Wing Flaps Cruise
6. Elevator Pull cautiously
Bring airplane from descent into level flight position. Do not exceed maximum permissible speed (Vne).


The DA20-C1 is equipped with a four-point safety belt. The latching buckle design utilizes a lock cover similar to that used by commercial airline passenger restraints. Anecdotal comments by two flight instructors at UVU imply that they themselves or their students have experienced unintentional release of the safety belt buckle. The Safety Board investigator-in-charge (IIC) examined the seating, safety harness, and crew position in the DA20 and found it possible to unintentionally release the buckle by grazing a jacket sleeve across the buckle face. The UVU Director of Operations (DO) was made aware of this fact and said he would document any future reports of an unintentional buckle release. A conversation with the UVU Director of Operations a few months after the accident indicated that there had been no reports of an unintentional buckle release. Diamond Aircraft was made aware of the finding and reported that none of their other operators had experienced this issue. Diamond stated that they conducted some tests and noted that if the harness is properly adjusted per the Aircraft Flight Manual (AFM) the buckle is not subject to inadvertent opening.

WRECKAGE AND IMPACT INFORMATION

The aircraft wreckage was located between two houses on hard compacted driveway ground. The student pilot was positioned in the left seat with his seat harness and shoulder straps buckled. The CFI was positioned in the right seat, her lap belt and shoulder straps were not buckled or positioned around her body. The aircraft was oriented facing a magnetic bearing of 041 degrees, with its nose and engine collapsed on the ground, fuselage elevated at a 30-degree angle, and the tail was broken off at a location 4 feet forward of the tail cone end. The wings remained attached to the fuselage at the wing root area. The canopy glass had shattered and was distributed in a fan like pattern 10-15 yards forward of the cockpit. The nose wheel had collapsed rearward and right, into the cockpit area. Both main landing gear were displaced aft and upward, the left main strut was displaced farther aft than the right main strut. The right wing had fractured along a diagonal line from the leading edge to the trailing edge beginning 4 feet inboard from the wing tip. Damage to the left landing gear main mount, left side of the cockpit, and left wing tip are consistent with the left-hand rotation of the aircraft about the vertical axis and vertical impact forces. Flaps and ailerons were attached to both wings; elevator and rudder were attached to their hinges on the tail.

Control continuity was established from the rudder pedals to the rudder, and from the control sticks to the elevator and ailerons. The flap jackscrew was removed and measured 0.5-inch extension, which according to the Diamond Aircraft technical representative, corresponded to a flap extension between the landing and takeoff positions.

The two bladed wood-composite propeller remained attached to the engine propeller flange. One blade was separated at the hub and in splinters; the other blade was undamaged. The spinner was crushed flat on one side. The angle measured between the spinner’s flat crush face and the longitudinal axis of the airplane was approximately 45 degrees. The engine oil pan was crushed; the starter and both left and right magnetos separated from the engine. The exhaust manifolds remained attached to the cylinders and exhibited damage consistent with plastic deformation. The spark plugs exhibited normal operating signatures in accordance with the Champion aviation check-a-plug chart. Blue liquid with a petroleum odor was observed in the fuel manifold valve assembly. The engine was rotated by hand and thumb compression was detected within all cylinders, and the valves moved in sequence.

Nothing was identified that would have precluded the normal operation or function of the airplane’s engine or flight controls.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on both the CFI and student pilot on November 18, 2010, by the State of Utah Medical Examiner. The autopsy findings for both pilots included blunt force injuries of the head, torso, and extremities.

The Safety Board IIC conducted a follow-up phone interview with the Utah State Medical Examiner concerning the injury patterns between the CFI and student pilot. The Medical Examiner stated that neither victim had definitive marks indicating the presence of a lap belt or shoulder harness; however, both victims exhibited similar skin discolorations across their clavicles, and the injuries to their extremities and torsos were similar.

Forensic toxicology was performed on the specimens from the CFI and student pilot by the FAA Bioaeronautical Sciences Research Laboratory CAMI, Oklahoma City, Oklahoma. The toxicology report for the CFI stated negative findings for carbon monoxide, cyanide, or ethanol. Ibuprofen was detected in urine. The toxicology report for the student pilot stated negative findings for carbon monoxide, cyanide, ethanol, and none of the specified drugs were detected.

ORGANIZATIONAL AND MANAGEMENT INFORMATION

Utah Valley University (UVU) Department of Aviation Science operates as a Federal Aviation Regulation (FAR) Part 61 flight training school, and offers flight training from the private pilot level through the commercial multi-engine pilot certificate, instrument ratings, and certified flight instructor certificates. The flight training staff consists of approximately 50 certified flight instructors that are employed on a part time basis and 4 chief flight instructors that are employed full time. The school operates 15 Diamond Katana DA20’s, 6 Diamond Star DA40’s, and 4 Diamond Twin Star DA42’s. The main facility is located at the Provo Municipal Airport, and the organization performs its own maintenance on all the airplanes. The Aviation Science Program offers the opportunity for students to earn Associate and Bachelor of Science in Aviation Science degrees. Approximately 2,000 students are enrolled in the program. A majority of those students are enrolled in the on-line program. About 250 students are enrolled locally taking flight instruction, with 90-100 students very active, and 150 students receiving periodic instruction.

The UVU Flight Training Safety Policies and Procedure Manual delineates the responsibilities of the CFI’s and students, and provides general operations guidance. Specifically it states that the CFI is the primary party responsible for the maintenance and accuracy of a student’s record. Spin and spin training may only be conducted by instructors designated by the Chief Pilot or the Chief Instructor responsible for CFI training. Each UVU instructor must complete a flight check every 12 months for each course of training they are approved to teach.

The Director of Operations (DO) directs the three major functional areas of the Aviation Science Department; Aviation Flight Training Center (which includes responsibility for flight training), dispatch, and maintenance operational areas. The DO reports directly to the Assistant Dean of Aviation Science. He was hired by UVU in 1996, and became Director of Operations, Aviation Science, in March 2010. The staff was reorganized in March 2010; the Chief Pilot position was vacated, and the flight training section was brought in under the DO with a new Chief Pilot assigned who reports to the DO. Before the reorganization, the flight training was its own section and the Chief Pilot reported directly to the Assistant Dean. The DO explained that UVU provides the CFI’s with proficiency & currency flights and stated the policy was, in essence, that each CFI was allocated one flight hour per month for either, at which expense was provided by UVU. The Chief Instructors have proficiency accounts that they can use to provide the CFI’s with these flights. If a CFI is deficient in a particular area or skill, it is up to the CFI to pay for any additional training that may be required to bring them in compliance with the pilot training standard. This policy is known by the Chief Instructors; however, it is not addressed in the UVU Flight Training Safety Policies and Procedures Manual (revision 7.1).

The Chief Pilot for the flight school is also the chief instructor for the commercial and multiengine program. He holds a commercial pilot certificate with ratings for single engine and multi-engine airplane, and instrument airplane. He holds a flight instructor certificate for single engine and multi-engine airplanes, and instrument airplane instructor rating. He has about 2,000 hours of flight time and 1,600 hours of that is dual instruction given. His direct supervisor is the DO. His duties include supervision of the chief instructors and all the CFI’s. He is the chief instructor for the commercial/multi-engine program, and conducts any required Flight Evaluation Board (FEB). FEB’s are held for students not progressing or with significant deficiencies. The Chief Pilot feels management listens to him. He said that the only proficiency requirement he was aware of was that CFIs are required to have one proficiency flight per year.

The Chief Instructor for the private pilot curriculum holds a commercial certificate with airplane single engine land, airplane multiengine land, and instrument airplane ratings. She holds a flight instructor certificate with airplane single engine and multiengine, and instrument airplane ratings. She has between 3,500 and 4,000 hours of flight time, which includes 3,000 hours of dual instruction given. She was hired by UVU in November 2006 as the Chief Instructor for the private pilot curriculum, and her direct supervisor is the Chief Pilot. She oversees about 21 CFI’s who teach the private pilot curriculum. She stated providing her CFIs with proficiency flights is difficult; managing the CFI’s and performing all the stage checks keeps her very busy. She also stated that there are proficiency accounts where each of her CFI's are allotted 1 hour per month of proficiency flight time. UVU billing records show that she flew 35 CFI proficiency flights between July and October; 7 in July, 13 in August, 7 in September, and 8 in October. She stated that the DO is always watching the proficiency accounts and is critical of her use of those funds. She said her relationship with the DO is strained, and she feels like she is always being scrutinized.

The Director of Safety for the flight school holds a commercial pilot certificate, has airplane single-engine, airplane multi-engine, airplane instrument ratings, and is type rated in the Boeing 707 and Boeing 720 series airplanes. He holds a CFI certificate and has a total of 3,700 flight hours. He became the Director of Safety in March 2010. The Director of Safety’s duties, as stated in the UVU Director of Safety position description, include responsibility for ground and flight safety, incident and accident action plans, standardization of employee and flight training, FAA regulatory compliance, and directing the Safety Committee. The Director of Safety stated that he posts a safety information flier on a common bulletin board monthly and places one in each of the CFIs in-boxes. There is a suggestion box available for staff and students but it does not get used often, and there is no formal way to anonymously report aviation safety issues. He does not formally track mishaps or close calls but does mention such incidents in safety meetings. Safety meetings are conducted during the CFI meetings that the Chief Pilot schedules. There is one mandatory safety meeting scheduled per semester, additional meetings are not regularly scheduled, and the most recent meeting occurred 3 months prior to the accident. The Safety Officer encourages CFIs and students to attend the FAA Safety Team (FAAST) presentations; however, those are poorly attended. The last FAAST meeting had 2 CFI’s attending and no students. The Director of Safety knew that the CFI’s fly with the Chief Flight Instructors, and that it was an annual requirement; however, he was not aware of the proficiency flight accounts that provide 1 hour of proficiency training per CFI per month. Although one of the Director of Safety’s duties is to provide management and oversight of off-site incidents or accidents, he was not actively engaged in the on-scene portion of the Safety Board’s accident investigation. During the post accident activities the Director of Safety was asked by UVU Aviation Science Department management to act as a liaison between the flight school and the victims’ families.

Additional interviews were conducted with the Chief CFI for instrument training and the Chief CFI for CFI and spin training. Both Chief CFI’s expressed a perception that the DO did not encourage or was critical of the use of the CFI proficiency accounts.

Spin training is required and is provided to the programs CFI applicants. After the initial exposure to spins and receipt of their spin endorsement, CFIs don’t normally receive additional spin training or spin proficiency opportunities, and none is required by FAR 61.183.

ADDITIONAL INFORMATION

One of the accident CFI’s current students who had just completed her solo flight related an event that happened during dual instruction about 2 weeks before the accident. The student stated that they were practicing slow flight. Slow flight requires the flaps to be in the landing position, the engine to be at a fairly high power setting, and airspeed maintained at 44 knots. During the transition back to normal cruise the engine cut out, the left wing dropped, and they entered a spin making 1 complete rotation. The CFI regained control of the airplane by adding full power, full right rudder, and opposite aileron. After they regained normal flight, the engine continued to run rough. The CFI restarted the engine and they returned to the airport.

The UVU Aviation Science Department has taken the following actions as a result of this accident.

-All flight training was halted until a full review of the training operations was completed.

-All CFI’s received additional spin awareness training.

-An agency outside of UVU conducted a Safety Program Audit.

-A certified safety professional was hired into the Director of Safety position.

-The Chief Instructor responsibilities have been modified to provide a supervisory role over 3-4 assistant chief instructors, and no longer directly manages the commercial and multi-engine program.

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