NTSB CAROL · Event
Event WPR22FA164
Registry · N321PF
FAA Aircraft Registry record.
Make / Model
DIAMOND AIRCRAFT DA 40
Year of manufacture
2004 · 18 years old at event
Engine
LYCOMING I0360 SER (180 hp)
Seats / Engines
4 seats · 1 engine
Last airworthiness date
20040716
ADS-B equipped
Yes — Mode-S A37352
Registrant of record
RRSF LLC
Source: FAA Aircraft Registry (releasable master file).
Aircraft involved
Probable cause & findings
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.
Factual narrative
HISTORY OF FLIGHTOn 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 that point, 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. PERSONNEL INFORMATIONDuring his last Federal Aviation Administration medical examination, the pilot reported that he was 74 inches tall and weighed 215 pounds. AIRCRAFT INFORMATIONThe 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. METEOROLOGICAL INFORMATIONThe 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. AIRPORT INFORMATIONThe 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. WRECKAGE AND IMPACT INFORMATIONExamination 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. MEDICAL AND PATHOLOGICAL INFORMATIONThe 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. 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. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- — Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot
- — Aircraft-Aircraft oper/perf/capability-Aircraft capability-Climb capability-Attain/maintain not possible
- — Environmental issues-Physical environment-Terrain-Mountainous/hilly terrain-Effect on equipment
Verbatim from NTSB's published report. Source file
NTSB_2022_WPR22FA164.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (controlled flight into terrain). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- Flight Safety Foundation 2023 · FSF / AeroSafety World
Controlled Flight Into Terrain (CFIT) — A 2023 Industry Refresh
Foundation 2023 CFIT data refresh — three decades after the original CFIT Task Force eliminated >95% of air-carrier CFIT, the GA + Part 135 communities still account for most CFIT fatalities.
- NASA NTRS 2019 · Technical Publication (TP)
Flight Simulator Evaluation of Synthetic Vision Display Concepts to Prevent Controlled Flight Into Terrain (CFIT)
In commercial aviation, over 30-percent of all fatal accidents worldwide are categorized as Controlled Flight Into Terrain (CFIT) accidents, where a fully functioning airplane is inadvertently flown i…
- NASA NTRS 2019 · Other
Preliminary Effect of Synthetic Vision Systems Displays to Reduce Low-Visibility Loss of Control and Controlled Flight Into Terrain Accidents
An experimental investigation was conducted to study the effectiveness of Synthetic Vision Systems (SVS) flight displays as a means of eliminating Low Visibility Loss of Control (LVLOC) and Controlled…
- NASA NTRS 2019 · Technical Memorandum (TM)
Rating the Relevance of QUORUM-Selected ASRS Incident Narratives to a "Controlled Flight into Terrain" Accident
An exploratory study was conducted to identify commercial aviation incidents that are relevant to a "controlled flight into terrain" (CFIT) accident using a NASA-developed text processing method.
- Embry-Riddle Scholarly Commons 2001 · Journal article (JAAER)
Controlled Flight into Terrain: How the Airlines and the Federal Aviation Administration are Addressing the Problem
Controlled Flight into Terrain (CFIT) is not a new problem. It has been around since the beginning of manned flight. A CFIT accident occurs when an airworthy aircraft, under the control of a pilot, is…
- Embry-Riddle Scholarly Commons 2023 · Conference paper
Aircraft Energy Management: A Best Practice for Integrating Safety and Efficiency
Aircraft Energy Management: A Best Practice for Integrating Safety and Efficiency The airplane is the quintessential energy system, constantly transforming, transferring, distributing, storing, and ex…
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