# NTSB CEN09FA220: Cessna E162, N162CE, El Dorado, KS, March 19, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Field investigation · Final report - Date: March 19, 2009, 09:50 local (14:50 UTC) - Place: El Dorado, KS - Coordinates: 37.980556, -96.829719 - Nearby events: https://openairdocs.org/map.md?lat=37.9806&lon=-96.8297&mi=10 - Phase of flight: [Other](https://openairdocs.org/ntsb-phases/800) (OpenAirDocs' grouping) - Defining event: [Other: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report May 6, 2010 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA, Ballistic Recovery Systems, Cessna Aircraft Company, Teledyne Continental Motors - NTSB case key (mKey): 73516 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN09FA220 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73516/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73516 - Page: https://openairdocs.org/ntsb/CEN09FA220 ## Probable cause The failure of the Ballistic Recovery System to disconnect due to twisted attachment straps. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Equipment/furnishings: parachute](https://openairdocs.org/ntsb-findings/01022563): Aircraft › Aircraft systems · Malfunction (probable cause); cases with it: [Cessna 162, 2 cases](https://openairdocs.org/ntsb-findings/01022563/cases.md?model=060005E), [All aircraft, 9 cases](https://openairdocs.org/ntsb-findings/01022563/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Cessna 162, 4 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=060005E), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Other: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Cessna 162, 9 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=060005E), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Other: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Cessna 162, 3 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=060005E), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Other: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 162, 3 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=060005E), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis The pilot was conducting spin testing in an experimental, pre-production, light sport airplane. The airplane was equipped with a non-production Ballistic Recovery System (BRS) chute which was modified to allow for chute jettison after chute deployment. During a full aft center of gravity (CG) test flight, the airplane was placed in a left spin. The pilot attempted to recover from the spin but was unsuccessful. The pilot described the spin as "uncontrollable." After three turns the pilot elected to deploy the BRS, as per the briefed procedures. After BRS deployment, the airplane continued to spin, twisting the BRS chute attachment straps. The pilot attempted to jettison the chute, but could not due to the twisting of the straps. The parachute-equipped pilot remained with the airplane until it reached the ground in the BRS chute. The airplane was substantially damaged when it was drug by the chute in surface winds. The winds four minutes after the accident, 30 miles to the southwest, were reported as being at 14 knots, gusting to 23 knots. After the accident the manufacturer made design changes to the airplane's elevator, aileron, and rudder systems to improve the airplane's spin recovery capabilities. ## Factual narrative HISTORY OF FLIGHT On March 19, 2009, at 0950 central daylight time, a Cessna Aircraft Company E162 model Skycatcher, experimental airplane, N162CE, was substantially damaged following a Ballistic Recovery System deployment and landing during a test flight near El Dorado, Kansas. The airline transport pilot was not injured. The flight was being conducted under the provisions of Title 14 Code of Federal Regulations Part 91 without a flight plan. The local test flight originated at Cessna Aircraft Field Airport (CEA), Wichita, Kansas. Visual meteorological conditions prevailed at the time of the accident. The pilot departed CEA about 0900 to conduct spin testing in the pre-production experimental airplane. The purpose of the flight was to accomplish spins in various flap and power configurations with a center of gravity in an aft limit condition. During a planned test condition the airplane was placed into a left spin. The pilot initiated spin recovery procedures, but the airplane continued to spin without apparent response. The pilot described the spin as "uncontrollable." After the third revolution the pilot deployed the airplane's Ballistic Recovery System (BRS) parachute. The BRS had been specifically modified to allow the chute to be jettisoned by the pilot if altitude and conditions allowed. After BRS deployment the airplane became stabilized in the parachute, but continued to spin under the chute. The pilot attempted to jettison the chute several times, but each jettison attempt was unsuccessful. The pilot then opened the airplane door to bailout and use a personal parachute, but realized he was too low to ensure a successful bailout and elected to stay with the airplane. The pilot shut down the engine prior to landing. PERSONNEL INFORMATION The pilot, age 50, held an Airline Transport Pilot certificate with ratings for airplane single-engine land and airplane multi-engine land and a Flight Instructor certificate for airplane single and multi-engine and instrument airplane. His last Federal Aviation Administration (FAA) first-class medical certificate was issued on June 2, 2008, with limitations “Must wear corrective lenses.” An examination of the pilot's logbook indicated a total flight time of 5,500 hours; of which 220 hours were in the accident airplane. He logged 36 total hours in the previous 90 days, 11 hours in the previous 30 days, and one hour in the previous 24 hours. His last noted biannual flight review was completed December 13, 2007. AIRCRAFT INFORMATION The Cessna Aircraft Company E162 experimental light sport airplane, serial number E16200001, was a high wing, metal covered airplane, with a fixed tricycle landing gear, and was configured for two occupants. The airplane was powered by a direct drive, horizontally opposed, fuel injected, air-cooled, four-cylinder engine. The engine was a Teledyne Continental E-0200DX1CS, serial number 916058, rated at 100 horsepower at 2,750 RPM, and was driving a two-bladed Sensenich fixedpitch propeller. METEOROLGICAL INFORMATION Weather at Colonel James Jabara Airport (AAO), Wichita, Kansas, at 0954 was reported temperature 48 degrees Fahrenheit (F), dew point 28 degrees F, visibility 10 miles, and winds from 070 degrees at 14 knots, gusting to 23 knots. WRECKAGE AND IMPACT INFORMATION The airplane landed upright in an open field, breaking off the nose gear and partially splaying the main landing gear. The pilot exited the airplane and attempted to disengage and collapse the BRS chute, but surface winds inflated the parachute and drug the airplane. The airplane traveled about .6 miles before getting caught in a fence and flipping over. Examination of the airplane revealed the right wing bent upward, left and right ailerons damaged, and the horizontal stabilizer bent. Flight control cable continuity was verified from the cockpit controls to each aileron, elevator and rudder control surfaces. One propeller blade was broken off at the midpoint with no leading edge marks. The second propeller blade showed no marks consistent with impact. TEST AND RESEARCH The airplane was equipped with a non-production, factory modified BRS chute. The modified BRS chute was designed to allow the pilot to deploy the BRS chute if conditions warranted, and then jettison the chute and recover the airplane to flight if altitude and conditions permitted. The modified BRS recovery chute consisted of a canopy attached to the airplane via four nylon straps connected to attach points at four points on the roof of the fuselage, at approximately the four corners of the cockpit. The four connector strap ends were sewn together into a single-point and contained a disconnect mechanism at the single-point end of the attachment strap. The attachment straps then connected to the recovery chute risers via the disconnect mechanism. The BRS disconnect mechanism and riser attachment consisted of a metal ring sewn into the single-point attachment strap. The metal ring was designed to be inserted into a metal D-ring sewn into the recovery chute riser attachment strap. The metal ring would then be folded back towards the single-point attachment strap and held in place by a metal pin and nylon loop mechanism. A nylon cord was run from the metal pin, along the rear left attachment strap, and then into the cockpit and terminated with a metal release handle. To activate the disconnect mechanism after BRS chute deployment, the pilot would pull the release handle. This action would pull the metal pin from its loop attachment and result in the metal ring pulling through the metal riser D-ring and release the BRS chute. The BRS system was removed from the airplane and examined by BRS personnel and investigators at their facilities. Examination of the attachment straps indicated fraying and stretching consistent with the four attachment straps twisting together after deployment. When the attachment straps were twisted together, the release cord could not be pulled along theattachment strap. As a result of this accident Cessna Aircraft Company made design changes to the airplane’s elevator, aileron, and rudder systems to improve the airplane’s spin characteristics. ## Aircraft - Registration: [N162CE](https://openairdocs.org/deregistered/N162CE-2020-05-29), registration cancelled 2020-05-29, S/N 16200001, built 2008 (OpenAirDocs) - Reported make and model: CESSNA AIRCRAFT CO E162 - Registry model: [Cessna 162](https://openairdocs.org/model/cessna-162) (registry code 060005E) (OpenAirDocs) - Registry engine: [Continental 0-200 series](https://openairdocs.org/engine/continental-0-200-series) (registry code 17020, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E16200001 - Airframe hours: 167 - Engines: Teledyne Continental 0200DX1CS 100 horsepower reciprocating - Damage: Substantial damage - Flight: Flight test, Part 91 - Operator: Cessna Aircraft Company - Registered owner: Cessna Aircraft Company - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Annual, November 7, 2008, 70 hours before - Departed: CEA, Cessna Airport, KS - Destination: CEA, Cessna Airport, KS - Airport: CEA, Cessna Aircraft Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: none; flight instructor, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review December 13, 2007; seat: left; flight hours: 5,500 total, 220 in this make and model, 5,300 as pilot in command, 50 in the last 90 days, 25 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 14 knots, gusting 23 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 48 °F, dew point 28 °F - Altimeter: 30.29 inHg - Observed at: AAO ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20090319003199A](https://openairdocs.org/incident/20090319003199A), Mar 19, 2009: Cessna C162, El Dorado, KS, Substantial damage. (-23) During experimental flight testing, the aircraft was undergoing a spin test profile. The pilot was unable to recover from one of the spins and deployed… ## Docket (8 files) The files NTSB released with the investigation on March 1, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73516. 2.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 669 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324876&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Statement-Pilot (item 2, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323419&FileExtension=.PDF&FileName=Witness%20Statement-Pilot-Redacted.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 3, .PDF, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323420&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 4, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324856&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 5, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324629&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo - Wreckage (item 6, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323421&FileExtension=.PDF&FileName=Photo%20-%20Wreckage-Master.PDF - Photo - BRS Attachment Straps (item 7, .PDF, 322 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323422&FileExtension=.PDF&FileName=Photo%20-%20BRS%20Attachment%20Straps-Master.PDF - Photo-BRS Disconnect Mechanism (item 8, .PDF, 381 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323424&FileExtension=.PDF&FileName=Photo-BRS%20Disconnect%20Mechanism-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.