CEN09FA363

NTSB accident investigation · Cirrus Design SR22 · Crystal, MN · June 17, 2009

Accident · FatalField investigationFinal report
Date
June 16, 2009, 22:02 local (Jun 17, 2009, 03:02 UTC)
Place
Crystal, MN
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N214BNCirrus Design SR22
Defining event
Approach-VFR go-around: Loss of control in flight
Weather
Visual (VMC) · Night/dark
Status
Completed · report April 22, 2010
Report
Approved by Office Director
NTSB office
Central Region
Parties
Cirrus Design, Teledyne Continental, FAA-MSP-FSDO
FAA report
20090616018739A
Case key
74065

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot's failure to maintain airspeed which resulted in a loss of aircraft control during a go-around. Factors associated with the accident were the dark night lighting conditions, moderate to heavy rain, and fatigue.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedCirrus Design SR22: 24 casesAll aircraft: 1,681 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCirrus Design SR22: 94 casesAll aircraft: 9,295 casesProbable cause
Ceiling/visibility/precip: rainEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeCirrus Design SR22: 1 caseAll aircraft: 56 casesProbable cause
Light condition: darkEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeCirrus Design SR22: 13 casesAll aircraft: 448 casesProbable cause
Alertness/FatiguePersonnel issues › Physical · PilotCirrus Design SR22: 1 caseAll aircraft: 48 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot reported having the runway in sight during the night landing. The tower controller reported that it appeared the airplane touched down on the runway after which time they closed and departed the tower. A witness, who was exiting a building on the south side of the airport when the accident occurred,reported that he heard the airplane and that the engine was very loud. He then heard the engine power increase as if the pilot was performing a “go-around.” He stated that he heard the impact and looked toward runway 14L where he saw the airplane engulfed in flames. The witness stated there was “moderate to heavy” rain at the time of the accident. Another witness reported that the airplane turned onto its right side and stalled. The airplane was destroyed by impact and a post impact fire. Inspection of the airplane and engine failed to reveal any pre-impact failure/malfunction. The pilot began the cross country flight about 10 hours and 30 minutes prior to the accident, and had flown about 7 hours and 17 minutes during that time.

Factual narrative

HISTORY OF FLIGHT On June 16, 2009, at 2202 central daylight time, a Cirrus SR22, N214BN, collided with the terrain following a loss of control while landing on runway 14L (3,263 feet by 75 feet wet asphalt) at the Crystal Airport (MIC), Crystal, Minnesota. The instrument rated private pilot was fatally injured. The airplane was consumed by post impact fire. The personal/business flight was being operated under Title 14 Code of Federal Regulations Part 91. An instrument flight plan was filed and visual meteorological conditions existed at the time of the accident. The last leg of the cross country flight originated at the Downtown-Wheeler Airport (MKC), Kansas City, Missouri, at approximately 1918. (All times are central daylight times unless noted.) According to information received from interviews and a FlightAware Activity Log, the first leg of the trip originated in Lawrenceville, Georgia, where the airplane departed from the Gwinnett County Airport (LZU) at 1235 eastern daylight time. The airplane arrived at the Memphis International Airport (MEM), Memphis, Tennessee, at 1339. the airplane departed MEM at 1558, and arrived at MKC at 1827. Records show the airplane was fueled with 37 gallons of 100LL aviation fuel at MKC prior to departing for MIC. At 2153, the pilot contacted MIC tower stating that he was outside OYNOP, the initial approach fix for the global positioning system (GPS) RWY 14L approach. The local controller asked the pilot if he was going to perform a missed approach or if he was going to make a full stop and the pilot replied, “stop.” The controller then instructed the pilot to report having the airport in sight. At 2158, the local controller cleared N214BN to land and asked the pilot how bright he wanted the lights to be. The pilot replied that he wanted them a little brighter than they were at the time and that it was a little hard to see the field. The pilot reported being at ZUNBE, the final approach fix, and that he was starting his descent. The controller replied that the lights were on “full blast.” The pilot replied, “ok” and the controller instructed the pilot to key the mike if he wanted the lights dimmer. The MIC control tower closes at 2200, and at 2159, the ground controller made the closing announcement over the tower frequency. Shortly thereafter, the pilot radioed that he had the runway in sight. The controller replied, “roger.” There were no further transmissions from the aircraft. The local controller reported that the airplane appeared to have landed on runway 14L at which time he and the two other controllers departed the tower for the night. All three controllers stated the first they knew of the accident was when they reached the parking lot outside the tower and saw the aircraft engulfed in flames. A Lieutenant Colonel with the Civil Air Patrol was exiting a building on the south side of the airport when the accident occurred. He reported that he heard the airplane and that the engine was very loud. Hethen heard the engine power increase as if the pilot was performing a “go-around.” He stated he heard the impact and looked toward runway 14L where he saw the airplane engulfed in flames. The witness stated there was “moderate to heavy” rain at the time of the accident. Another witness, who was on the southeast side of the airport perimeter stated he saw the airplane coming in from the north and watched it as it attempted to land. He reported the airplane turned over on its right side, appeared to stall, and impacted the ground. PERSONNEL INFORMATION The pilot, age 60, held a private pilot certificate with airplane single engine land and instrument ratings. His last Federal Aviation Administration (FAA) third-class medical was issued on September 3, 2008. The medical certificate contained the limitation “Holder shall wear corrective lenses.” The pilot’s family stated that his logbooks were in the airplane at the time of the accident. The logbooks were not located amongst the burned wreckage. The pilot received his instrument airplane rating on February 23, 2009. On the application for that rating, which was dated February 20, 2009, the pilot reported having 505 hours of total flight time. This included 388 hours of flight time in a Cirrus SR-22, and 38 hours of night flight time. The airplane owner stated the accident pilot was the one who flew the SR22 most frequently. AIRCRAFT INFORMATION The airplane was a 2004-model Cirrus SR22, serial number 1137. The SR22 is a four-place, single-engine, low wing, composite structure airplane. The airplane was equipped from the factory with an Avidyne FlightMax multi-function flight display (MFD), an Avidyne FlightMax primary flight display (PFD), and a S-Tec System 55X autopilot. The airplane was also equipped with a Cirrus Airframe Parachute System (CAPS). The airplane was equipped with a fuel-injected, Teledyne Continental IO-550-N(27), 310-horsepower engine, serial number 917356. It was also equipped with a three-bladed, constant speed, Hartzell propeller. According to the aircraft owner, the aircraft logbooks were in the airplane at the time of the accident. Small, burnt pieces of what appeared to be aircraft logbooks were located amongst the wreckage. Records obtained from the fixed base operator that maintained the airplane showed the last annual inspection was completed on October 29, 2008. The aircraft and engine total times at the time of the last annual inspection were both listed as being 689.4 hours. The aircraft owner stated he purchased the airplane in 2004. He stated that Cirrus leased the airplane from him at the time of purchase. He stated the airplane had 270 hours of flight time on it when he took delivery of it in October 2005. METEOROLOGICAL INFORMATION The weather conditions reported at MIC at 2153 were: Wind from 080 degrees at 3 knots; visibility 3 statute miles; light rain and mist; overcast clouds at 4,200 feet; temperature 17 degree Celsius; dew point 17 degrees Celsius;altimeter 29.90 inches of mercury. The weather conditions reported at MIC at 2209 were: Wind from 100 degrees at 4 knots; visibility 4 statute miles; rain and mist; overcast clouds at 4,400 feet; temperature 17 degree Celsius; dew point 17 degrees Celsius; altimeter 29.90 inches of mercury WRECKAGE AND IMPACT INFORMATION The airplane came to rest in a grass area located approximately 266 feet south of taxiway Alpha and 138 feet east of runway 14L. There was no debris on the runway, nor were there any marks on the runway that could be attributed to the airplane. There were no marks in the grass between the runway and the first impact mark. Four terrain impact marks led up to the main wreckage. These marks were along a magnetic heading of 74 degrees and covered a distance of about 30 feet. The first mark was approximately 100 feet east of runway 14L and it consisted of a slash type mark which was about 27 inches in length. This was closely followed by a 12 inch long impact mark which contained red glass. The third mark was approximately 45 inches long and 6 inches deep. This mark also contained red glass along with pieces of hardware from the left wing navigational light. The last mark was about 10 feet 7 inches long. The main wreckage came to rest inverted on a magnetic heading of 134 degrees. The fuselage area was destroyed by the post impact fire. The empennage was separated from the fuselage. The empennage exhibited impact and fire damage; however, the stabilizers and flight control surfaces remained attached to the empennage. Both elevator control cables remained attached at the forward elevator torque tube. The upper elevator cable separated from the empennage elevator bellcrank and the lower elevator cable remained attached. The rudder cables remained attached to the torque tubes on the rudder pedals. The upper rudder cable remained attached to the rudder bellcrank in the empennage, and the lower cable had separated from the bellcrank. The right wing which remained partially attached to the fuselage, sustained impact and fire damage. The right aileron remained attached to the wing as did the outboard portion of the right flap. The inboard portion of the right wing flap was destroyed by fire. The left wing was folded over the fuselage and found near the right wing. The left wingtip, aileron, and flap were separated from the remainder of the wing which was destroyed by fire. The brass portion on two of the three aileron turnbuckles was melted away. The forward, left, and right aileron cables were in place. The roll trim motor and cartridge were separated from the wing. The trim motor shaft was bent and the actuator arm was positioned in an almost full right trim position. The CAPS rocket motor was located near the horizontal stabilizer. Portions of the rocket motor launch tube were located about 30 feet in front of the main wreckage. About 8 to 10 inches of the activation cable remained attached to the igniter assembly for the CAPS rocketmotor. The parachute remained folded and had not been deployed. One propeller blade had gouges on both the leading and trailing edges. The blade contained chordwise scratches on both sides of the blade. The blade exhibited slight “S” bending and it was rotated past the stops in the hub in the high pitch direction. The second blade was loose in the propeller hub and the blade was bent forward beginning near the blade hub. The third blade contained leading edge polishing and chordwise scratches along with a slight forward bend. The propeller spinner exhibited rotational crushing. The engine remained partially attached to the airframe. Impact damage was visible on the exhaust system, the induction system, the oil sump, fuel injection nozzles, number 2 alternator, and the starter. The ignition harness, magnetos, fuel pump, oil sump, and both alternators sustained heat damage. Neither magneto would produce a spark when turned by hand. The magnetos were opened and extensive internal heat damage was visible. The fuel pump rotated with some binding when turned by hand. The fuel pump was opened and internal heat damage was visible. The mixture lever was bound in position near the full rich stop. The fuel manifold contained fuel and a slight amount of debris in the screen. The spark plugs indicated normal wear. The crankshaft was rotated by hand at which time continuity was established throughout the engine. The flash memory module from the multi-function display and the memory card from the primary flight display were removed and sent to the Safety Board recorders laboratory. Both units were too badly burned to retrieve any information from them. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot on June 17, 2009, by the Hennepin County Medical Examiner’s Office. The autopsy report listed the cause of death as “Multiple Blunt Force Injuries Due to Airplane Crash.” Forensic Toxicology Fatal Accident Reports were prepared for the pilot by the FAA Civil Aeromedical Institute, Oklahoma City, Oklahoma. The results for all tests conducted were negative with the exception of 0.012 (ug/ml, ug/g) Oxazepam which was detected in urine. Oxazepam was not detected in the blood. TESTS AND RESEARCH The airplane’s flight path was reconstructed using radar track data. Around 2155, while at an altitude of 3,000 feet mean seal level (msl), the airplane made a turn to the southeast toward MIC. The airplane’s ground speed at that time was about 100 knots. The airplane then began a descent. Altitude and ground speed continued to decrease until 2158 when the ground speed increased to a maximum of 121 knots at 2200, prior to decreasing again. The last radar contact occurred at 2201:15 at an altitude of 1,100 feet msl (approximately 230 feet above ground level) and a ground speed of 81 knots.

Aircraft

Registration
N214BN
Reported as
Cirrus Design SR22
Category
Airplane
Serial number
1137
Airframe hours
689
Engine
Cont Motor IO-550 SERIES, 300 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Steven K. Case
Registered owner
Laserman Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 29, 2008
Departed
MKC · Kansas City, MO
Destination
MIC · Crystal, MN
Flight plan
IFR
Airport
MIC · Crystal Airport, runway 14L, 3,263 × 75 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
60
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
505 total · 388 in this make and model

Weather

Conditions
Visual (VMC) · Night/dark
Wind
100° at 4 knots
Visibility
4 statute miles
Lowest ceiling
4,400 ft overcast
Temperature
63 °F, dew point 63 °F
Altimeter
29.89 inHg
Observed at
MIC

Docket · 43

The files NTSB released with the investigation on January 7, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 25.5 MB in all.

Record of InterviewsItem 1 · .PDF · 68 KBAdditional Record of InterviewItem 2 · .PDF · 22 KBController's StatementsItem 3 · .PDF · 243 KBCrystal Airport Aerial ViewsItem 4 · .PDF · 5.8 MBGPS Rwy 14L ApproachItem 5 · .PDF · 48 KBAirport DiagramItem 6 · .PDF · 67 KBWeather InformationItem 7 · .PDF · 29 KBAir Traffic Control TranscriptItem 8 · .PDF · 313 KBRadar Data and PlotsItem 9 · .PDF · 6.8 MBCrystal Police Department ReportItem 10 · .PDF · 764 KBMaintenance InvoicesItem 11 · .PDF · 381 KBN214BN Equipment ListItem 12 · .PDF · 259 KBFuel InvoiceItem 13 · .PDF · 27 KBToxicological ReportItem 14 · .PDF · 62 KBStatement of Party Representatives to NTSB InvestigationItem 15 · .PDF · 384 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 16 · .PDF · 68 KBPhoto 1. View of N214BN Off the Left Side of Runway 14LItem 17 · .PDF · 956 KBPhoto 2. Slash Mark Located Along Wreckage PathItem 18 · .PDF · 500 KBPhoto 3. View of N214BNItem 19 · .PDF · 303 KBPhoto 4. View of N214BNItem 20 · .PDF · 305 KBPhoto 5. View of N214BNItem 21 · .PDF · 334 KBPhoto 6. View of N214BNItem 22 · .PDF · 308 KBPhoto 7. View of Inverted Right Wing of N214BNItem 23 · .PDF · 326 KBPhoto 8. View of N214BNItem 24 · .PDF · 278 KBPhoto 9. View of N214BNItem 25 · .PDF · 289 KBPhoto 10. Elevator and Rudder Control Cables/LinkagesItem 26 · .PDF · 395 KBPhoto 11. PropellerItem 27 · .PDF · 429 KBPhoto 12. Left Wing SparItem 28 · .PDF · 447 KBPhoto 13. Cockpit AreaItem 29 · .PDF · 434 KBPhoto 14. Aileron Control LinkagesItem 30 · .PDF · 357 KBPhoto 15. Left and Right WingsItem 31 · .PDF · 378 KBPhoto 16. Cabin AreaItem 32 · .PDF · 426 KBPhoto 17. Elevator and Rudder Control CablesItem 33 · .PDF · 403 KBPhoto 18. Multi-Function and Primary Flight DisplaysItem 34 · .PDF · 408 KBPhoto 19. Bottom of EngineItem 35 · .PDF · 375 KBPhoto 20. Cylinders 2, 4, and 6Item 36 · .PDF · 338 KBPhoto 21. Cylinders 1, 3, and 5Item 37 · .PDF · 335 KBPhoto 22. Accessory Case on EngineItem 38 · .PDF · 338 KBPhoto 23. Propeller SpinnerItem 39 · .PDF · 249 KBPhoto 24. PropellerItem 40 · .PDF · 360 KBPhoto 25. PropellerItem 41 · .PDF · 318 KBPhoto 26. Propeller BladeItem 42 · .PDF · 375 KBPhoto 27. Propeller BladeItem 43 · .PDF · 187 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.