CEN11LA164

NTSB accident investigation · Cirrus Design SR22 · Bennett, CO · January 30, 2011

Accident · Minor injuriesLimited investigationFinal report
Date
January 30, 2011, 05:58 local (12:58 UTC)
Place
Bennett, CO
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N787CBCirrus Design SR22
Defining event
Approach: Loss of control in flight
Weather
Visual (VMC) · Night/dark
Status
Completed · report November 17, 2011
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA FSDO, Cirrus Aircraft, Teledyne Continental Motors
FAA report
20110130001029A
Case key
78243

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

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Probable cause

The pilot's failure to maintain control of the airplane during an instrument approach due to spatial disorientation.

Findings · 3

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.

Light condition: darkEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeCirrus Design SR22: 13 casesAll aircraft: 448 cases
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedCirrus Design SR22: 35 casesAll aircraft: 3,958 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 that he was practicing night instrument approaches in visual flight rules conditions. During the accident approach, he said he was in a right turn and had turned his head to the right to look at some instrumentation. He felt the airplane accelerate and looked at his flight displays, which indicated he was in an extreme unusual attitude, possibly inverted. He attempted to recover from the unusual attitude but realized that he had severe vertigo and spatial disorientation, so he activated the airplane’s ballistic parachute recovery system. After the parachute deployed, the airplane struck terrain in a nose low attitude, sustaining substantial damage. Postaccident inspection of the airplane disclosed no preimpact mechanical problems with the airplane. Federal Aviation Administration guidance indicates, that if neither horizon nor surface references exist, the attitude of an airplane must be determined by artificial means from the flight instruments. However, during periods of low visibility and night conditions, the supporting senses sometimes conflict with what is seen; when this happens, a pilot is particularly vulnerable to disorientation.

Factual narrative

On January 30, 2011, about 0558 Mountain Standard Time, a Cirrus SR-22, N787CB, sustained substantial damage after impacting terrain near Bennett, Colorado, following the activation of the Cirrus Airframe Parachute System (CAPS). The airplane was registered to Fitch Bergner Aviation LLC, and operated by the pilot. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91, without a flight plan. Dark night, visual meteorological conditions prevailed at the time of the accident. The solo private pilot reported minor injuries. The local flight originated from the Centennial Airport (APA), Denver, Colorado. According to the pilot, he was practicing night instrument approaches at Front Range Airport (FTG). He received air traffic control clearance to fly a practice GPS 35 approach at FTG under his own navigation from the “AVNEW” intersection, which is the initial approach fix. Upon reaching AVNEW, he initiated a right turn toward the next approach fix (HRMER intersection). During the right turn, the pilot stated that he looked to his right to cross check the GPS and set up the autopilot for a coupled approach. He felt the airplane start to accelerate rapidly, and he looked back to the Primary Flight Display (PFD) which was “showing all brown with no sky and 6-7 chevrons, indicating a severe unusual attitude.” He tried to correct the unusual attitude, but said that he had severe vertigo, and was unable to regain control of the airplane. He elected to deploy the ballistic recovery parachute, and the aircraft impacted terrain in a nose low attitude in a creek bed. The nearest weather reporting facility to the accident site is FTG. The 0555 surface observation at FTG recorded: wind 220 degrees at 3 knots; 10 statute miles visibility; sky condition clear; temperature zero degrees Celsius (C); dew point minus four degrees C; altimeter 29.92 inches of mercury. Sunrise was at 0708 MST. Examination of the airplane at the accident site by the NTSB investigator-in-charge (IIC) revealed that the front cowling was crushed aft and the engine firewall had impact damage and buckling. A postaccident examination of the airplane was done by representatives of the airplane manufacturer and the engine manufacturer, under the direction of the NTSB. No anomalies consistent with a preimpact failure or malfunction associated with the airframe or engine were observed. The airplane was equipped with Avidyne Entegra Primary Flight Display (PFD) and Multi-Function Displays (MFD). This equipment displays flight and navigational data to the pilot, and also records data regarding airplane pitch, roll, airspeed, altitude, heading, acceleration forces, GPS position, and engine data. The PFD and MFD were removed from the airplane, and sent to the NTSB’s Vehicle Recorder Division for download. The downloaded data showed that, just prior to the accident, the airplane went through a series pitch and roll oscillations, with maximum pitch values ofapproximately 26 degrees nose up, and 75 degrees nose down. The airplane reached maximum roll values of approximately 83 degrees right wing down, and 120 degrees left wing down. The maximum indicated airspeed, which occurred just prior to the parachute deployment, was 190 knots. This data corroborates the pilot’s description of events.

Aircraft

Registration
N787CB
Reported as
Cirrus Design SR22
Category
Airplane
Serial number
0787
Airframe hours
1,754
Engine
Cont Motor IO-550 SERIES, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
October 12, 2010
Departed
APA · Englewood, CO
Destination
FTG · Watkins, CO
Airport
FTG · Front Range Airport

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
Minor
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
December 22, 2010
Seat
Left
Flight hours
1,740 total · 1,042 in this make and model · 1,715 as pilot in command · 18 in the last 90 days · 2 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
220° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
32 °F, dew point 25 °F
Altimeter
29.90 inHg
Observed at
KFTG, 1,526 nm away

Docket · 5

The files NTSB released with the investigation on October 3, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.5 MB in all.

FAA reports on this event · 1

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