# NTSB CEN11LA164: Cirrus Design SR22, N787CB, Bennett, CO, January 30, 2011

- Type: NTSB accident investigation
- Classification: Accident · Minor injuries · Limited investigation · Final report
- Date: January 30, 2011, 05:58 local (12:58 UTC)
- Place: Bennett, CO
- Coordinates: 39.543609, -104.431663
- Nearby events: https://openairdocs.org/map.md?lat=39.5436&lon=-104.4317&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Defining event: [Approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240)
- Highest injury: Minor injuries
- Injuries: 1 minor
- Status: Completed, report November 17, 2011
- Report: Approved by Office Director
- NTSB office: Central Region
- Parties: FAA FSDO, Cirrus Aircraft, Teledyne Continental Motors
- NTSB case key (mKey): 78243
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN11LA164
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/78243/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=78243
- Page: https://openairdocs.org/ntsb/CEN11LA164

## Probable cause

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

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cirrus Design SR22, 17 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=2130001), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md)
- [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Contributed to outcome; cases with it: [Cirrus Design SR22, 13 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=2130001), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md)
- [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cirrus Design SR22, 35 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=2130001), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cirrus Design SR22, 74 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2130001), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cirrus Design SR22, 113 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2130001), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## 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](https://openairdocs.org/aircraft/N787CB), registered now, S/N 0787, built 2003 (OpenAirDocs)
- Reported make and model: CIRRUS DESIGN CORP SR22
- Registry model: [Cirrus Design SR22](https://openairdocs.org/model/cirrus-design-sr22) (registry code 2130001) (OpenAirDocs)
- Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 0787
- Airframe hours: 1754
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 60; injuries: minor; 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

## 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 20110130001029A](https://openairdocs.org/incident/20110130001029A), Jan 30, 2011: Cirrus Desi SR22, Bennett, CO, Substantial damage. While practicing instrument approaches at front range airport (ftg) during night flying conditions, pilot became spatially disoriented and lost control of…

## Docket (5 files)

The files NTSB released with the investigation on October 3, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=78243. 3.5 MB in all.

- Cockpit Display(s) - Recorded Flight Data - Specialist's Factual Report (item 1, .PDF, 10 photos, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40353742&FileExtension=.PDF&FileName=Cockpit%20Display(s)%20-%20Recorded%20Flight%20Data%20-%20Specialist%27s%20Factual%20Report-Master.PDF
- Cockpit Display(s) - Recorded Flight Data - Attachment 1 Tabular Data - (CSV Format) (item 2, .CSV, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40353743&FileExtension=.csv&FileName=Cockpit%20Display(s)%20-%20Recorded%20Flight%20Data%20-%20Attachment%201%20Tabular%20Data%20-%20(CSV%20Format)-Master.csv
- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 3, .PDF, 567 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40354862&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Statement of Party Representatives to NTSB Investigation (item 4, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40354864&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF
- Retention / Release of Wreckage Form (item 5, .PDF, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40354865&FileExtension=.PDF&FileName=Retention%20%2F%20Release%20of%20Wreckage%20Form-Redacted.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.

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