CEN13LA212

NTSB accident investigation · Cirrus SR22T · Alexandria, MN · March 29, 2013

Accident · Minor injuriesLimited investigationFinal report
Date
March 29, 2013, 10:45 local (15:45 UTC)
Place
Alexandria, MN
Injuries
2 minor, 2 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N1967NCirrus SR22T
Defining event
Approach-VFR pattern downwind: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report December 11, 2013
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration, Cirrus Aircraft
FAA report
20130329004219A
Case key
86545

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 failure of maintenance personnel to install a safety wire during reinstallation of the right flap, which led to the separation of the right flap rod from the right flap actuation fitting during flap extension. Contributing to the accident were inadequate inspections of the right flap during subsequent annual, prebuy, and preflight inspections.

Findings · 4

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.

Flight control system: tE flap control systemAircraft › Aircraft systems · Incorrect service/maintenanceCirrus Design SR22T: 1 caseAll aircraft: 74 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelCirrus Design SR22T: 3 casesAll aircraft: 371 casesProbable cause
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelCirrus Design SR22T: 1 caseAll aircraft: 167 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotCirrus Design SR22T: 2 casesAll aircraft: 551 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

About 18 months prior to the accident flight, the airplane underwent maintenance to remove and replace both the left and right flaps. While on pattern downwind, the pilot adjusted flaps from up to half, at which time the right flap rod end separated from the right flap actuation fitting. The pilot initiated a climb and struggled to maintain roll control. He briefly adjusted flaps to the up position in an attempt to alleviate the problem, and then adjusted the flaps back to half. The pilot then adjusted the flaps from half to full and the airplane began to roll right due to flap asymmetry, eventually reaching 86 degrees of right bank. The airplane began to stall and the pilot initiated the airplane’s ballistic parachute recovery system about 509 feet above ground level. Subsequently, the airplane descended to the ground with the aid of the parachute and came to rest upright on a frozen lake. A postflight examination of the right flap rod end area revealed the mounting bolt and washer were missing and lying under the airplane. No evidence of a safety wire was present on the mounting bolt or on the right flap actuation fitting. The safety wire was most likely not installed when the right flap was reinstalled and went unnoticed for over 211 hours of operation. During this time there was a subsequent annual inspection at 114 hours prior to the accident and a pre-buy inspection at 101 hours prior to the accident.

Factual narrative

**This report was modified on 9/20/2013. Please see the public docket for this accident to view the original report.** On March 29, 2013, about 1045 central daylight time, a Cirrus SR22T airplane, N1967N, was substantially damaged after impact with terrain (frozen lake) near the Chandler Field Airport (AXN), Alexandria, Minnesota. The private pilot and one passenger sustained minor injuries, and two passengers were not injured. The airplane was registered to MWBS Holdings LLC and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 with no flight plan filed. Day visual meteorological conditions prevailed for the flight, which originated from the Marv Skie-Lincoln County Airport (Y14), Tea, South Dakota about 0904. While on pattern downwind to AXN, the pilot reported a loud noise during flap extension. The pilot initiated a climb as he struggled to maintain roll control. He attempted to reduce the airplane’s rolling tendency by adjusting flap position. As his control of the airplane worsened, the pilot pulled the ballistic recovery system handle. The parachute deployed and the airplane descended onto a frozen lake. The flight recording device was recovered from the accident airplane and forwarded to the National Transportation Safety Board’s Vehicle Recorder Laboratory for evaluation. While on pattern downwind, the recorder indicated that the flaps were adjusted from up to half and the airplane made several left bank turns, with a maximum of 30 degrees of left bank. About 18 seconds after initial flap movement, the flaps were briefly adjusted to up and returned to half. About 36 seconds after initial flap movement, the flaps were adjusted from half to full and the airplane began a right roll to a steep right bank attitude. A stall indication was recorded 38 seconds after the flaps were adjusted to full. The Cirrus Airframe Parachute System (CAPS) was deployed two seconds after the stall indication. The CAPS handle pull occurred at a pitch of 22 degrees nose down, a roll attitude of 86 degrees right bank, and an altitude of about 519 feet above ground level. The airplane was examined at the accident site by Federal Aviation Administration (FAA) inspectors and a representative of Cirrus Design Corporation. The right flap rod end was found disconnected from the right flap actuation fitting. The right flap rod end mounting bolt and washer were found lying on the snow under the airplane. No evidence of a safety wire was present on the mounting bolt or on the right flap actuation fitting. An examination of the CAPS Rear Harness assembly revealed that both reefing line cutters had fired but the rear harness remained “snubbed.” The impact scars on the snow and Ice, and the damage to the aircraft indicated that touch-down occurred while the airplane was in a 40-50 degree nose-down attitude. This nose-down attitude is consistent with a touch-down prior to “tail drop.” A review of maintenance records indicated that the rightflap was reinstalled on August 3, 2011, at a Hobbs time of 66.4. According to maintenance manual procedures, the mounting bolt and washer hardware were to be torqued to a measured 50-70 inch pounds, then safety wired to the flap actuation fitting. An annual inspection was conducted on July 10, 2012 (163.9 Hobbs), a pre-buy inspection was conducted on November 5, 2012 (177.2 Hobbs) and the accident occurred with a Hobbs time of 278.0. According to the Cirrus SR22T pilot operating handbook, the preflight checklist states to "inspect flap hinges, actuation arm, bolts, and cotter pins.....secure."

Aircraft

Registration
N1967N
Reported as
Cirrus SR22T
Category
Airplane
Serial number
0031
Airframe hours
278
Engine
Continental TSIO550, 314 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Hamid Abbasi
Registered owner
MWBS Holdings LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 15, 2012 · 114 hours before
Departed
Y14 · Marv Skie, SD
Destination
KAXN · Alexandria, MN
Airport
KAXN · Chandler Field, Alexandria

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
44
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
November 8, 2012
Seat
Left
Flight hours
138 total · 80 in this make and model · 90 as pilot in command · 70 in the last 90 days · 20 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 6 knots
Visibility
5 statute miles
Lowest ceiling
None
Temperature
34 °F, dew point 30 °F
Altimeter
30.19 inHg
Observed at
KAXN, 2 nm away

Docket · 4

The files NTSB released with the investigation on August 28, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.0 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.