# NTSB CEN18LA195: Cirrus Design SR20, N67Y, Katy, TX, May 27, 2018 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: May 27, 2018, 17:15 local (22:15 UTC) - Place: Katy, TX - Coordinates: 29.780841, -95.950424 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.7808&lon=-95.9504&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA FSDO, Cirrus Aircraft - NTSB case key (mKey): 97333 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN18LA195 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/97333/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=97333 - Page: https://openairdocs.org/ntsb/CEN18LA195 ## Probable cause The loss of airplane control on takeoff due to the absence of the attachment bolt for the left aileron actuation arm. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Flight control system: aileron control system](https://openairdocs.org/ntsb-findings/01022710): Aircraft › Aircraft systems · Not installed/available (probable cause); cases with it: [Cirrus Design SR20, 2 cases](https://openairdocs.org/ntsb-findings/01022710/cases.md?model=2130000), [All aircraft, 45 cases](https://openairdocs.org/ntsb-findings/01022710/cases.md) - [Misc hardware: fasteners](https://openairdocs.org/ntsb-findings/01071430): Aircraft › Fluids/misc hardware · Not installed/available (probable cause); cases with it: [Cirrus Design SR20, 1 case](https://openairdocs.org/ntsb-findings/01071430/cases.md?model=2130000), [All aircraft, 58 cases](https://openairdocs.org/ntsb-findings/01071430/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) (defining event); cases with it: [Cirrus Design SR20, 2 cases](https://openairdocs.org/ntsb-events/333/sequence.md?model=2130000), [All aircraft, 410 cases](https://openairdocs.org/ntsb-events/333/sequence.md) - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Cirrus Design SR20, 36 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2130000), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis The pilot reported that immediately after takeoff, the airplane began to roll to the left. He attempted to counteract the roll with right aileron input but could not control the rolling motion; the airplane continued to roll to the left. The pilot continued to use right aileron and trim, lowered the nose, and executed a forced landing in a field adjacent to the departure airport. Examination of the wreckage showed that the left aileron actuation arm and attachment bolt were missing; there was no associated impact damage. Impact marks were present on the inboard hinge consistent with the aileron striking it. No distress or markings were found in the hole for the attachment bolt. The bolt or remnants of safety wire were not found. The pilot reported that he had flown the airplane the day before the accident and noted no problems with the flight controls. The most recent annual inspection and maintenance documents did not show any work performed on the ailerons. It could not be determined when the bolt came loose from the attachment. The absence of the bolt would severely affect aileron flight control as reported by the pilot, allowing the aileron to rotate freely around the hinge point with no connection to the flight controls. After the accident, the Federal Aviation Administration issued an aviation maintenance alert advising owners and operators of SR20 and SR22 airplanes to visually inspect the bolt for the aileron actuation arm for the presence of a safety wire. ## Factual narrative On May 27, 2018, about 1715 central daylight time, a Cirrus SR20 airplane, N67Y, was substantially damaged when it was involved in an accident near Katy, Texas. The pilot sustained minor injuries. The airplane was being operated as a Title 14 Federal Code of Regulations Part 91 personal flight. The pilot was departing Houston Executive Airport (TME), Houston, Texas. He reported that he performed a preflight inspection and an engine run-up; completed a before takeoff checklist, which included a check of the flight controls; and taxied to runway 18 for departure. After receiving takeoff clearance, the pilot applied power and accelerated down the runway. He stated that during the takeoff roll, he had no difficulty maintaining directional control using the rudder; however, at rotation, the airplane began a slight left rolling motion. The pilot stated that he applied right aileron but could not control the rolling motion; the airplane continued rolling to the left. He informed the tower that he had a problem and prepared for a forced landing. He continued to use right aileron and trim, lowered the nose, and landed in a field adjacent to TME. The pilot reported that he had flown the airplane the day before and noted no problems with the flight controls. Postaccident examination revealed that the left side of the wing was separated at the wing root and at the inboard end of the aileron. The left wingtip exhibited impact damage, and parts of it were identified at the initial point of impact. The left aileron exhibited impact damage and remained attached to the wing at both hinge points with hardware and safeties present. The left aileron actuation arm and attachment bolt were missing; there was no associated impact damage. Impact marks were present on the inboard hinge consistent with the aileron striking it. No distress or markings were found in the hole for the attachment bolt. The bolt or remnants of safety wire were not found. See Figures 1, 2 and 3. Figure 1. Missing left aileron attachment bolt. Figure 2. Schematic of aileron attachment hardware. Item 4 denotes missing bolt. Documentation from the airplane’s most recent annual inspection on May 11, 2018, did not show any work performed on the aileron control system. Review of historical maintenance documents did not reveal any recent maintenance performed on the aileron system. The Federal Aviation Administration Safety Team posted a notice on March 19, 2019, titled “Aviation Maintenance Alert for Cirrus SR20 and SR22 Aircraft,” advising owners and operators to visually inspect the bolt for the aileron actuation arm for the presence of a safety wire. The notice stated, in part, the following: As the bolt is readily visible during a walk around inspection, we recommend that all owners and operators visually verify the presence of the required safety wire before further flight. If safety wire is not present, have a qualified maintenance provider correct the situation before further flight. Inaddition, Cirrus aircraft will be updating their recommended pilot preflight walk around to better define the examination of the Aileron area and the maintenance manuals to emphasize the requirement of proper safety wiring of associated hardware. We recommended that all operators adopt the new manual practices and revisions. Figure 3. Exemplar properly installed bolt and safety wire. ## Aircraft - Registration: [N67Y](https://openairdocs.org/deregistered/N67Y-2019-11-04), registration cancelled 2019-11-04, S/N 1286, built 2003 (OpenAirDocs) - Reported make and model: CIRRUS DESIGN CORP SR20 (NO SERIES) - Registry model: [Cirrus Design SR20](https://openairdocs.org/model/cirrus-design-sr20) (registry code 2130000) (OpenAirDocs) - Registry engine: [Continental IO-360 series](https://openairdocs.org/engine/continental-io-360-series) (registry code 17025, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1286 - Year built: 2003 - Airframe hours: 992.3 - Engines: CONT MOTOR IO-360 SER 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 11, 2018 - Departed: TME, Katy, TX - Destination: TKJ, McKinney, TX - Flight plan: IFR - Airport: TME, Houston Executive Airport, runway 18, 6,610 × 100 ft, asphalt - Equipment: Stall warning system, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: minor; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review April 24, 2018; seat: left; restraint: 4-point; flight hours: 4,673 total, 13 in this make and model, 123 in the last 90 days, 39.9 in the last 30 days, 1.7 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 93 °F, dew point 73 °F - Altimeter: 29.78 inHg - Observed at: TME ## 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 20180527006079A](https://openairdocs.org/incident/20180527006079A), May 27, 2018: Cirrus Design Corp SR20, Brookshire, TX, Destroyed. The aircraft was attempting to depart on runway 18. The pilot stated shortly after takeoff, the aircraft began to roll left. He attempted to correct the roll… ## Docket (6 files) The files NTSB released with the investigation on March 31, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=97333. 12.6 MB in all. - NTSB form 6120 pilot operator report CEN18LA195 (item 1, PDF, 9 pages, 4.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12020515&FileExtension=pdf&FileName=NTSB%20Form%206120%20Pilot%20Operator%20Report%20CEN18LA195_Redacted-Rel.pdf - Pilot statement CEN18LA195 (item 2, PDF, 2 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12020723&FileExtension=pdf&FileName=Pilot%20Statement%20CEN18LA195_Redacted-Rel.pdf - Annual inspection documents CEN18LA195 (item 3, PDF, 2 pages, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12021246&FileExtension=pdf&FileName=Annual%20Inspection%20Documents%20CEN18LA195_Redacted-Rel.pdf - Factual information schematics and photos CEN18LA195 (item 4, PDF, 9 pages, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12021352&FileExtension=pdf&FileName=Factual%20Information%20Schematics%20and%20Photos%20CEN18LA195-Rel.pdf - Schematic of aileron attachment components CEN18LA195 (item 5, PDF, 1 page, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12021256&FileExtension=pdf&FileName=Schematic%20of%20Aileron%20Attachment%20Components%20CEN18LA195-Rel.pdf - FAA aviation maintenance alert Cirrus SR20 and 22 aircraft CEN18LA195 (item 6, PDF, 2 pages, 206 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12021189&FileExtension=pdf&FileName=FAA%20Aviation%20Maintenance%20Alert%20Cirrus%20SR20%20and%2022%20Aircraft%20CEN18LA195-Rel.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.