# NTSB CEN21FA215: Swearingen SA226TC, N280KL, Englewood, CO, May 12, 2021 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Field · Final report - Date: May 12, 2021, 10:23 local (16:23 UTC) - Place: Englewood, CO - Coordinates: 39.585036, -104.85469 - Nearby events: https://openairdocs.org/map.md?lat=39.5850&lon=-104.8547&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining events: [Approach-IFR final approach: Midair collision](https://openairdocs.org/ntsb-events/250); [Approach-VFR pattern base: Midair collision](https://openairdocs.org/ntsb-events/250) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA, Key Lime Air - NTSB case key (mKey): 103073 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21FA215 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103073/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103073 - Page: https://openairdocs.org/ntsb/CEN21FA215 ## Probable cause (aircraft 1) The Cirrus pilot’s failure to maintain the final approach course for the assigned runway, which resulted in a collision with the Swearingen which was on final approach to the parallel runway. Contributing to the accident was the failure of the controller to issue a traffic advisory to the Swearingen pilot regarding the location of Cirrus, and the Cirrus pilot’s decision to fly higher than recommended approach speed which resulted in a larger turn radius and contributed to his overshoot of the final approach course. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · ATC personnel, aircraft 1; cases with it: [Swearingen SA226TC, 1 case](https://openairdocs.org/ntsb-findings/02041035/cases.md?model=8780404), [All aircraft, 440 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained, aircraft 2; cases with it: [Cirrus Design SR22, 24 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=2130001), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause), aircraft 2; cases with it: [Cirrus Design SR22, 94 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2130001), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-IFR final approach: Midair collision](https://openairdocs.org/ntsb-events/250) (defining event), aircraft 1; cases with it: [Swearingen SA226TC, 1 case](https://openairdocs.org/ntsb-events/250/sequence.md?model=8780404), [All aircraft, 196 cases](https://openairdocs.org/ntsb-events/250/sequence.md) - [Approach-VFR pattern base: Midair collision](https://openairdocs.org/ntsb-events/250) (defining event), aircraft 2; cases with it: [Cirrus Design SR22, 5 cases](https://openairdocs.org/ntsb-events/250/sequence.md?model=2130001), [All aircraft, 196 cases](https://openairdocs.org/ntsb-events/250/sequence.md) ## Analysis (aircraft 1) A Cirrus SR22 and a Swearingen AS226TC were approaching to land on parallel runways and being controlled by different controllers on different control tower frequencies. The pilot of the Swearingen was established on an extended final approach for the left runway, while the pilot of the Cirrus was flying a right traffic pattern for the right runway. Data from an on-board recording device showed that the Cirrus’ airspeed on the base leg of the approach was more than 50 kts above the manufacturer’s recommended speed of 90 to 95 kts. As the Cirrus made the right turn from the base leg to the final approach, its flight path carried it through the extended centerline for the assigned runway (right), and into the extended centerline for the left runway where the collision occurred. At the time of the collision, the Cirrus had completed about ½ of the 90° turn from base to final and its trajectory would have taken it even further left of the final approach course for the left runway. The pilot of the Swearingen landed uneventfully; the pilot of the Cirrus deployed the airframe parachute system, and the airplane came to rest upright about 3 nautical miles from the airport. Both airplanes sustained substantial damage to their fuselage. During the approach sequence the controller working the Swearingen did not issue a traffic advisory to the pilot regarding the location of the Cirrus and the potential conflict. The issuance of traffic information during simultaneous parallel runway operations was required by Federal Aviation Administration Order JO 7110.65Y, which details air traffic control procedures and phraseology for use by persons providing air traffic control services. The controller working the Cirrus did issue a traffic advisory to the Cirrus pilot regarding the Swearingen on the parallel approach. Based on the available information, the pilot of the Cirrus utilized a much higher than recommended approach speed which increased the airplane’s radius of turn. The pilot then misjudged the airplane’s flight path, which resulted in the airplane flying through the assigned final approach course and into the path of the parallel runway. The controller did not issue a traffic advisory to the pilot of Swearingen regarding the location of the Cirrus. The two airplanes were on different tower frequencies and had the controller issued an advisory, the pilot of the Swearingen may have been able to identify the conflict and maneuver his airplane to avoid the collision. ## Factual narrative (aircraft 1) On May 12, 2021, at 1023 mountain daylight time, a Cirrus SR22 airplane, N416DJ, and a Swearingen SA226TC airplane, N280KL, were substantially damaged when they collided in flight while approaching to land at Centennial Airport (APA), Englewood, Colorado. The pilot and passenger onboard the Cirrus were not injured, and the pilot onboard the Swearingen was not injured. The Cirrus was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight, and the Swearingen was operated as a Title 14 CFR Part 91 positioning flight. At the time of the accident, parallel runways 17R and 17L were being utilized for simultaneous operations at APA. Automatic Dependent Surveillance-Broadcast (ADS-B) data was provided by the Federal Aviation Administration (FAA), and data from the on-board Remote Data Module (RDM) was downloaded from the Cirrus. The data showed that the Cirrus departed APA for a local flight about 0921, and the Swearingen departed the Salida Airport (ANK), Salida, Colorado, about 0956. About 1022:43, the Swearingen was about 5.5 nm from APA and had completed a right turn to align with the final approach course to runway 17L. At this same time, the Cirrus was on the downwind leg of the right-hand traffic pattern for runway 17R just before commencing a right turn to the base leg of the traffic pattern. The Swearingen continued its approach and remained aligned with runway 17L. The Cirrus continued the right-hand traffic pattern through the base leg, and then began to turn toward the final approach course for the runway. The Cirrus continued through the extended centerline for runway 17R, and then continued to the extended centerline for runway 17L where it collided with the Swearingen. The airplanes collided at 1023:52 when they were about 3.2 nm from APA. The Swearingen was aligned with runway 17L while the Cirrus had not completed the turn from base to final and was heading about 146° when the collision occurred. Figure 1 – Plot of ADS-B and RDM flight path information After the impact, the pilot of the Swearingen declared an emergency, continued to APA, and landed successfully on runway 17L. The pilot of the Cirrus reported that the airplane was not controllable after the impact, and he deployed the Cirrus Airframe Parachute System (CAPS). The Cirrus came to rest about 3 nm north of APA. Both airplanes sustained substantial damage (see figures 2 & 3) Figure 2 – Photograph of the Swearingen after the accident. Figure 3 – Photograph of the Cirrus at the accident scene. Review of the data retrieved from the RDM from the Cirrus revealed that the airplane’s autopilot was disengaged at 1018:50 and stayed off for the remainder of the flight, indicating that the pilot was manually flying the airplane during the landing approach. At 1023:16, the avionics system issued a traffic alert which remained on until the collision. RDM data further indicated that that during the downwind portion of the airplane’s approach, the airspeed was about125 kts and the flaps were up. Once the airplane was established on the base leg of the traffic pattern the recorded airspeed was about 148 kts and the flaps were still up. As the airplane maneuvered from the base leg to final approach, the airspeed was about 140 kts and the flaps were lowered to 50% about 4 seconds before impact. When the collision occurred, the airplane was about halfway through its turn from base to final at an airspeed of 140 kts, and an altitude of 6,619 ft msl. At 1023:54, the CAPS handle was pulled. According to the Cirrus “Pilot’s Operating Handbook and FAA Approved Airplane Flight Manual” (POH/AFM), the recommended approach speed for the airplane was 90-95 knots indicated airspeed (KIAS) with flaps up, 85-90 KIAS with 50% flaps, and 80-85 KIAS with 100% flaps. Review of communications between both airplanes and the APA Airport Traffic Control Tower (ATCT) revealed that the local control 1 (LC1) controller had cleared the Swearingen for a straight in landing to runway 17L and the local control 2 (LC2) controller had cleared the Cirrus to land on runway 17R. The two controllers communicated with the respective airplanes on different ATCT frequencies. FAA Order JO 7110.65Y detailed air traffic control procedures and phraseology for use by personnel providing air traffic control services. Included in the order were instructions for prioritizing the issuance of traffic alerts when potential conflicts with other aircraft exist. The order also specified conditions in which parallel runway operations could be authorized, including visual flight rules meteorological conditions, and that two-way radio communication be maintained with the aircraft involved and that pertinent traffic information be issued. Further review of the communications at APA revealed that although the LC2 controller had issued pertinent traffic advisories to the pilot of the Cirrus, the LC1 controller did not issue a traffic advisory to the pilot of the Swearingen regarding the location of the Cirrus. ## Aircraft 1 - Registration: [N280KL](https://openairdocs.org/aircraft/N280KL), registered now, S/N TC-280, built 1978 (OpenAirDocs) - Reported make and model: SWEARINGEN SA226TC - Registry model: [Swearingen SA226TC](https://openairdocs.org/model/swearingen-sa226tc) (registry code 8780404) (OpenAirDocs) - Registry engine: [AiResearch TPE331 series](https://openairdocs.org/engine/airesearch-tpe331-series) (registry code 01514, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: TC-280 - Year built: 1978 - Airframe hours: 29525 - Engines: Honeywell TPE331-10UA-511G 840 horsepower turbo prop; Honeywell TPE331-10UA-511G 840 horsepower turbo prop - Damage: Substantial damage - Flight: Positioning, Part 91 - Operator: Key Lime Air - Registered owner: Cbg LLC - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, March 9, 2021 - Departed: ANK, Salida, CO - Destination: Same as departure - Flight plan: IFR - Airport: APA, Centennial, runway 17L, 10,000 × 100 ft, concrete - Equipment: ADS-B, Angle of attack indicator, Electronic flight bag or handheld device, Stall warning system ## Aircraft 2 - Registration: [N416DJ](https://openairdocs.org/deregistered/N416DJ-2023-02-04), registration cancelled 2023-02-04, S/N 4394, built 2016 (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-N](https://openairdocs.org/engine/continental-io-550-n) (registry code 17215, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 4394 - Year built: 2016 - Engines: CONT MOTOR IO-550-N 310 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Independence Aviation - Registered owner: Bb Co LLC - Airworthiness certificate: Standard, Normal - Equipment: Electronic primary flight display, Stall warning system, ADS-B, Auto-pilot, Data recorder, Electronic multifunction display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N280KL; age 50; injuries: none; airline transport; airplane ratings: single-engine sea, single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review April 1, 2021; seat: left; restraint: 3-point; flight hours: 11,184 total, 2,656 in this make and model, 10,373 as pilot in command, 112 in the last 90 days, 75 in the last 30 days, 2 in the last 24 hours - Pilot, aircraft N416DJ; age 59; injuries: none; private; airplane ratings: single-engine land; medical: class 3, unknown; seat: left ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 50 °F, dew point 30 °F - Altimeter: 30.27 inHg - Observed at: APA, 3 nm away - METAR: KAPA 121653Z 00000KT 10SM FEW080 FEW140 10/M01 A3027 RMK AO2 SLP249 T01001006 ## FAA reports on this event (2) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20210512002812A](https://openairdocs.org/incident/20210512002812A), May 12, 2021: Swearingen SA226TC, Englewood, CO, Substantial damage. On 5/12/2021 at approximately 1024MDT, a 2016 Cirrus SR22, registration number N416DJ, serial number 4394 and a 1978 Swearingen SA2267TC, registration number… - [Accident 20210512008362A](https://openairdocs.org/incident/20210512008362A), May 12, 2021: Cirrus Design Corp SR22, Englewood, CO, Substantial damage. On 5/12/2021 at approximately 1024MDT, a 2016 Cirrus SR22, registration number N416DJ, serial number 4394 and a 1978 swearingen SA2267TC, registration number… ## Docket (13 files) The files NTSB released with the investigation on March 29, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103073. 29.8 MB in all. - Structures group chairman's factual report (item 1, PDF, 6 pages, 5 photos, 877 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12348803&FileExtension=pdf&FileName=CEN21FA215%20Structures%20Factual-Rel.pdf - Air traffic control group chair's factual report (item 2, PDF, 13 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14686784&FileExtension=pdf&FileName=CEN21FA215%20ATC%20Group%20Chair%27s%20Factual%20Report-Rel.pdf - Air traffic control factual report attachment 1 (item 3, PDF, 27 pages, 168 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14687503&FileExtension=pdf&FileName=CEN21FA215%20ATC%20Group%20Chair%27s%20Factual%20Report%20Attachment%201%20Interview%20Summaries-Rel.pdf - Recoverable data module specialist factual repot (item 4, PDF, 12 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14936095&FileExtension=pdf&FileName=RDM%20factual-Rel.pdf - Recoverable data module specialist's factual report - attachment 1 - tabular data (item 5, CSV, 155 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14937202&FileExtension=csv&FileName=data%20for%20dms-Rel.csv - ADS-B data for N280KL (item 6, CSV, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14949111&FileExtension=csv&FileName=LYM970%20-%2020210512_A2CEE7_453989333_ADSB-Rel.csv - ADS-B data for N416DJ (item 7, CSV, 13.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14949647&FileExtension=csv&FileName=N419DJ%20-%2020210512_A4EABE_453985615_ADSB-Rel.csv - Weather metars (item 8, PDF, 1 page, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14949726&FileExtension=pdf&FileName=METARS-Rel.pdf - Excerpt from afm/poh for N416DJ (item 9, PDF, 1 page, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14949038&FileExtension=pdf&FileName=poh%20excerpt-Rel.pdf - N280KL - pilot/operator aircraft accident report, NTSB form 6120.1 (item 10, PDF, 9 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14949319&FileExtension=pdf&FileName=280KL%20NTSB%20830%20Report%20ORGINAL_Redacted-Rel.pdf - N416DJ pilot statement (item 11, PDF, 1 page, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14949240&FileExtension=pdf&FileName=N416DJ%20Pilot%20statement_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 12, PDF, 8 pages, 6.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14949056&FileExtension=pdf&FileName=Party%20Forms_Redacted-Rel.pdf - N280KL wreckage release (item 13, PDF, 1 page, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14949349&FileExtension=pdf&FileName=N280KL%20Wreckage%20release%20copy_Redacted-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.