# NTSB CEN21FA277: Cirrus Design SR20, N62WR, Conway, AR, June 18, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: June 18, 2021, 13:57 local (18:57 UTC) - Place: Conway, AR - Coordinates: 35.025973, -92.547776 - Nearby events: https://openairdocs.org/map.md?lat=35.0260&lon=-92.5478&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA, Cirrus Aircraft - NTSB case key (mKey): 103289 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21FA277 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103289/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103289 - Page: https://openairdocs.org/ntsb/CEN21FA277 ## Probable cause The pilot’s failure to maintain adequate airspeed, which resulted in an aerodynamic stall and spin. Contributing to the accident was the failure of the pilot to perform an adequate preflight inspection, to include removal of the pitot tube cover. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cirrus Design SR20, 13 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=2130000), [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); cases with it: [Cirrus Design SR20, 47 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2130000), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cirrus Design SR20, 8 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=2130000), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cirrus Design SR20, 3 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=2130000), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern final: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); 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 A witness reported that he heard the accident pilot report an emergency landing on runway 2, which was not a runway at the accident airport. Shortly thereafter, he observed the airplane make a left turn and it overflew the runway. He stated that the airplane appeared “crazy fast.” The airplane then entered a steep left bank and spun 1 ½ rotations before impacting the ground. During the impact sequence, the airframe parachute deployed, and the canopy was found still bundled in a straight line away from the wreckage. A postaccident examination revealed the pitot tube cover remained secured on the pitot tube with a “REMOVE BEFORE FLIGHT” banner attached. Toxicology testing detected an antidepressant and a mood stabilizing medication in the pilot’s blood and urine. These medications and the associated medical conditions for which they are prescribed can negatively impact judgment and psychomotor performance. However, the investigation was unable to obtain psychiatric records to determine the severity of the conditions for which the pilot was being treated. Also, given the pilot’s skill and experience in this model airplane, the investigation was unable to distinguish between deficits in his capabilities and signs of his psychiatric illness. Thus, this investigation was unable to determine whether the effects from the pilot’s use of the medications or his psychiatric condition were factors in the accident. ## Factual narrative The Cirrus Design SR20 Pilot’s Operating Handbook contained a description for the conduct of a preflight inspection under the normal procedures section. That procedure contained the following: 12. Left Wing Tip b. Pitot Mast (underside) ................. Cover Removed, Tube Clear On June 18, 2021, about 1357 central daylight time, a Cirrus SR20 airplane, N62WR, was destroyed when it was involved in an accident at Conway Regional Airport (CXW), Conway, Arkansas. The pilot, who was the sole occupant, sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A witness reported that after the airplane departed runway 22 at CXW, he heard a transmission over the Universal Integrated Communications (UNICOM) frequency that stated, “six-two whiskey romeo emergency landing runway 2.” There is no runway 2 at CXW. Shortly thereafter, he observed the accident airplane make a left turn and overfly runway 4 and stated that the airplane appeared “crazy fast.” After the airplane overflew runway 4, it entered a steep left bank, made 1 1/2 rotations and then impacted the ground. Recovered GPS data from the airplane revealed that the highest altitude achieved on the flight was 593 ft above ground level (agl) when the airplane was on a crosswind leg in the traffic pattern. The airplane then began a continuous descent until impact. The downwind leg was flown about 0.1 nautical mile south of the runway (see figure 1). Figure 1: Pictorial view of flight path Federal Aviation Administration (FAA) Forensic Sciences Laboratory toxicology testing detected the antidepressant bupropion at 6,618 nanograms per milliliter (ng/mL) and its metabolite hydroxybupropion at 444 ng/mL in the pilot’s cavity blood. The mood stabilizing medication lamotrigine was detected in his cavity blood at 2,134 ng/mL. All three compounds were also detected in his urine. Bupropion is a medication prescribed as an antidepressant (commonly marketed as Wellbutrin) or for smoking cessation (commonly marketed as Zyban). Hydroxybupropion is the major active metabolite of bupropion. The treatment of depression would require FAA review before flying, and bupropion is not one of the drugs that FAA will permit use for depression. According to the FAA, bupropion carries the warning that the medication may impair mental or physical ability required to perform hazardous tasks. Lamotrigine is a prescription medication indicated for treatment of bipolar disorder and adjunctive treatment of epilepsy. It is commonly marketed as Lamictal. Lamotrigine can have impairing performance effects including dizziness and drowsiness, and patients should be warned not to operate complex machinery while on the medication. One record was obtained from the healthcare provider who completed the pilot’s BasicMed form on January 16, 2021. The pilot reported no medical conditions and the use of no medications. The airplane impacted the ground in a nose-low, invertedattitude. The right wing was fractured, and pieces of the wing were located in the initial ground scar. Propeller slash marks were found in the ground near the initial impact point and contained white paint transfer signatures (see figure 2). The propeller blades were found fractured and separated from the crankshaft flange. Figure 2: Propeller slash mark with white paint transfer Fragments of windscreen were found in the vicinity of the propeller. During the impact sequence, the Cirrus Airframe Parachute System (CAPS) deployed, and the canopy was found still bundled in a straight line away from the wreckage. The total debris field from the CAPS rocket to the main wreckage was about 110 ft. A postaccident examination revealed the pitot tube cover remained secured on the pitot tube with a “REMOVE BEFORE FLIGHT” banner attached (see figure 3). Figure 3: Airplane as it came to rest with pitot tube cover secured in place ## Aircraft - Registration: [N62WR](https://openairdocs.org/aircraft/N62WR), registered now, S/N 1606, built 2006 (OpenAirDocs) - Reported make and model: CIRRUS DESIGN CORP SR20 - Registry model: [Cirrus Design SR20](https://openairdocs.org/model/cirrus-design-sr20) (registry code 2130000) (OpenAirDocs) - Registry engine: [Continental IO-360-ES](https://openairdocs.org/engine/continental-io-360-es) (registry code 17160, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1606 - Year built: 2006 - Engines: Continental IO360 reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Lamay-O Inc - Airworthiness certificate: Standard, Normal - Airport: CXW, Conway Rgnl, runway 04/22, 5,500 × 100 ft, concrete - Equipment: Electronic primary flight display, Onboard weather, Stall warning system, ADS-B, Airframe parachute, Auto-pilot, Electronic multifunction display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 38; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: basicmed; last flight review March 6, 2021; seat: left; restraint: 4-point; toxicology performed; flight hours: 210.9 total ## Weather - Conditions: Visual (VMC), Day - Wind: 120° at 5 knots, gusting 12 - Visibility: 6 statute miles - Temperature: 90 °F, dew point 68 °F - Altimeter: 29.95 inHg - Observed at: KCXW, 1 nm away - METAR: KCXW 181850Z AUTO 12005G12KT 6SM HZ CLR 32/20 2995 RMK A01 ## 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 20210618014119A](https://openairdocs.org/incident/20210618014119A), Jun 18, 2021: Cirrus Design Corp SR20, Conway, AR, Substantial damage, 1 fatal. On June 18, 2021 on or about 1353 CST, a Cirrus SR22, N62WR, [privacy data omitted], departed runway 22 at the Conway municipal airport (kcxw). After… ## Docket (8 files) The files NTSB released with the investigation on May 10, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103289. 5.3 MB in all. - Witness statements (item 1, PDF, 2 pages, 418 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12401183&FileExtension=pdf&FileName=Witness%20Interviews-Rel.pdf - Examination summary (item 2, PDF, 3 pages, 205 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13087209&FileExtension=pdf&FileName=Examination%20Summary-Rel.pdf - Photos (item 3, PDF, 2 pages, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12400911&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Medical factual (item 4, PDF, 3 pages, 230 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12850269&FileExtension=pdf&FileName=CEN21FA277_Conway_AR_Medical_Factual_FINAL_102521-Rel.pdf - Toxicological report (item 5, PDF, 1 page, 179 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13659674&FileExtension=pdf&FileName=Toxicology_Redacted-Rel.pdf - Cockpit displays - specialist's factual report (item 6, PDF, 12 pages, 8 photos, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13625693&FileExtension=pdf&FileName=CEN21FA277_Displays-Rel.pdf - Cockpit displays - attachment 1 (PFD tabular data) (item 7, CSV, 242 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13627941&FileExtension=csv&FileName=Attachment1-Rel.csv - Cockpit displays - attachment 2 (MFD tabular data) (item 8, CSV, 18 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13627951&FileExtension=csv&FileName=Attachment2-Rel.csv 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.