# NTSB CEN21FA299: Cirrus Design SR22, N123RE, Lamoni, IA, July 1, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: July 1, 2021, 07:55 local (12:55 UTC) - Place: Lamoni, IA · Bean field west of airport - Coordinates: 40.630195, -93.902882 - Nearby events: https://openairdocs.org/map.md?lat=40.6302&lon=-93.9029&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR go-around: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Flight Standards District Office, Cirrus Aircraft - NTSB case key (mKey): 103396 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21FA299 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103396/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103396 - Page: https://openairdocs.org/ntsb/CEN21FA299 ## Probable cause The pilot did not maintain aircraft control during an attempted go-around after a bounced landing, which resulted in impact with terrain and a postimpact fire. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); 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) - [Performance/control parameters: lateral/bank control](https://openairdocs.org/ntsb-findings/01062023): Aircraft › Aircraft oper/perf/capability · Not attained/maintained; cases with it: [Cirrus Design SR22, 5 cases](https://openairdocs.org/ntsb-findings/01062023/cases.md?model=2130001), [All aircraft, 390 cases](https://openairdocs.org/ntsb-findings/01062023/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR go-around: 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) - [Approach-VFR go-around: 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 flew a visual approach to the airport, where several witnesses observed the airplane bounce on the runway then heard an increase in engine power, consistent with the pilot’s attempt to initiate a go-around. The airplane banked left, with the left-wing tip striking the ground. It then cartwheeled and impacted the ground to the left of the runway. A postimpact fire ensued, and the pilot and passenger were not able to egress the airplane. Postaccident examinations of the airplane revealed no evidence of preimpact mechanical malfunctions or failures that would preclude normal operation. The airplane’s flaps were found in the retracted position. The airplane’s acute left bank during the attempted go-around was consistent with the pilot’s insufficient right rudder control to counter the airplane’s left-turning tendency associated with the increased engine power. ## Factual narrative According to the FAA Pilot’s Handbook of Aeronautical Knowledge, Aerodynamics of Flight (Chapter 5): To the pilot, “torque” (the left turning tendency of the airplane) is made up of four elements that cause or produce a twisting or rotating motion around at least one of the airplane’s three axes. These four elements are: Torque reaction from engine and propeller Corkscrewing effect of the slipstream Gyroscopic action of the propeller Asymmetric loading of the propeller (P-factor) The effects of each of these four elements of torque vary in value with changes in flight situations…to maintain positive control of the aircraft in all flight conditions, the pilot must apply the flight controls as necessary to compensate for these varying values. The airplane was equipped with an emergency egress hammer located in the center armrest that could be used to break through the windows. The use of the hammer to egress was described in the emergency procedures section of the pilot operating handbook. On July 1, 2021, about 0755 central daylight time, a Cirrus SR22 airplane, N123RE, was destroyed when it was involved in an accident at Lamoni Municipal Airport (LWD), Lamoni, Iowa. The private pilot and passenger sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to automatic dependent surveillance-broadcast (ADS-B) information, the airplane departed Creston Municipal Airport (CSQ), Creston, Iowa, at 0736, and flew to LWD. The pilot received flight-following from air traffic control (ATC) until about 14 miles northwest of LWD, an uncontrolled airport. The pilot did not communicate any concerns to ATC prior to leaving the frequency. The last ADS-B information showed the airplane on short final to runway 36 at LWD with a groundspeed of 74 knots. Several witnesses saw the airplane bounce during the landing on runway 36, followed by increase in engine noise “as if just making a touch and go.” Witnesses then observed the airplane bank left, with the left wing tip striking the ground. The airplane then “cartwheeled” and impacted the ground to the left of the runway. A postimpact fire ensued during which the pilot and passenger were not able to egress the airplane. An autopsy of the pilot was performed by the Iowa Office of the State Medical Examiner, Ankeny, Iowa. The cause of death was thermal injuries and smoke inhalation. Toxicology testing identified a carboxyhemoglobin saturation of 23% in the pilot’s blood, which was a level consistent with smoke inhalation. The pilot began flying in 2019. On November 4, 2020, the pilot failed a practical examination for a private pilot certificate that required reexamination for the areas of takeoff, landing, go-around, and navigation. On December 28, 2020, the pilot earned a private pilot certificate flying a Cessna 172. On March 28, 2021, the pilot completed transition training for the SR22 that included about 23 hours of flight instruction. Theairplane initially contacted the ground about 75 ft left of the runway edge and about 1,050 ft beyond the runway 36 threshold. Left wingtip debris was located about 60 ft beyond the initial ground scar and the debris path was on a heading of about 300°. Ground scars, consistent with propeller blade strikes, were located about 15 ft beyond the left wingtip debris, and the distance between five ground scars was about 3 ft. The airplane came to rest in a soybean field (see figure) about 60 ft beyond the propeller strike ground scars. Figure – Airplane at Accident Site The airplane sustained significant fire damage. Flight control continuity was confirmed, and the wing flaps were in the retracted position. The engine separated from the airframe during impact sequence. Engine continuity was established throughout the rotating group, valve train, and accessory section during hand rotation of the crankshaft. No evidence of preimpact mechanical malfunctions were observed during the postaccident examinations of the engine and airframe. ## Aircraft - Registration: [N123RE](https://openairdocs.org/deregistered/N123RE-2023-08-26), registration cancelled 2023-08-26, S/N 1051, built 2004 (OpenAirDocs) - Reported make and model: CIRRUS DESIGN CORP SR22 (1051) - 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: 1051 - Year built: 2004 - Airframe hours: 1157 - Engines: Continental IO-550-N 310 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Airmark Group LLC - Registered owner: Airmark Group LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 1, 2020, 132 hours before - Departed: CSQ, Creston, IA - Destination: LWD, Lamoni, IA - Airport: LWD, Lamoni Muni, runway 18/36, 2,900 × 60 ft, concrete - Equipment: Electronic primary flight display, Stall warning system, ADS-B, Airframe parachute, Auto-pilot, Electronic multifunction display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review December 28, 2020; seat: left; restraint: 4-point; toxicology performed; flight hours: 166 total, 45 in this make and model, 23 in the last 90 days, 8 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 360° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 70 °F, dew point 64 °F - Altimeter: 30.05 inHg - Observed at: KLWD - METAR: KLWD 011253Z AUTO 36007KT 10SM CLR 21/18 A3005 RMK AO2 SLP170 T02110183 ## 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 20210701013269A](https://openairdocs.org/incident/20210701013269A), Jul 1, 2021: Cirrus Design Corp SR22, Lamoni, IA, Destroyed, 2 fatal. The aircraft was landing runway 36, upon touchdown the aircraft became airborne. The pilot advanced the throttle to full, the left wing descended into the… ## Docket (11 files) The files NTSB released with the investigation on April 20, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103396. 31.8 MB in all. - Witness statements (item 1, PDF, 4 pages, 5.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13377948&FileExtension=pdf&FileName=Witness%20Statements_Redacted-Rel.pdf - Accident pilot transition training information (item 2, PDF, 11 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13378065&FileExtension=pdf&FileName=Transition%20Training%20Information_Redacted-Rel.pdf - Flight path information - overview (item 3, PDF, 1 page, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13380543&FileExtension=pdf&FileName=Flight%20Path%20Information%20-%20Overview-Rel.pdf - Automated dependent surveillance-broadcast (ADS-B) data (item 4, CSV, 8.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13381003&FileExtension=csv&FileName=ADS-B%20information-Rel.csv - Photos of accident airplane (item 5, PDF, 5 pages, 5.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13378724&FileExtension=pdf&FileName=Photos-Rel.pdf - Aircraft examination summary (item 6, PDF, 3 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13377004&FileExtension=pdf&FileName=Aircraft%20Examination%20Summary-Rel.pdf - Toxicological report (item 7, PDF, 1 page, 176 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13378248&FileExtension=pdf&FileName=Tox%20report%20--_Redacted-Rel.pdf - Autopsy memorandum (item 8, PDF, 1 page, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13378082&FileExtension=pdf&FileName=Autopsy%20Memo-Rel.pdf - Excerpt of pilot operating handbook - emergency egress information (item 9, PDF, 2 pages, 513 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13398374&FileExtension=pdf&FileName=Excerpt%20of%20Pilot%20Operating%20Handbook-Rel.pdf - Excerpt of FAA pilot's handbook of aeronautical knowledge (item 10, PDF, 3 pages, 7.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13377766&FileExtension=pdf&FileName=Excerpt%20of%20FAA%20Pilot%27s%20Handbook%20of%20Aeronautical%20Knowledge-Rel.pdf - Statement of party representatives to NTSB investigation (item 11, PDF, 1 page, 890 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13397444&FileExtension=pdf&FileName=Party%20Member_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.