CEN21LA232

NTSB accident investigation · Cirrus Design SR22 · Whitewater, WI · May 16, 2021

Accident · No injuriesClass 3 · LimitedFinal report
Date
May 15, 2021, 21:15 local (May 16, 2021, 02:15 UTC)
Place
Whitewater, WI
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N4144BCirrus Design SR22
Defining event
Enroute: Flight instrument malf/fail
Weather
Instrument (IMC) · Night
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA, Cirrus Aircraft, Sandel, Mid-Continent Instruments and Avionics
FAA report
20210515009169A
Case key
103136

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

An inflight instrument malfunction for reasons that could not be determined based on available information, which led to the pilot’s decision to activate the airframe parachute system.

Findings · 1

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.

Navigation systemAircraft › Aircraft systems · MalfunctionCirrus Design SR22: 1 caseAll aircraft: 13 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

The pilot reported that, during an instrument flight rules flight, he began receiving conflicting information from the flight instruments and digital flight information display. He stated that the turn coordinator and GPS were displaying opposite information, the heading bug was moving erratically, and he felt as if he was flying in circles. After determining that he could not rely on the information from the flight instruments, he elected to activate the Cirrus airframe parachute system. The airplane came to rest in a stand of trees, resulting in substantial damage. Postaccident testing of the electronic horizonal situation indicator, directional gyro, and horizon reference indicator revealed no anomalies except for the directional gyro counterclockwise heading stability, which exceed the testing limits by about 3°. The heading stability finding, although outside the testing limits, would not result in the instrument anomalies reported by the pilot. The reason for the flight instrument disagreement/malfunction could not be determined based on the available information.

Factual narrative

On May 15, 2021, about 2115 central daylight time, a Cirrus SR22, N4144B, sustained substantial damage when it was involved in an accident near Whitewater, Wisconsin. The pilot and passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. According to the pilot, while on an instrument flight rules flight, he began receiving conflicting information from the flight instruments and digital flight information display. He stated that the turn coordinator and GPS were displaying opposite information, the heading bug was moving erratically, and he felt as if he was flying in circles. After determining that he could not rely on the information from the flight instruments, he elected to activate the Cirrus airframe parachute system. The airplane came to rest in a stand of 60-ft-tall trees, resulting in substantial damage. The airplane was equipped with a Sandel SN3308 electronic horizontal situation indicator (EHSI), Mid-Continent 4305-150 directional gyro, BF Goodrich Aerospace horizon reference indicator, and the pilot was utilizing Foreflight on a personal tablet. A postaccident examination of the airplane revealed no pre-impact mechanical anomalies that would have precluded normal operation. External power was supplied to the airplane and all instruments powered up normally. The airplane was situated on a movable dolly cart which allowed for it to be manipulated to verify instrument functionality. The turn coordinator operated as designed when the empennage was moved, as did the horizon reference indicator. The EHSI powered up but displayed a configuration error; however, the remote gyro wire harness wires were cut during recovery and the flux detector was disconnected. The EHSI, directional gyro, and horizon reference indicator were removed and subsequently tested. The EHSI was connected to an automated tester, which tested the inputs and outputs of the unit. The unit passed all tests. The directional gyro was connected to 28V DC power. The heading was steady and did not drift. The unit passed all testing with the exception of counterclockwise heading stability. The limit for the test was ±2°, but the unit was at +5°. When the unit was shut down, the rotor coasted in excess of 9 minutes, consistent with a free and stable rotor. The horizon reference indicator was connected to an external power source and allowed time to steady the gyro. After caging the gyro, the unit was pitched up and down as well as rolled left and right. The unit responded as designed through all movements. Power was removed and the gyro coasted to a stop, consistent with a free gyro.

Aircraft

Registration
N4144B
Reported as
Cirrus Design SR22
Category
Airplane
Serial number
0131
Built
2001
Airframe hours
3,637.6
Engine
Continental IO550, 310 hp, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 30, 2020
Departed
KSBM · Sheboygan, WI
Destination
KBUU · Burlington, WI
Flight plan
IFR
Airport
n/a
Equipment
Onboard weather, Electronic multifunction display, Electronic flight bag or handheld device, Angle of attack indicator, Airframe parachute, ADS-B, Stall warning system

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
50
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
January 23, 2020
Seat
Left
Restraint
4-point
Flight hours
588.7 total · 280.1 in this make and model · 491.1 as pilot in command · 15.8 in the last 90 days · 9.5 in the last 30 days · 1.3 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night
Wind
210° at 5 knots
Visibility
4 statute miles
Lowest ceiling
400 ft overcast
Temperature
55 °F, dew point 55 °F
Altimeter
30.13 inHg
Observed at
KJVL, 18 nm away
METAR
METAR KJVL 160145Z 21005KT 4SM BR OVC004 13/13 A3013

Docket · 7

The files NTSB released with the investigation on July 28, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.8 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.