# NTSB CEN21LA232: Cirrus Design SR22, N4144B, Whitewater, WI, May 16, 2021 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: May 15, 2021, 21:15 local (May 16, 2021, 02:15 UTC) - Place: Whitewater, WI - Coordinates: 42.787917, -88.684086 - Nearby events: https://openairdocs.org/map.md?lat=42.7879&lon=-88.6841&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Flight instrument malf/fail](https://openairdocs.org/ntsb-events/334) - Highest injury: No injuries - Injuries: 3 uninjured - 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 - NTSB case key (mKey): 103136 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21LA232 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103136/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103136 - Page: https://openairdocs.org/ntsb/CEN21LA232 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Navigation system](https://openairdocs.org/ntsb-findings/01023400): Aircraft › Aircraft systems · Malfunction (probable cause); cases with it: [Cirrus Design SR22, 1 case](https://openairdocs.org/ntsb-findings/01023400/cases.md?model=2130001), [All aircraft, 13 cases](https://openairdocs.org/ntsb-findings/01023400/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Flight instrument malf/fail](https://openairdocs.org/ntsb-events/334) (defining event); cases with it: [Cirrus Design SR22, 1 case](https://openairdocs.org/ntsb-events/334/sequence.md?model=2130001), [All aircraft, 56 cases](https://openairdocs.org/ntsb-events/334/sequence.md) ## 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](https://openairdocs.org/deregistered/N4144B-2022-08-27), registration cancelled 2022-08-27, S/N 0131, built 2001 (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 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 0131 - Year built: 2001 - Airframe hours: 3637.6 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: none; 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 ## 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 20210515009169A](https://openairdocs.org/incident/20210515009169A), May 15, 2021: Cirrus Design Corp SR22, Whitewater, WI, Substantial damage. On may 15, 2021 at approximately 2115 local time a Cirrus SR22 registration number N4144B with the pilot and two passengers departed on an IFR part 91 flight… ## Docket (7 files) The files NTSB released with the investigation on July 28, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103136. 7.8 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12838105&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Attitude indicator examination (item 2, PDF, 1 page, 150 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12850034&FileExtension=pdf&FileName=Attitude%20Indicator%20Exam-Rel.pdf - Midcontinent test report factual (item 3, PDF, 3 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12836724&FileExtension=pdf&FileName=MC%20Docket%20Test%20Report_Redacted-Rel.pdf - Sandel test report (item 4, PDF, 1 page, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12837026&FileExtension=pdf&FileName=Sandel%20unit%20test%20report-Rel.pdf - Photos (item 5, PDF, 3 pages, 898 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12838125&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Statement of party representatives (item 6, PDF, 3 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12848878&FileExtension=pdf&FileName=Party%20Forms_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 7, PDF, 1 page, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12850082&FileExtension=pdf&FileName=Signed%20Wreckage%20Release_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.