CHI06FA245

NTSB accident investigation · Cirrus SR22 · Indianapolis, IN · August 28, 2006

Accident · FatalField investigationFinal report
Date
August 28, 2006, 10:38 local (14:38 UTC)
Place
Indianapolis, IN
Injuries
1 fatal, 3 serious
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N91MBCirrus SR22
Weather
Instrument (IMC) · Day
Status
Completed · report August 15, 2008
Report
Approved by Office Director
Parties
FAA-Indianapolis FSDO, Cirrus Design Corporation, AMSAFE, BRS, Teledyne Continental Motors, Avidyne
FAA report
20060828027879A
Case key
64419

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's failure to maintain sufficient airspeed, which resulted in a stall and subsequent spin. Contributing to the accident were the pilot's inadequate preflight planning, the overloaded condition of the airplane, and the CG aft of the CG limit.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - in flightClimb - to cruise
Preflight planning/preparation - inadequatePilot in commandFactor
Aircraft weight and balance - exceededPilot in commandFactor
Airspeed - lowPilot in commandCause
Stall/spin - encounteredPilot in command
Weather condition - low ceiling
Weather condition - low ceilingFactor
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - water

Analysis

"This case was modified on March 25, 2009."

The right seat passenger reported that the takeoff and initial climb were uneventful until the airplane reached about 4,000 feet of altitude. That was when he noticed that the sound of the engine had changed and saw that the pilot was struggling to control the airplane. The airplane went through a series of three quick rolls and the wing dipped down. The airplane entered a counterclockwise spin. The pilot told the right seat passenger to pull the emergency parachute handle, so he pulled the throttle back to idle, and then pulled the parachute handle. The airplane impacted a water retention pond about 4 seconds later. Witnesses observed the airplane descending through the clouds with a partially deployed parachute. The inspection of the engine and airframe revealed no pre-existing anomalies. The engine data obtained from the Multi-Function Display indicated the engine was operating at full power for the entire flight. Instrument meteorological conditions prevailed with variable cloud bases of 400 - 1,100 feet above the ground (agl) and with cloud tops reported at 3,200 feet above mean sea level. The baggage found in the baggage compartment weighed 262 pounds. The weight limit of the baggage compartment was 130 pounds maximum. The calculated takeoff condition weight of the accident airplane was 3,733 pounds. The Maximum Takeoff Weight was limited to 3,400 pounds. The center-of-gravity (CG) position was at fuselage station (FS) 148.7 inches, or 32.8 percent mean aerodynamic chord (MAC). The CG limits at maximum gross weight are from FS 143.8 inches to FS 148.1 inches. The airplane was overloaded and the CG position was aft of the CG limit. An aircraft performance study, which utilized data extracted from accident airplane, indicated that the airplane's airspeed decayed until the stall angle of attack of the wing was exceeded. The airplane was in a stalled condition for about 30 seconds and then entered a spin.

Factual narrative

"This case was modified on March 25, 2009."

History of flight

On August 28, 2006, at 1038 eastern daylight time, a Cirrus SR22, N91MB, was destroyed when it impacted a water retention pond located about 2.4 miles from the Eagle Creek Airpark (EYE), Indianapolis, Indiana, after a loss of control during cruise climb. The 14 Code of Federal Regulations Part 91 personal flight departed EYE at 1034 en route to Hilton Head Airport (HXD), Hilton Head Island, South Carolina. The pilot received fatal injuries, and the three passengers received serious injuries. Instrument meteorological conditions prevailed at the time of the accident. The flight was on an instrument flight plan.

On Saturday, August 26th, the co-owner of N91MB (the accident pilot was the other co-owner) took ownership of the new airplane, and along with a Cirrus Standardized Instructor Program (CSIP) pilot, flew it from Duluth, Minnesota, where it was manufactured, to EYE. The co-owner of the airplane reported the approximately 500 nautical mile flight took about 3.5 hours to complete. A fuel receipt indicated that 50.9 gallons of fuel were added to the airplane after the flight.

On Sunday, August 27th, the accident pilot and the CSIP pilot flew N91MB for 1.7 hours on an instrument proficiency check flight. Instrument meteorological conditions were encountered during the flight and the accident pilot practiced instrument procedures and flew 2 instrument approaches. The CSIP pilot reported that the accident pilot was on the "top of his game" and that he flew a very good check ride. After the flight, the CSIP pilot topped off the airplane with fuel. A fuel receipt indicated that 14.4 gallons of fuel were added to the airplane. Although the accident pilot had recently undergone surgery, the CSIP pilot reported that the accident pilot was feeling good and that he had told the CSIP pilot that he did not feel any side effects and was not taking any medications. The CSIP pilot reported that the engine, navigation, and communication systems on the airplane operated normally.

The accident pilot telephoned the Terre Haute Flight Service Station (FSS) at 2131 on Sunday night to get a weather brief for a flight from EYE to HXD. The briefer informed him to expect marginal visual meteorological conditions and temporary instrument meteorological conditions at the departure airport between 0800 - 1200 the next morning.

On Monday morning, August 28th, the pilot and the three passengers met at the pilot's hangar prior to the flight. The pilot's 29-year-old son, who was not a pilot, assisted loading the cargo on board the airplane. The pilot's son sat in the right front seat, the pilot's wife sat in the right rear seat, and a friend of the family sat in the left rear seat.

The pilot taxied the airplane to the EYE ramp prior to takeoff, but was unable to contact Indianapolis Clearance Delivery, which was located at the Indianapolis International Airport, on his airplane's radio. At 1018, while the airplane's engine was running, he telephoned the Terre Haute FSS with his cellular telephone and requested an IFR departure clearance. The pilot was informed that his IFR flight plan was not in the system and that he would need to re-file the flight plan. The pilot stated to the briefer that he had filed an IFR flight plan the night before using Direct User Access Terminal Service (DUATS), but he re-filed his flight plan over the telephone with FSS. At 1030, he received his takeoff clearance, which included the following information: N91MB was cleared from the Eagle Creek Airport to the Hilton Head Airport via radar vectors as filed. He was cleared to climb and maintain 3,000 feet and expect 9,000 feet 10 minutes after departure. Contact departure control on 119.05, squawk 4004, and when able, fly heading 270 degrees. Void time was 1040.

The transcript of radio communications between the pilot and Indianapolis Airport Traffic Control (ATC) indicated the following:

At 1034:38, the pilot stated, "Indianapolis Departure, Cirrus, uh, Nine One Mike Bravo is off Eagle Creek, uh, turning to heading two seven zero, passing through fifteen hundred."

At 1034:48, ATC responded, "Cirrus Niner One Mike Bravo, Indy Departure, ident. What is your on course heading?"

At 1034:53, the pilot responded, "Uh, on course is going to be, uh, standby."

At 1035:03, the pilot stated, "Uh, we're with you at one five one."

At 1035:07, ATC stated, "Cirrus One Mike Bravo, roger. Radar contact one mile southwest of Eagle Creek. Climb and maintain six thousand."

At 1035:11, the pilot responded, "Up to six thousand, Niner One Mike."

About 1035, track data, which was derived from Airport Surveillance Radar (ASR) and the airplane's Avidyne Entegra EXP5000 Primary Flight Display (PFD), indicated that the airplane was on about a 270 degree heading at about 1,670 feet mean sea altitude with an indicated airspeed of about 117 knots. For about the next 30 seconds, the airplane's heading remained about 270 degrees. About 1035:50, the airplane's heading turned about 30 degrees left to about 240 degrees. The airplane's altitude was about 2,500 feet msl and the indicated airspeed was about 97 knots.

At 1036:12, ATC stated, "Cirrus One Mike Bravo, turn left on course."

At 103614, the pilot responded, "Uh, thank you, Nine One Mike Bravo, on course."

At 1036:19, ATC stated, "And still one fifty?"

At 1036:21, the pilot responded, "Uh, that's correct, sir."

There were no further radio transmissions recorded from N91MB. At 1036:21, track data indicated that the airplane's altitude was about 3,000 feet msl and the indicated airspeed was about 87 knots. For about the next 20 - 25 seconds the airplane turned left to a heading of about 105 degrees and remained on that heading for about the next 60 seconds.

At 1037:52, ATC stated, "One Mike Bravo, you say your on course heading is one five zero." At 1037:52, the airplane's heading was about 105 degrees, the altitude was about 3,800 feet msl, and the indicated airspeed was about 75 knots.

Track data indicated that the airplane's heading turned to the northeast on about a 075-degree heading and the airplane lost altitude. The last radar return recorded at 1038:22 indicated that the airplane's altitude was about 1,600 feet msl.

The pilot's son reported that the takeoff and initial climb were uneventful until the airplane reached about 4,000 feet of altitude. That was when he noticed that the sound of the engine had changed and saw that the pilot was struggling to control the airplane. The airplane went through a series of three quick rolls and the wing dipped down. The pilot was still attempting to control the airplane when he made an emergency call over the radio but there was no response. The pilot's son reported that the airplane entered a counterclockwise spin. The pilot told him to pull the parachute so he pulled the throttle back to idle and then pulled the parachute handle.

An officer of the Indianapolis International Airport Police Department interviewed the pilot's son. The officer's report stated that the pilot's son observed the pilot "pulling backwards on the control yoke of the aircraft trying to keep the aircraft's nose up." The report stated that the pilot's son "grabbed the right sided yoke and attempted to help his father keep the aircraft nose elevated."

The family friend who was sitting in the left rear seat reported "everything seemed normal" until "just to the point where we could be leveling off, just to the top of the clouds." She stated, "I remember hearing a different sound. I would call it the engine sounded differently, but something sounding differently. Kind of feeling and hearing something underneath of me." She stated, "The only thing I have to compare it to is when the wheels on a commercial flight are put down or up. And feeling two dips to the side,

Aircraft

Registration
N91MB
Reported as
Cirrus SR22
Category
Airplane
Serial number
1973
Airframe hours
121.3
Engine
Continental IO-550-N, 310 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Bob Law Air LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 1, 2006 · 11.6 hours before
Departed
EYE · Indianapolis, IN
Destination
HDX · Hilton Head, SC
Flight plan
IFR

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
66
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
August 1, 2006
Seat
Left
Toxicology
Performed
Flight hours
2,570 total · 365 in this make and model · 2,566 as pilot in command · 2 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
170° at 4 knots
Visibility
6 statute miles
Lowest ceiling
600 ft overcast
Temperature
73 °F, dew point 72 °F
Altimeter
29.88 inHg
Observed at
EYE, 2 nm away

Docket · 62

The files NTSB released with the investigation on August 13, 2008, on NTSB’s docket system: statements, records, photos and specialists’ reports. 58.5 MB in all.

Systems 9 - Factual Report of Group ChairmanItem 1 · .PDF · 2.7 MBFlight Data Recorder 10 - Factual Report of Investigation - Cockpit DisplaysItem 2 · .PDF · 714 KBFlight Data Recorder 10 - Attachment 1 MFD DataItem 3 · .CSV · 19 KBFlight Data Recorder 10 - Attachment 2 PFD DataItem 4 · .CSV · 95 KBAircraft Performance 13 - Factual Report of Group ChairmanItem 5 · .PDF · 6.4 MBSurvival Factors and Biomechanics Factual ReportItem 6 · .PDF · 12.6 MBRecord of InterviewsItem 7 · .PDF · 107 KBInterview of Poolsiri Edesess Sept 12, 2006Item 8 · .PDF · 65 KBInterview of Jeremy A. Edesess Sept 12, 2006Item 9 · .PDF · 95 KBInterview of Janet Adams July 11, 2007Item 10 · .PDF · 54 KBInterview of Poolsiri Edesess July 11, 2007Item 11 · .PDF · 56 KBInterview of Jeremy Edesess July 11, 2007Item 12 · .PDF · 82 KBInterview of Chuck Huff July 11, 2007Item 13 · .PDF · 90 KBMedical Records InformationItem 14 · .PDF · 20 KBWreckage DiagramItem 15 · .PDF · 914 KBRadar Plot 1Item 16 · .PDF · 416 KBRadar Plot 2Item 17 · .PDF · 281 KBFSS Transcript PF2Item 18 · .PDF · 34 KBFSS Transcript PF15Item 19 · .PDF · 43 KBIndianapolis ATC Transcript PackageItem 20 · .PDF · 2.0 MBFAA Inspection of Stall Warning HornItem 21 · .PDF · 76 KBIndianapolis International Airport Police Department ReportItem 22 · .PDF · 1.3 MBFAA Report of Weight & BalanceItem 23 · .PDF · 134 KBGA Airbag Safety Study Data FormItem 24 · .PDF · 264 KBAirbag Study Summary ReportItem 25 · .PDF · 63 KBAvidyne Examination ReportItem 26 · .PDF · 14 KBBRS Preliminary ReportItem 27 · .PDF · 777 KBTCM Engine Run Report ExcerptsItem 28 · .PDF · 910 KBStall Warning Horn InspectionItem 29 · .PDF · 6.3 MBUND Flight Training RecordsItem 30 · .PDF · 328 KBPilot's LogbookItem 31 · .PDF · 195 KBAircraft LogbooksItem 32 · .PDF · 1.9 MBFlight Plans & Fuel ReceiptsItem 33 · .PDF · 4.3 MBAircraft Equipment ListItem 34 · .PDF · 458 KBAircraft OptionsItem 35 · .XLS · 15 KBAircraft Insurance ApplicationItem 36 · .PDF · 260 KBRE-40 Memorandum on PFD Log FilesItem 37 · .PDF · 213 KBPFD Tracks of 3 FlightsItem 38 · .PDF · 6.5 MBCSV Tabular data (Lat/Long) for Last 3 FlightsItem 39 · .CSV · 242 KBToxicological ReportItem 40 · .PDF · 71 KBStatement of Party Representatives to NTSB InvestigationItem 41 · .PDF · 457 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 42 · .PDF · 184 KBPhoto 1. Aircraft Wreckage in Water Retention PondItem 43 · .PDF · 43 KBPhoto 2. View of Partially Submerged Aircraft and Deployed ParachuteItem 44 · .PDF · 44 KBPhoto 3. Top of Cabin and Parachute StrapsItem 45 · .PDF · 44 KBPhoto 4. Parachute Strap and Rocket MotorItem 46 · .PDF · 44 KBPhoto 5. View of Aircraft in Retention PondItem 47 · .PDF · 43 KBPhoto 6. Aircraft Recovery From Retention PondItem 48 · .PDF · 44 KBPhoto 7. View of Cockpit During RecoveryItem 49 · .PDF · 45 KBPhoto 8. View of Cockpit During RecoveryItem 50 · .PDF · 44 KBPhoto 9. View of Cockpit During RecoveryItem 51 · .PDF · 44 KBPhoto 10. View of Cockpit During RecoveryItem 52 · .PDF · 45 KBPhoto 11. View of Cockpit During Recovery. Deployed AirbagItem 53 · .PDF · 44 KBPhoto 12. View of Cockpit During Recovery. Flap Handle Position.Item 54 · .PDF · 45 KBPhoto 13. View of Cockpit During Recovery. Right Wing.Item 55 · .PDF · 43 KBPhoto 14. Cockpit Instruments.Item 56 · .PDF · 44 KBPhoto 15. Ignition SwitchItem 57 · .PDF · 43 KBPhoto 16. Power LeverItem 58 · .PDF · 44 KBPhoto 17. Top View of EngineItem 59 · .PDF · 46 KBPhoto 18. Deployed AirbagItem 60 · .PDF · 43 KB
All 62 files on NTSB’s docket

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.