# NTSB DEN06FA131: Cirrus Design SR20, N787SL, Maybell, CO, September 15, 2006 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 15, 2006, 13:32 local (19:32 UTC) - Place: Maybell, CO - Coordinates: 40.984443, -108.800003 - Nearby events: https://openairdocs.org/map.md?lat=40.9844&lon=-108.8000&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report May 29, 2007 - Report: Approved by Office Director - Parties: FAA AAI-100, Teledyne Continental Motors, Inc, Cirrus Design Corporation, BRS, AMSAFE Aviation, FAA Flight Sandards Field Office - NTSB case key (mKey): 64526 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN06FA131 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/64526/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=64526 - Page: https://openairdocs.org/ntsb/DEN06FA131 ## Probable cause The pilot's improper in-flight planning and decision making resulting in an inadvertent encounter with severe icing conditions during cruise flight and subsequent loss of aircraft control. Contributing factors include the pilot's failure to obtain a weather briefing, the thunderstorm, conditions conducive for structural icing, and the pilot's failure to deploy the parachute recovery system. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - flight into adverse weather - inadvertent, pilot in command (cause) - weather condition - icing conditions (contributing factor) - weather condition - thunderstorm (contributing factor) - in-flight planning/decision - improper, pilot in command (cause) - weather evaluation - not performed, pilot in command (contributing factor) - Loss of control - in flight, cruise - aircraft control - not possible, pilot in command (cause) - airframe - ice (contributing factor) - stall - encountered - emergency procedure - not followed, pilot in command (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The pilot contacted ARTCC and stated he needed a lower altitude, as he was encountering icing conditions. Several altitude changes were assigned. Ultimately the pilot was assigned a block altitude from 12,000 feet to 13,000 feet. The pilot reported that they were in serious icing conditions and the controller cleared the pilot to an altitude of 11,000 feet. Shortly thereafter, voice and radar communications with the airplane were lost. The wreckage was located scattered over a 1.5 mile area between Colorado and Wyoming. Signatures at the scene showed evidence consistent with a ground impact deployment of the parachute recovery system, resulting in fragmentation of the airplane, as it was drug by high winds. An examination of the remaining airplane systems revealed no anomalies. Thunderstorm activity existed along the route of flight along with severe icing and turbulence. The pilot had not obtained a full weather briefing prior to the flight. ## Factual narrative HISTORY OF FLIGHT On September 15, 2006, at 1332 mountain daylight time, a Cirrus Design Corp SR20, N787SL, owned by East End Aviation LLC, and piloted by a private pilot, was destroyed when it impacted terrain 50 nautical miles (nm) north northwest of Maybell, Colorado. Visual meteorological conditions prevailed at the time of the accident. The personal flight was being conducted under the provisions of Title 14 Code of Federal Regulations Part 91 on an instrument flight rules flight (IFR) plan. The private pilot and private pilot rated passenger were fatally injured. The cross-country flight departed Bolinder Field - Tooele Valley Airport (TVY), Tooele, Utah, approximately 1150 and was en route to Lincoln, Nebraska (LNK). The pilot and his passenger were returning from a business meeting in California and had departed Metropolitan Oakland International Airport (OAK) approximately 0640 Pacific daylight time. A flight log found within the wreckage indicated that they landed at TVY. According to a receipt from Tooele Valley Airport, the passenger paid for 36.26 gallons of fuel at 1120. At 1221:13, the pilot contacted Cedar City radio with a request to file an IFR flight plan from his present position (10 miles east of FFU VOR) to LNK. The flight plan was filed for 14,000 feet. Afterwards, the briefer mentioned Airman's Meteorological Information (AIRMETS) along the route of flight for mountain obscuration, turbulence, and icing, and advised them to contact Flight Watch if they needed further weather information. At 1320:20, the pilot reported to Denver (DEN) Air Route Traffic Control Center (ARTCC) that they were at 13,800 feet and "need a (unintelligible) altitude… [they] picked a little bit of ice." The controller issued an altimeter setting of 29.65. At 1323:29, the controller asked about the flight's assigned altitude. The pilot responded 14,000 feet and stated that he was unable to maintain that altitude. Several altitude assignments were issued by the controller and ultimately a block altitude from 12,000 feet to 13,000 feet was assigned. At 1330:51, the pilot reported to ARTCC that they were having "serious" icing issues and were unable to maintain 12,000 feet. The controller asked the pilot if he had terrain in sight and the pilot responded in the affirmative. The controller cleared the pilot to descend to 11,000 feet and maintain his own terrain separation. At 1331:57, the controller asked the pilot what type of icing he was encountering. No further transmissions were received from the pilot. National Track Analysis Program (NTAP) radar data depicted the airplane on a northeasterly heading at an encoded altitude of 12,500 feet mean sea level (msl). At 1329:40, the airplane reversed course to a northerly direction and continued to descend. Radar contact was lost at 1332:13. No encoded altitude was available for this time stamp. An Alert Notification (ALNOT) was issued at 1349 and search and rescue operations were initiated. The wreckage and debris path were located approximately 1440 by law enforcement personnel from the Sweetwater County Sheriff's office. A witness in the area observed a portion of the fuselage being drug by the aircraft recovery parachute. They did not witness the actual impact. PERSONNEL INFORMATION The pilot, age 48, held a private pilot certificate with airplane single and multi-engine land, and instrument ratings, initially issued on October 30, 2004. He had been issued a second class airman medical certificate on May 24, 2006. The certificate contained no limitations. According to the Cirrus Factory Training Course records, the pilot attended aircraft familiarization training from September 16 through September 19, 2005. The pilot logged 12.2 hours of flight training and 8.0 hours of ground school during this time. All areas of training were completed with a satisfactory rating. A copy of the pilot's logbook was provided to the National Transportation Safety Board (Safety Board) investigator-in-charge (IIC) for review. The pilot had logged no less than 583.6 hours; 88.3 in multi-engine airplanes and 495.3 hours in single engine airplanes. A total of 275.8 hours had been logged in a Cirrus SR-20, all but 1.2 hours of which were in the accident airplane. In addition, the pilot had logged 95.8 hours of instrument time; 35.7 of which were in actual instrument conditions, and 28 hours of which were in the accident airplane. The pilot successfully completed the requirements of a Flight Review on July 4, 2005. The passenger, age 46, held a private pilot certificate with an airplane single engine land rating which was issued on May 2, 2005. He had been issued a third class airman medical certificate on September 10, 2003. The certificate contained no limitations. According to a flight log located within the wreckage, the passenger had flown the previous leg from California. There was no record that the passenger had attended the Cirrus Factory Training Course. AIRCRAFT INFORMATION The accident airplane, a Cirrus Design Corp (serial number 1556), was manufactured in 2005. It was registered with the FAA on a standard airworthiness certificate for normal operations. The airplane was equipped with a Teledyne Continental Motors IO-360-ES engine rated at 210 horsepower at 2,800 rpm. The engine was equipped with a Hartzell 2-blade, constant speed propeller. The pilot purchased the airplane in September of 2005. The airplane was registered to and operated by East End Aviation, LLC., and was maintained under an annual inspection program. A review of the maintenance records indicated that a 100-hour inspection had been completed on April 4, 2006, at an airframe total time of 259.9 hours. The airplane had flown approximately 243.5 hours between the last inspection and the accident and had a total airframe time of 503.4 hours. METEOROLOGICAL INFORMATION On September 15, 2006, a Surface Analysis chart, prepared by the National Weather Service (NWS), National Center for Environmental Prediction, depicted a stationary front that extended from a low pressure area, located in southwest North Dakota, diagonally through Wyoming and into northern Utah and Nevada. A high pressure ridge extended from western Colorado into northern New Mexico. The accident site was located to the south of the stationary front and near the ridge of high pressure. The NWS Freezing Level chart issued on the day of the accident depicted the freezing level along the route of flight ranging from 11,600 feet to 14,200 feet msl. Doppler weather radar (approximately 120 miles south-southeast of the accident location) scanned the accident area at 1322. Data indicated reflectivity values of 25 to 34 dBz, or moderate intensity precipitation, in the accident area around the accident time. According to NTAP data, the accident airplane was in the immediate vicinity of a 35 dBz cell when the pilot first reported icing conditions. An Aviation area forecast was issued for eastern Utah, southern Wyoming, and northern Colorado by the Aviation Weather Center (AWC) in Kansas City, Missouri, the day of the accident, at 0445. The forecast for the route from Utah into Colorado and Wyoming was for scattered to broken clouds at 10,000 feet, broken to overcast clouds at 15,000 feet, southerly winds gusting to 30 knots, widely scattered light rain showers with scattered thunderstorms, and rain showers, thunderstorms possibly severe, cumulonimbus cloud tops to 40,000 feet. Multiple pilot reports (PIREPS) had been issued for the Colorado/Wyoming area regarding icing. Reports given for icing included light to moderate clear and rime icing from 8,500 feet msl to 19,000 feet msl. The NWS Current Icing Potential chart valid at the time of the accident depicted a 90 percent chance of icing conditions at 14,000 feet, 70 percent chance of icing conditions at 13,000 feet, and less than 40 percent chance of icing below 12,000 feet, al ## Aircraft - Registration: [N787SL](https://openairdocs.org/deregistered/N787SL-2007-03-30), registration cancelled 2007-03-30, S/N 1556, built 2005 (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 series](https://openairdocs.org/engine/continental-io-360-series) (registry code 17025, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1556 - Airframe hours: 503.4 - Engines: Teledyne Continental IO-360-E 210 horsepower reciprocating - Damage: Destroyed - Flight: Business, Part 91 - Registered owner: East End Aviation LLC - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, April 1, 2006, 243.5 hours before - Departed: TVY, Tooele, UT - Destination: LNK, LINCOLN, NE - Flight plan: IFR - Airport: Na ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review July 1, 2005; seat: left; toxicology performed; flight hours: 584 total, 276 in this make and model, 2 in the last 24 hours - Other flight crew; age 46; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review May 1, 2005; seat: rear; toxicology performed; flight hours: 5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 180° at 24 knots, gusting 29 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 59 °F, dew point 45 °F - Altimeter: 29.64 inHg - Observed at: RKS, 50 nm away ## 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 20060915030799A](https://openairdocs.org/incident/20060915030799A), Sep 15, 2006: Cirrus SR20, Maybell, CO, Destroyed, 2 fatal. (-23) For the last twelve minutes of flight before impact with terrain, aircraft continually lost altitude after pilot notified ATC "that aircraft picked up a… ## Docket (21 files) The files NTSB released with the investigation on March 28, 2007, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=64526. 26.5 MB in all. - Meteorology 5 - Factual Report of Group Chairman (item 1, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269820&FileExtension=.PDF&FileName=Meteorology%205%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Meteorology 5 - Attachment 1 Lightning data (item 2, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40269822&FileExtension=.PDF&FileName=Meteorology%205%20-%20Attachment%201%20Lightning%20data-Master.PDF - Survival Factors 6 - Report for Airbag Safety Study (item 3, .PDF, 6 photos, 374 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40271640&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Report%20for%20Airbag%20Safety%20Study-Master.PDF - Avidyne Exam Report (item 4, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272349&FileExtension=.PDF&FileName=Avidyne%20Exam%20Report-Redacted.PDF - Supplement E (item 5, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272350&FileExtension=.PDF&FileName=Supplement%20E-Master.PDF - Witness Statements (item 6, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272351&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Maps and Diagrams (item 7, .PDF, 17.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272352&FileExtension=.PDF&FileName=Maps%20and%20Diagrams-Master.PDF - ATC FAA Transcripts (item 8, .PDF, 444 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272353&FileExtension=.PDF&FileName=ATC%20FAA%20Transcripts-Redacted.PDF - Parties Reports (item 9, .PDF, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272354&FileExtension=.PDF&FileName=Parties%20Reports-Redacted.PDF - Radar Data (item 10, .PDF, 467 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272355&FileExtension=.PDF&FileName=Radar%20Data-Master.PDF - Toxicological Reports (item 11, .PDF, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472125&FileExtension=.PDF&FileName=Toxicological%20Reports-Master.PDF - Parties Statements (item 12, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272357&FileExtension=.PDF&FileName=Parties%20Statements-Redacted.PDF - Wreckage Relase (item 13, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273343&FileExtension=.PDF&FileName=Wreckage%20Relase-Redacted.PDF - Photograph 01 - Initial impact point and Debris path (item 14, .PDF, 296 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272358&FileExtension=.PDF&FileName=Photograph%2001%20-%20Initial%20impact%20point%20and%20Debris%20path-Master.PDF - Photograph 02 - Propeller Assembly (item 15, .PDF, 318 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272359&FileExtension=.PDF&FileName=Photograph%2002%20-%20Propeller%20Assembly-Master.PDF - Photograph 03 - Engine Assembly (item 16, .PDF, 314 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272360&FileExtension=.PDF&FileName=Photograph%2003%20-%20Engine%20Assembly-Master.PDF - Photograph 04 - Wing Assembly and Portion of Cabin (item 17, .PDF, 299 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272361&FileExtension=.PDF&FileName=Photograph%2004%20-%20Wing%20Assembly%20and%20Portion%20of%20Cabin-Master.PDF - Photograph 05 - Aft Particle Streaking on Wing (item 18, .PDF, 321 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272362&FileExtension=.PDF&FileName=Photograph%2005%20-%20Aft%20Particle%20Streaking%20on%20Wing-Master.PDF - Photograph 06 - Portion of Empennage (item 19, .PDF, 309 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272363&FileExtension=.PDF&FileName=Photograph%2006%20-%20Portion%20of%20Empennage-Master.PDF - Photograph 07 - Fuselage and Canopy (item 20, .PDF, 291 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272364&FileExtension=.PDF&FileName=Photograph%2007%20-%20Fuselage%20and%20Canopy-Master.PDF - Photograph 08 - Stowed Handle (item 21, .PDF, 310 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40272365&FileExtension=.PDF&FileName=Photograph%2008%20-%20Stowed%20Handle-Master.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.