ERA09FA515

NTSB accident investigation · Cirrus SR-22 · Rock Hill, SC · September 11, 2009

Accident · FatalField investigationFinal report
Date
September 11, 2009, 07:15 local (11:15 UTC)
Place
Rock Hill, SC
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N922XXCirrus SR-22
Defining event
Maneuvering: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report January 7, 2011
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Cirrus Design Corporation, Teledyne Continental Motors, Inc., FAA/FSDO
FAA report
20090911049289A
Case key
74707

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

The pilot's failure to maintain aircraft control and altitude while maneuvering after takeoff.

Findings · 3

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.

Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedCirrus Design SR22: 15 casesAll aircraft: 1,269 casesProbable cause
Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Not attained/maintainedCirrus Design SR22: 10 casesAll aircraft: 1,310 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCirrus Design SR22: 94 casesAll aircraft: 9,295 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, who usually flew with a certificated flight instructor copilot, intended to practice takeoffs and landings in the high performance airplane. Information retrieved from the airplane's remote data module, a crash-hardened unit installed in the tail of the airplane intended to record flight, engine and autopilot parameters, indicated that the airplane accelerated and lifted off runway 2 normally. The airplane then made a slight right turn for about 35 seconds, which transitioned to a left turn. Approximately 9 seconds later, the roll attitude reached 46 degrees left wing down, and the airplane reached its maximum altitude of 1,241 feet mean sea level, about 575 feet above ground level. Over the next 20 seconds, the turn continued at about the same roll attitude (40-50 degrees left wing down), as the speed increased to 158 knots. Shortly thereafter, the airplane's pitch attitude began to decrease toward a peak of 10 degrees nose down, and the roll attitude began a sharp change toward the right, reaching about 70 degrees right wing down, by the end of the recorded data. The last recorded data points included a heading of 165 degrees, an engine rpm of 2,687, an indicated airspeed of 184 knots, and a vertical descent rate of 2,064 feet-per-minute. The stall warning parameter indicated “off” (not stalled) for the duration of the flight. The airplane initially impacted the ground about 100 feet below the top of a 20-degree slope, about 150 feet from a taxiway, and 255 feet right of the extended center line of runway 20. The airplane was destroyed by fire and impact forces. Fragments of the right wing tip were located near the initial impact point. A debris path, oriented on a 160-degree heading, extended for about 400 feet. The airplane had been operated for approximately 93 hours since new. Examination of the wreckage and recorded data did not reveal evidence of any preimpact mechanical malfunctions. At the time of the accident, the pilot had accumulated about 390 hours of total flight experience, all in the same make and model as the accident airplane. It was also noted that all logged flights in the accident airplane, with the exception of a 1.4 hour flight about two months prior to the accident, included a flight instructor onboard. The pilot had a history of attention deficit disorder and depression (both previously treated with medications) and of anxiety (for which he had previously been hospitalized and for which he had been prescribed a potentially impairing medication for use "as needed"). None of this information had been reported to the Federal Aviation Administration. The pilot was at risk (but had not been evaluated) for obstructive sleep apnea because of his history of snoring, obesity, and high blood pressure. It is possible that the pilot was experiencing symptoms of his unreported mental conditions, that he was fatigued due to undiagnosed obstructive sleep apnea, or that he had recently used an anti-anxiety medication at thetime of the accident. While it is possible that impairment from one or more of those sources could have adversely impacted his performance during the accident sequence, the investigation was unable to determine the role that impairment may have played in the accident.

Factual narrative

HISTORY OF FLIGHT On September 11, 2009, about 0715 eastern daylight time, a Cirrus SR-22, N922XX, was destroyed when it impacted terrain while maneuvering after takeoff, at the Rock Hill Airport (UZA), Rock Hill, South Carolina. The certificated private pilot was killed. Visual meteorological conditions prevailed and no flight plan had been filed for the local flight. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. The airplane was owned by the pilot through a limited liability company and based at UZA. According to the pilot's wife, the pilot normally flew with a copilot, who was also a certificated flight instructor (CFI). The pilot, his wife, and the CFI flew to Teterboro Airport (TEB), Teterboro, New Jersey, on September 7, 2009. The pilot and CFI returned to UZA on September 9, 2009, and planned to return to TEB, on September 13, 2009. The pilot's wife stated that the purpose of the accident flight was for the pilot to practice takeoffs and landings by himself. A witness located at the UZA airport terminal, observed the airplane depart from runway 2, a 5,500-foot-long, 100-foot-wide, asphalt runway. After takeoff, the airplane made a shallow right turn and disappeared from his view. In addition, the witness and another individual both stated that they did not hear any communications from the pilot over the airport's common traffic advisory frequency. A third witness, who lived near the airport, reported that he heard a "loud" engine noise, looked up, and observed an airplane in a vertical (90-degree bank) left turn. It was traveling "really fast" and the engine sounded "like it was at full-throttle." The airplane disappeared below the tree line and was followed by the sound of a "muffled-boom" and rising smoke. PERSONNEL INFORMATION The pilot, age 49, held a private pilot certificate, with a rating for airplane single-engine land. According to Federal Aviation Administration (FAA) records, the pilot received his private pilot certificate on November 21, 2008. Review of the pilot's logbook revealed entries beginning on March 16, 2008, through August 22, 2009, for approximately 368 hours of total flight experience, of which about 333 hours were logged as "dual received." It was also noted that all flights in the accident airplane, with the exception of a 1.4 hour flight on July 15, 2009, included a flight instructor onboard. It was estimated that at the time of the accident, the pilot had accumulated about 390 hours of total flight experience, all in the same make and model as the accident airplane. The pilot's most recent FAA second-class medical certificate was issued on February 21, 2008. AIRCRAFT INFORMATION The four-seat, low-wing, fixed-gear airplane, serial number 3455, was manufactured in 2009. It was constructed primarily of composite materials, and equipped with a Teledyne Continental Motors IO-550-N, 310-horsepower engine. According to an FAA bill of sale, the airplane waspurchased new by the pilot through a limited liability company during June 2009. According to maintenance records, the airplane had undergone a 50-hour inspection in accordance with the Cirrus SR22 maintenance manual on August 26, 2009, about 40 hours prior to the accident. At the time of the accident, the airplane had been operated for approximately 93 hours since new. METEOROLOGICAL INFORMATION A weather observation taken at UZA, which was at an elevation of 666 feet mean sea level (msl), at 0705 reported, wind from 020 degrees at 4 knots; visibility 9 statute miles; scattered clouds at 6,000 feet, temperature 16 degrees Celsius (C), dew point 14 degrees C; altimeter 30.20 inches of mercury. WRECKAGE AND IMPACT INFORMATION The airplane initially impacted the ground about 100 feet below the top of a 20-degree slope, about 150 feet from taxiway "B," and 255 feet right of the extended center line of runway 20. The airplane was destroyed by fire and impact forces. Fragments of right wingtip were located near the initial impact point. A debris path, oriented on a 160-degree magnetic heading, extended for about 400 feet. Evidence of burnt terrain was observed on the left and right side of the debris path, on an embankment leading up to the taxiway. The airplane was equipped with a Cirrus Airplane Parachutes System (CAPS). The parachute assembly was observed deployed, along the debris path; however, examination of the parachute assembly was consistent with activation due to impact forces. Both wings and all control surfaces were separated and strewn along the debris path, with the majority of the fuselage structure. The main wreckage was located 205 feet from the initial point of impact, and consisted of a top portion of the fuselage from the "b-pillar," aft to the forward side of the CAPS enclosure. A portion of the fuselage station 222 bulkhead was also located with the main wreckage. The roll trim motor was observed in an approximate neutral position. The flap actuator corresponded to the "flaps up" position. All major components of the airplane were accounted for at the accident site. The engine and engine cowling assembly separated from the airframe and came to rest about 70 feet from the initial impact point. The engine remained attached to the firewall via the control cables. The engine exhibited extensive impact and fire related damage. Portions of the No. 1 and No. 5 cylinder head assemblies were separated. The majority of engine accessories, which included both magnetos, the oil filter, the oil cooler, and both turbochargers were separated from the engine. A borescope inspection of all engine cylinders did not reveal any preimpact failures. The No.1 cylinder was impact damaged and the exhaust valve seat was separated from the cylinder head. After removing several components from the engine, including the No.1 cylinder, the engine was rotated via the crankshaft propeller flange. Thumb compression and valve train continuity were establishedon cylinders No.2, 3, 4, and 6. Thumb compression and valve train continuity could not be established on cylinders No.1, and No.5 due to impact related damage. The fuel pump remained attached to the engine and did not exhibit any preimpact failures. Both magnetos were separated from their respective mounting locations and sustained impact and fire damage. The propeller hub remained attached to the engine and exhibited impact damage. All three composite propeller blades were separated from the propeller hub. They all displayed impact damage with leading edge polishing and chordwise scratching. The airplane was equipped with a "Garmin Perspective" cockpit instrumentation system, and a remote data module (RDM). The RDM, which was a crash hardened unit installed in the tail of the airplane intended to record flight, engine and autopilot parameters, was located in the debris path and forwarded to the NTSB Vehicle Recorders Laboratory, Washington, D.C., for download. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot, on September 11, 2009, at Piedmont Medical Center, Rock Hill, South Carolina. The autopsy report indicated the cause of death as "multiple traumatic sharp and blunt force injuries secondary to plane accident." Toxicological testing performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma, was negative for alcohol and positive for Metoprolol detected in the pilot's liver and kidney. The pilot’s most recent application for a second-class airman medical certificate noted a history of high blood pressure and metabolic syndrome, and the use of the medications omeprazole, atorvastatin, benazepril, metoprolol, aspirin and metformin. No other medications or conditions were noted, and the most recent medical certificate application specifically indicated "No" to "Mental disorders of any sort; depression, anxiety, etc.," "Admission to hospital," and "Other illness, disability, or surgery." Height and weight on that application were noted to be 74 inches and 248 pounds, and blood pressure was noted as 124/72. The pilot's previous application for a third-class airman medical certificate was dated November 13, 1992. Review of the pilot’s primary care records indicated additional diagnoses, prior to the pilot’s most recent application for an airman medical certificate, of attention deficit disorder (with prior use of the prescription medication amphetamine/dextroamphetamine), depression (with prior use of the prescription medications bupropion and fluoxetine), anxiety (with hospitalization for anxiety in 2001 and use of the prescription medication clonazepam "0.5 mg three times a day as needed"), and ENT surgery in 2006 for severe snoring (with no indications that a sleep study had been performed). The pilot’s weight on a February 10, 2009, physician’s office visit was noted as 265 pounds. TESTS AND RESEARCH The RDM was successfully downloaded by an NTSB Vehicle Recorder Specialist.Examination of the RDM data revealed that it recorded about 90 hours of data, which included the accident flight. The data was logged once per second. Review of the data for the accident flight revealed that the pilot began the takeoff about 0712:11, when the engine rpm was advanced to about 2700 rpm. The airplane proceeded along a heading of about 020 degrees magnetic, consistent with runway 2. Takeoff rotation occurred at an airspeed of 74 knots. At 0712:31, the airplane began a slight right turn. This turn lasted about 35 seconds, and generally varied from about 5 to 8 degrees of right roll, with a peak of about 17 degrees. During the turn, the airspeed and altitude continued to increase. At 0713:06, at an altitude of 1,051 feet msl, about 385 feet above ground level (agl) and a speed of about 133 knots, the right turn transitioned into a left turn. By 0713:15, the roll attitude had reached 46 degrees left wing down. At about the same time, the airplane reached its maximum altitude of 1,241 feet msl (about 575 feet agl). Over the next 20 seconds, the turn continued at about the same roll attitude (40-50 degrees left wing down), with the pitch remaining relatively level (within about 2 degrees up or down) as the speed increased to 158 knots. At 0713:34, the pitch attitude began to decrease toward a peak of 10 degrees nose down. At 0713:40, the roll attitude began a sharp change toward the right, reaching about 70 degrees right wing down by the end of the recorded data. The last recorded data points included the following: Engine: 2,687 RPM Heading: 165 degrees magnetic Indicated Airspeed: 184 knots Pitch Attitude: 5 degrees nose down Roll Attitude: 69 degrees right wing down Vertical Speed: 2064 feet per minute downward Corrected Altitude 784 feet msl It was noted that the stall warning parameter indicated "off" (not stalled) for the duration of the flight.

Aircraft

Registration
N922XX
Reported as
Cirrus SR-22
Category
Airplane
Serial number
3455
Airframe hours
93
Engine
TCM IO-550-N, 310 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Beck Management Group LLC
Registered owner
Beck Management Group LLC
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · August 26, 2009 · 40 hours before
Departed
UZA · Rock Hill, SC
Destination
UZA · Rock Hill, SC
Airport
UZA · Rock Hill, runway 02, 5,500 × 100 ft, asphalt

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
49
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 2, Without waivers/limitations
Last flight review
November 21, 2008
Seat
Left
Toxicology
Performed
Flight hours
400 total · 400 in this make and model · 50 in the last 90 days · 15 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
20° at 4 knots
Visibility
9 statute miles
Lowest ceiling
None
Temperature
61 °F, dew point 57 °F
Altimeter
30.20 inHg
Observed at
UZA

Docket · 25

The files NTSB released with the investigation on September 29, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 13.6 MB in all.

Aircraft Bill of SaleItem 1 · .PDF · 54 KBMaintenance Records (excerpts)Item 2 · .PDF · 172 KBPilot's Logbook (excerpt)Item 3 · .PDF · 1.1 MBWitness Statements and MemorandumsItem 4 · .PDF · 156 KBStatement of Party Representatives to NTSB InvestigationItem 5 · .PDF · 68 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 6 · .PDF · 50 KBFAA Forensic Toxicology ReportItem 7 · .PDF · 61 KBMedical Records InformationItem 8 · .PDF · 18 KBRecoverable Data Module - Factual ReportItem 9 · .PDF · 1.6 MBRecoverable Data Module - Tabular Data - Figure 5Item 10 · .CSV · 11 KBRecoverable Data Module - Tabular Data - Figure 6Item 11 · .CSV · 12 KBRecoverable Data Module - Tabular Data - Figure 7Item 12 · .CSV · 4 KBRecoverable Data Module - Tabular Data - Figure 8Item 13 · .CSV · 9 KBRecoverable Data Module - Tabular Data - Figure 9Item 14 · .CSV · 20 KBPhotograph # 1 – View of debris path facing north-northwest (opposite direction of travel)Item 15 · .PDF · 911 KBPhotograph # 2 – View of debris path along embankment facing south-southeastItem 16 · .PDF · 1.6 MBPhotograph # 3 – View of debris path from top of embankment facing south-southeastItem 17 · .PDF · 1.0 MBPhotograph # 4 – View of main wreckageItem 18 · .PDF · 1.1 MBPhotograph # 5 – View of debris strewn along and around taxiwayItem 19 · .PDF · 734 KBPhotograph # 6 – View of engine as it came to rest on an embankmentItem 20 · .PDF · 1.6 MBPhotograph # 7 – View of wreckage at recovery facilityItem 21 · .PDF · 860 KBPhotograph # 8 – View of airplane control cables taken at recovery facilityItem 22 · .PDF · 839 KBPhotograph # 9 – View of remote data module (RDM) and panel mount memory cards which were recovered from the debris pathItem 23 · .PDF · 311 KBPhotograph # 10 – View of engine taken at recovery facilityItem 24 · .PDF · 836 KBPhotograph # 11 – View of separated propeller blades taken at recovery facilityItem 25 · .PDF · 463 KB

FAA reports on this event · 1

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