# NTSB ERA16LA070: Cirrus Design SR20, N614CD, Charles Town, WV, December 16, 2015

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: December 16, 2015, 09:35 local (14:35 UTC)
- Place: Charles Town, WV
- Coordinates: 39.238887, -77.906387
- Nearby events: https://openairdocs.org/map.md?lat=39.2389&lon=-77.9064&mi=10
- Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping)
- Defining event: [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240)
- Highest injury: No injuries
- Injuries: 2 uninjured
- Status: Completed, report November 15, 2018
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: Federal Aviation Administration, Cirrus Design Corp
- NTSB case key (mKey): 92457
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16LA070
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92457/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92457
- Page: https://openairdocs.org/ntsb/ERA16LA070

## Probable cause

The flight instructor's inadequate remedial action and the student pilot's failure to maintain yaw control while practicing a stall, which resulted in an unintentional spin.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Cirrus Design SR20, 15 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=2130000), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Student/instructed pilot (probable cause); cases with it: [Cirrus Design SR20, 47 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2130000), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Attention/monitoring: monitoring other person](https://openairdocs.org/ntsb-findings/02021535): Personnel issues › Psychological · Instructor/check pilot (probable cause); cases with it: [Cirrus Design SR20, 2 cases](https://openairdocs.org/ntsb-findings/02021535/cases.md?model=2130000), [All aircraft, 200 cases](https://openairdocs.org/ntsb-findings/02021535/cases.md)
- [Performance/control parameters: yaw control](https://openairdocs.org/ntsb-findings/01062024): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cirrus Design SR20, 4 cases](https://openairdocs.org/ntsb-findings/01062024/cases.md?model=2130000), [All aircraft, 149 cases](https://openairdocs.org/ntsb-findings/01062024/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Maneuvering: Simulated/training event](https://openairdocs.org/ntsb-events/600); cases with it: [Cirrus Design SR20, 1 case](https://openairdocs.org/ntsb-events/600/sequence.md?model=2130000), [All aircraft, 173 cases](https://openairdocs.org/ntsb-events/600/sequence.md)
- [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cirrus Design SR20, 36 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2130000), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Maneuvering: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Cirrus Design SR20, 9 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=2130000), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md)
- [Uncontrolled descent: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Cirrus Design SR20, 9 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=2130000), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md)

## Analysis

The student pilot and flight instructor were practicing maneuvers, followed by takeoffs and landings. After successfully practicing slow flight, the student performed a power-off stall by slowly elevating the nose until the airplane stalled. The airplane banked right, and the student let go of the stick while applying full left rudder. The airplane then rolled over to the right and began to spin nose down. After two rotations, the flight instructor activated the airplane's parachute system. The student added that he had practiced turning stalls on at least two previous occasions in a different make and model airplane and that, in that airplane, it was easy to recover from those stalls. The flight instructor provided a similar statement about the accident sequence. During the landing, the airplane sustained substantial damage to the right wing and right elevator. Examination of the wreckage did not reveal any evidence of preimpact mechanical malfunctions that would have precluded normal operation. The roll trim, pitch trim, and aileron-rudder interconnect were all in their proper positions. Further, the airplane was last flown 4 days before the accident flight by the operator's chief flight instructor. He reported that the previous flight included both power-on and power-off stalls and that he did not notice anything unusual about the airplane or its handling characteristics during that flight. The student had not flown for about 2 months before the accident and had accrued only 1 flight hour during the 90-day period before the accident. He had accumulated a total flight experience of 81 hours, of which 19 hours were in the accident airplane make and model. Data downloaded from the primary flight display, autopilot computer, and a multifunction display revealed that there was right yaw before the stall. It is likely that the student did not adequately control yaw before the stall due to his lack of recent experience and lack of experience in the make and model airplane, which resulted in a right roll and spin. Additionally, the instructor did not correct the yaw before the stall and did not recover the airplane as it began to enter a spin.

## Factual narrative

On December 16, 2015, at 0935 eastern standard time, a Cirrus SR20, N614CD, was substantially damaged during impact with terrain, after deployment of the Cirrus Airplane Parachute System (CAPS), following a loss of control near Charles Town, West Virginia. The flight instructor and student pilot were not injured. Visual meteorological conditions prevailed and no flight plan was filed for the instructional flight that departed Leesburg Executive Airport (JYO), Leesburg, Virginia, about 0915, destined for Winchester Regional Airport (OKV), Winchester, Virginia. The airplane was operated by Atlantic Airways under the provisions of Title 14 Code of Federal Regulations Part 91.According to the flight instructor, the training flight was planned to include slow flight, stalls, simulated engine failure, and landings. The student pilot was at the controls for the duration of the flight. The takeoff and climb out were normal, and after climbing to a suitable altitude they practiced slow flight before transitioning to a power-off stall exercise. They began the exercise with a descent and increased airspeed to 75 knots, and upon reaching about 3,800 feet msl the student pilot reduced the power to idle, and began to pitch the nose up. Just after the airplane stalled, the student pilot began the recovery. As the airplane pitched downward, it also rolled to the right. The instructor felt the student pilot input left rudder (the flight instructor had his feet on the rudder pedals in order to monitor the student pilot's inputs) which initially reduced the roll, but then the airplane again rolled to the right and entered a spin. After about two rotations, the instructor activated the CAPS. The flight instructor reported at total flight experience of 1,747 hours; of which, 131 hours were in the same make and model as the accident airplane. The student pilot reported that he had not flown for about 2 months and the lesson plan for the day was to practice maneuvers, followed by takeoffs and landings. He first practiced slow flight with flaps fully extended and the stall horn sounding. He then performed a power-off stall by slowly elevating the nose until the airplane stalled. The airplane banked to the right and the student pilot let go of the stick while applying full left rudder. The airplane then rolled over to the right and began to spin nose down. The student pilot added that he had practiced turning stalls on at least two previous occasions in a Cessna 172 and that airplane was easily returned to straight and level flight by applying opposite rudder, full power and neutralizing the ailerons. The Cirrus began to spin so quickly that it seemed like something broke. The student pilot reported a total flight experience of 81 hours; of which, 19 hours were in the same make and model as the accident airplane. The student pilot had flown 1 hour during the 90-day period preceding the accident. The airplane descended under canopy into a wooded area and came to rest inan approximate 30 degrees nose down and 45 degrees left wing down attitude. Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed substantial damage to the right wing leading edge, the nose landing gear, and the right elevator. Flight control continuity was established from the cockpit controls to the control surfaces. The flap control was found in the 50% indicated position, and the flaps were partially deployed. The parachute remained attached to the airplane through its harness, and the canopy remained in the trees. Further examination of the wreckage by an FAA inspector and representative from the airplane manufacturer did not reveal any preimpact mechanical malfunctions with aileron and roll trim control, elevator and pitch trim control, or rudder and rudder-aileron interconnect. The roll trim motor was in an approximate neutral roll trim position. The pitch trim motor was in a slight nose-up pitch trim position. The rudder-aileron interconnect bungie was positioned evenly in the rudder-aileron interconnect arm bungie clamp and evenly spaced between the two cable clamps near the swage of the cable terminal on each end of the right aileron cable turnbuckle. Prior to the accident flight, the airplane was last flown on December 12, 2015, by the chief flight instructor for the operator. He reported that the previous flight was an instructional flight that included both power-on and power-off stalls. The chief flight instructor added that he did not notice anything unusual about the airplane or its handling characteristics during that flight. The primary flight display, autopilot computer, and a memory card from the multifunction display were sent to the National Transportation Safety Board Vehicle Recorders Laboratory, Washington, D.C., for data recovery. The data was plotted and also used for an animation of the stall preceding the spin. Review of the plots and animation revealed that there was right yaw prior to the stall.

## Aircraft

- Registration: [N614CD](https://openairdocs.org/deregistered/N614CD-2016-07-06), registration cancelled 2016-07-06, S/N 1473, built 2004 (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: 1473
- Year built: 2004
- Airframe hours: 1745
- Engines: CONT MOTOR IO-360 200 horsepower reciprocating
- Damage: Substantial damage
- Flight: Instructional, Part 91
- Operator: Atlantic Airways
- Registered owner: Thunderbolt Aviation LLC
- Airworthiness certificate: Standard, Normal
- Last inspection: 100 hour, April 1, 2015, 60 hours before
- Departed: JYO, LEESBURG, VA
- Destination: OKV, WINCHESTER, VA
- Equipment: Electronic multifunction display, Electronic primary flight display, Onboard weather, Stall warning system, Airframe parachute, Auto-pilot, Data recorder

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Flight instructor; age 47; injuries: none; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; seat: right; restraint: 4-point; flight hours: 1,747 total, 131 in this make and model, 1,634 as pilot in command, 44 in the last 90 days, 23 in the last 30 days, 0 in the last 24 hours
- Student pilot; age 61; injuries: none; seat: left; restraint: 4-point; flight hours: 81 total, 19 in this make and model, 3 as pilot in command, 1 in the last 90 days

## Weather

- Conditions: Visual (VMC), Day
- Wind: 80° at 3 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 50 °F, dew point 41 °F
- Altimeter: 30.12 inHg
- Observed at: KJYO, 19 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 20151216023639A](https://openairdocs.org/incident/20151216023639A), Dec 16, 2015: Cirrus Design Corp SR20, Charles Town, WV, Destroyed. [privacy data omitted], CFI, was giving dual instruction to [privacy data omitted], student pilot, in VMC conditions near Charles Town, WV. During a practice…

## Docket (10 files)

The files NTSB released with the investigation on October 18, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92457.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (CFI) (item 1, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467475&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20(CFI)-Master.PDF
- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (Student) (item 2, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467476&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20(Student)-Master.PDF
- Interview Summary (item 3, .PDF, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467477&FileExtension=.PDF&FileName=Interview%20Summary-Master.PDF
- Photo Array (item 4, .PDF, 2 photos): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467478&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF
- Email Correspondence FAA Inspector (item 5, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467479&FileExtension=.PDF&FileName=Email%20Correspondence%20FAA%20Inspector-Master.PDF
- Cockpit Displays Factual Report (item 6, .PDF, 232 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467480&FileExtension=.PDF&FileName=Cockpit%20Displays%20Factual%20Report-Master.PDF
- Attachment 1 to Cockpit Displays Factual Report (item 7, .CSV, 792 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467481&FileExtension=.csv&FileName=Attachment%201%20to%20Cockpit%20Displays%20Factual%20Report-Master.csv
- Animation Based on Recorded Flight Data From Cockpit Displays (15 Sec, MP4, 11MB) (item 8, MP4, 11.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467482&FileExtension=mp4&FileName=Animation%20Based%20on%20Recorded%20Flight%20Data%20From%20Cockpit%20Displays%20(15%20Sec,%20MP4,%2011MB)-Master
- Statement of Party Representatives to NTSB Investigation (item 9, .PDF, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467483&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF
- Release of Aircraft Wreckage, NTSB Form 6120.15 and Evidence Control Documents (item 10, .PDF, 727 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467484&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15%20and%20Evidence%20Control%20Documents-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.

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