ERA17LA201

NTSB accident investigation · Cirrus Design SR22 · Gordonville, FL · June 11, 2017

Accident · Serious injuriesLimited investigationFinal report
Date
June 11, 2017, 12:00 local (16:00 UTC)
Place
Gordonville, FL
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N592BCCirrus Design SR22
Defining event
Approach-VFR pattern final: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report April 4, 2019
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Cirrus, FAA/FSDO, Continental
FAA report
20170611014419A
Case key
95342

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 properly configure the mixture control for landing due to disorientation because he had the airport diagram upside down, which resulted in a total loss of engine power.

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.

Engine controls: mixture controlAircraft › Aircraft power plant · Incorrect use/operationCirrus Design SR22: 3 casesAll aircraft: 41 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 private pilot stated that he had "disoriented" himself by holding the airport diagram "upside down" as the airplane approached the destination airport. Once oriented, he turned the airplane onto the downwind leg of the traffic pattern, noticed the airplane was "high," and disconnected the autopilot. During the final approach, the airplane was descending rapidly, and the pilot added power to complete the landing. However, nothing happened because he had not properly set the mixture control, which resulted in a loss of engine power once he advanced the throttle. With little time and altitude remaining, the pilot was unable to regain engine power before the airplane struck the ground about 1/2 mile from the runway threshold. A postaccident test-run and examination of the engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation.

Factual narrative

On June 11, 2017, about 1200 eastern daylight time, a Cirrus SR22, N592BC, was substantially damaged when it impacted a power pole, trees, and terrain while on approach to Bartow Municipal Airport (BOW), Bartow, Florida. The private pilot, who was also the owner of the airplane, was seriously injured. Visual meteorological conditions prevailed and no flight plan was filed for the flight which departed Gainesville Regional Airport (GNV) about 1120. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91.The pilot was not immediately available due to his injuries, but was later interviewed by a police detective. During that interview, the pilot stated that he had "disoriented" himself by holding the airport diagram "upside down" as the airplane approached BOW. Once oriented, he turned the airplane on to the downwind leg of the traffic pattern, noticed he was "high" and disconnected the autopilot. During the final approach, the airplane was descending "rapidly" and the pilot added power to complete the landing, but "nothing happened" as he "hadn't reset [the] mixture." According to the pilot, he lacked the time and the altitude to "remedy the problem." In a telephone interview, an air traffic controller stated that the accident airplane contacted the tower north of BOW and was instructed to report entering a left base for landing on runway 9L. Instead, the pilot reported the airplane was on a left downwind for runway 9L and was cleared to land. There were no further communications from the pilot. The final radar target was recorded about 1 mile from the threshold of runway 9L at 700 feet and 130 knots groundspeed. The airplane came to rest in a church yard about 1/2 mile from the threshold of runway 9L. On-scene examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed substantial impact damage to the entire airframe, but no fire damage. There was evidence of fuel, and control continuity was established from the cockpit to the flight control surfaces. Initial visual examination of the engine did not reveal any anomalies. The engine was forwarded to the manufacturer for a detailed examination. Flight and multifunction displays, as well as components from the autopilot system were retained for examination in the NTSB recorders laboratory. The pilot held a private pilot certificate with a rating for airplane single-engine land. His most recent FAA third class medical certificate was issued on March 9, 2011. The pilot reported 750 total hours of flight experience on that date. The four-seat, low-wing, tricycle-gear airplane was manufactured in 2005 and was powered by a Continental IO-550, 310-horsepower engine. The airplane's hobbs meter displayed 2101.6 aircraft hours. The maintenance records were not reviewed, and the maintenance history could not be verified. The aircraft recovery company in possession of the airplane requested the maintenance records from the owner. Hereported that the records were "in a storage facility" and that he could not access them due to his injuries. A copy of the most recent annual inspection forwarded by the pilot's attorney revealed the inspection was completed October 28, 2016 at 2065.3 total aircraft hours. At 1545, weather reported at BOW included a broken ceiling at 3,000 ft, wind from 050° at 4 knots, and 10 statute miles of visibility. The temperature was 27° C, the dew point was 21° C, and the altimeter setting was 30.15 inches of mercury. The engine was removed from the airframe and placed in a test cell at the engine manufacturer's facility in Mobile, Alabama. The engine started immediately, accelerated smoothly, and ran continuously at all power settings with no anomalies noted.

Aircraft

Registration
N592BC
Reported as
Cirrus Design SR22 (NO SERIES)
Category
Airplane
Serial number
1519
Built
2005
Airframe hours
2,065
Engine
Cont Motor IO-550 SERIES, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 28, 2016 · 36 hours before
Departed
GNV · Ganesville, FL
Destination
BOW · Bartow, FL

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
61
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Seat
Left
Flight hours
750 total · 100 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
50° at 4 knots
Visibility
10 statute miles
Lowest ceiling
3,000 ft broken
Temperature
81 °F, dew point 70 °F
Observed at
BOW, 1 nm away

Docket · 11

The files NTSB released with the investigation on January 28, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.7 MB in all.

FAA reports on this event · 1

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