# NTSB ERA17LA201: Cirrus Design SR22, N592BC, Gordonville, FL, June 11, 2017 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: June 11, 2017, 12:00 local (16:00 UTC) - Place: Gordonville, FL - Coordinates: 27.945554, -81.798614 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=27.9456&lon=-81.7986&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report April 4, 2019 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Cirrus, FAA/FSDO, Continental - NTSB case key (mKey): 95342 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA17LA201 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95342/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95342 - Page: https://openairdocs.org/ntsb/ERA17LA201 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine controls: mixture control](https://openairdocs.org/ntsb-findings/01057602): Aircraft › Aircraft power plant · Incorrect use/operation (probable cause); cases with it: [Cirrus Design SR22, 3 cases](https://openairdocs.org/ntsb-findings/01057602/cases.md?model=2130001), [All aircraft, 41 cases](https://openairdocs.org/ntsb-findings/01057602/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cirrus Design SR22, 16 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=2130001), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Perception/orientation/illusion: visual illusion/disorientation](https://openairdocs.org/ntsb-findings/02022015): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cirrus Design SR22, 1 case](https://openairdocs.org/ntsb-findings/02022015/cases.md?model=2130001), [All aircraft, 51 cases](https://openairdocs.org/ntsb-findings/02022015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern final: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Cirrus Design SR22, 23 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=2130001), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Approach-VFR pattern final: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cirrus Design SR22, 50 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2130001), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cirrus Design SR22, 113 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2130001), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N592BC-2020-10-03), registration cancelled 2020-10-03, S/N 1519, built 2005 (OpenAirDocs) - Reported make and model: CIRRUS DESIGN CORP SR22 (NO SERIES) - Registry model: [Cirrus Design SR22](https://openairdocs.org/model/cirrus-design-sr22) (registry code 2130001) (OpenAirDocs) - Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1519 - Year built: 2005 - Airframe hours: 2065 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: serious; 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 ## 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 20170611014419A](https://openairdocs.org/incident/20170611014419A), Jun 11, 2017: Cirrus Design Corp SR22, Bartow, FL, Destroyed. Pilot recalls getting low on final. When adding power to correct, the engine was unresponsive. Pilot believes he forgot to advance mixture control to full rich. ## Docket (11 files) The files NTSB released with the investigation on January 28, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95342. 8.7 MB in all. - Cockpit Displays – Recorded Flight Data - Specialist's Factual Report (item 1, .PDF, 6.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469823&FileExtension=.PDF&FileName=Cockpit%20Displays%20%E2%80%93%20Recorded%20Flight%20Data%20-%20Specialist%27s%20Factual%20Report-Master.PDF - Cockpit Displays – Recorded Flight Data - Attachment 1 (PFD) - Tabular Data (CSV) (item 2, .CSV, 655 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469824&FileExtension=.csv&FileName=Cockpit%20Displays%20%E2%80%93%20Recorded%20Flight%20Data%20-%20Attachment%201%20(PFD)%20-%20Tabular%20Data%20(CSV)-Master.csv - Cockpit Displays – Recorded Flight Data - Attachment 2 (MFD) - Tabular Data (CSV) (item 3, .CSV, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469825&FileExtension=.csv&FileName=Cockpit%20Displays%20%E2%80%93%20Recorded%20Flight%20Data%20-%20Attachment%202%20(MFD)%20-%20Tabular%20Data%20(CSV)-Master.csv - Memo for Record - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 4, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469826&FileExtension=.PDF&FileName=Memo%20for%20Record%20-%20Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Maintenance Records Annual Inspection (item 5, .PDF, 186 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469827&FileExtension=.PDF&FileName=Maintenance%20Records%20Annual%20Inspection-Master.PDF - Memo for Record - Pilot's Statement (item 6, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469828&FileExtension=.PDF&FileName=Memo%20for%20Record%20-%20Pilot%27s%20Statement-Master.PDF - Employee Statements Florida Air Recovery (item 7, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469829&FileExtension=.PDF&FileName=Employee%20Statements%20Florida%20Air%20Recovery-Master.PDF - Air Traffic Control Interview Summary (item 8, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469830&FileExtension=.PDF&FileName=Air%20Traffic%20Control%20Interview%20Summary-Master.PDF - Photos (item 9, .PDF, 2 photos, 605 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469831&FileExtension=.PDF&FileName=Photos-Master.PDF - Statement of Party Representatives to NTSB Investigation (Cirrus) (item 10, .PDF, 236 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469832&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%20(Cirrus)-Master.PDF - Statement of Party Representatives to NTSB Investigation (CMG) (item 11, .PDF, 666 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469833&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%20(CMG)-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.