ERA18LA124

NTSB accident investigation · Cirrus SR22 · Lowville, NY · April 8, 2018

Accident · No injuriesLimited investigationFinal report
Date
April 8, 2018, 16:53 local (20:53 UTC)
Place
Lowville, NY
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
C-GMDQCirrus SR22
Defining event
Enroute-cruise: Loss of control in flight
Weather
Instrument (IMC) · Day
Status
Completed · report May 29, 2019
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Continental Motors Inc, FAA/FSDO, Cirrus Design Corporation
Case key
97020

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's diverted attention, which resulted in his inadequate monitoring of the airplane's attitude and a loss of control in flight.

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.

Attention/monitoring: attentionPersonnel issues › Psychological · PilotAll aircraft: 226 casesProbable cause
Attention/monitoring: monitoring equip/instrumentsPersonnel issues › Psychological · PilotAll aircraft: 142 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedAll aircraft: 1,269 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 airplane was on a cross-country flight at 9,000 ft mean sea level, which was about 1,000 ft above clouds. At that time, the private pilot had the autopilot engaged and in navigation mode for the airplane to proceed directly to the next waypoint. An air traffic controller requested that the pilot turn right 20° or more, which the pilot complied with by switching the autopilot to heading mode and selecting the desired heading. Subsequently, the controller advised the pilot that he could proceed back on course. The pilot switched the autopilot back to navigation mode but did not select the next waypoint on the GPS. He realized immediately that he was returning to his previous navigation course and then selected the next waypoint on the GPS and again selected navigation mode on the autopilot. By the time he returned his attention to the primary flight display, the airplane was descending out of control through clouds, and the pilot subsequently activated the airplane's parachute system. The airplane descended via parachute and landed upright in a field, but wind gusts blew the parachute, which inverted the airplane. Examination of the wreckage revealed that during the hard landing, the nose landing gear collapsed and both main landing gear spread outward, which resulted in substantial damage to the primary structure of the airplane. The primary flight display did not record any data. Thus, the investigation could not determine if the autopilot was engaged when the airplane departed controlled flight. However, regardless of whether or not the autopilot was engaged, it is likely that the pilot's attention was diverted to the GPS, which resulted in his failure to adequately monitor the airplane's attitude and maintain control of the airplane.

Factual narrative

On April 8, 2018, about 1653 eastern daylight time, a Cirrus SR22, Canadian registration C-GMDQ, owned and operated by the private pilot, was substantially damaged during a hard landing, following a Cirrus Airframe Parachute System (CAPS) deployment near Lowville, New York. The Canadian-certificated private pilot and two passengers were not injured. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the flight that departed Bedford County Airport (HMZ), Bedford, Pennsylvania. The intended destination for the flight was Montreal Mirabel International Airport (CYMX), Mirabel, Quebec, Canada.The pilot reported that the airplane was in cruise flight at 9,000 ft mean sea level, which was 1,000 feet above clouds. At that time, the autopilot was engaged and in navigation mode to proceed direct to the next waypoint, which was Massena International Airport (MSS), Massena, New York. Air traffic control (ATC) requested that the pilot turn right 20° or more, which the pilot complied with by switching the autopilot to heading mode and selecting the desired heading. Subsequently, ATC advised the pilot that he could proceed back on course. The pilot selected the autopilot back to navigation mode but did not select direct MSS on the GPS. He realized immediately that he was returning to his previous navigation course and then selected direct MSS in the GPS and again selected navigation mode on the autopilot. By the time he returned his vision and attention to the primary flight display, the airplane was descending out of control through clouds. Additionally, the depicted horizon on the primary flight display (PFD) did not appear correct and the pilot activated the CAPS. The pilot reported a total flight experience of 292 hours; of which, 220 hours were in the same make and model as the accident airplane. Examination of the wreckage by a Federal Aviation Administration inspector revealed that the airplane descended via parachute and landed upright in a field. Subsequently, after all occupants egressed, wind gusts blew the parachute, which inverted the airplane. Further examination of the damage by a National Transportation Safety Board structural engineer revealed that during the upright landing on firm ground, the nose landing gear collapsed and both main landing gear spread outward, which resulted in substantial damage to the primary structure of the airplane. Examination of the PFD revealed that it did not record any data. A check of the PFD's serial number by the manufacturer revealed that it was 16 years old and had not had a software update in 12 years. As such, the PFD, multifunction display and autopilot did not record any data. Without the data, the investigation could not determine if the autopilot was engaged or disengaged at the time when the airplane departed controlled flight.

Aircraft

Registration
C-GMDQ
Reported as
Cirrus SR22
Category
Airplane
Serial number
0654
Built
2003
Airframe hours
2,706
Engine
Continental IO-550-N, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 5, 2018 · 15 hours before
Departed
HMZ · Bedord, PA
Destination
CYMX · Mirabel
Flight plan
IFR
Equipment
Electronic primary flight display, Onboard weather, Satellite tracking device, Stall warning system, Airframe parachute, Electronic multifunction display, Auto-pilot

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
47
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
November 1, 2017
Seat
Left
Restraint
4-point
Flight hours
292 total · 220 in this make and model · 124 as pilot in command · 19 in the last 90 days · 17 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
310° at 3 knots
Visibility
1.37 statute miles
Lowest ceiling
1,000 ft broken
Temperature
27 °F, dew point 21 °F
Altimeter
29.92 inHg
Observed at
GTB, 15 nm away

Docket · 6

The files NTSB released with the investigation on December 4, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.7 MB in all.