# NTSB ERA18LA124: Cirrus SR22, Lowville, NY, April 8, 2018

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: April 8, 2018, 16:53 local (20:53 UTC)
- Place: Lowville, NY
- Coordinates: 43.821388, -75.571388 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=43.8214&lon=-75.5714&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute-cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240)
- Highest injury: No injuries
- Injuries: 3 uninjured
- 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
- NTSB case key (mKey): 97020
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA18LA124
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/97020/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=97020
- Page: https://openairdocs.org/ntsb/ERA18LA124

## 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

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

- [Attention/monitoring: attention](https://openairdocs.org/ntsb-findings/02021510): Personnel issues › Psychological · Pilot (probable cause); cases with it: [All aircraft, 226 cases](https://openairdocs.org/ntsb-findings/02021510/cases.md)
- [Attention/monitoring: monitoring equip/instruments](https://openairdocs.org/ntsb-findings/02021525): Personnel issues › Psychological · Pilot (probable cause); cases with it: [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/02021525/cases.md)
- [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md)

## Sequence of events

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

- [Enroute-cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Uncontrolled descent: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md)
- [Landing: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md)

## 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 (not matched to a registry record)
- Reported make and model: CIRRUS SR22
- Category: Airplane
- Serial number: 0654
- Year built: 2003
- Airframe hours: 2706
- Engines: 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.

- Pilot; age 47; injuries: none; 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 files)

The files NTSB released with the investigation on December 4, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=97020. 3.7 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468859&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF
- Interview Summary (item 2, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468860&FileExtension=.PDF&FileName=Interview%20Summary-Master.PDF
- Weather Report (item 3, .PDF, 268 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468861&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF
- Photo (item 4, .PDF, 1 photo, 432 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468862&FileExtension=.PDF&FileName=Photo-Master.PDF
- Statement of Party Representatives to NTSB Investigation (item 5, .PDF, 470 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468863&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF
- Evidence Control Form (item 6, .PDF, 229 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468864&FileExtension=.PDF&FileName=Evidence%20Control%20Form-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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