# NTSB ERA21FA263: Cirrus SR22, N333LZ, Mercer, TN, June 21, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: June 21, 2021, 09:30 local (14:30 UTC) - Place: Mercer, TN - Coordinates: 35.465254, -89.056968 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.4653&lon=-89.0570&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-climb to cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Cirrus, FAA - NTSB case key (mKey): 103304 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA21FA263 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103304/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103304 - Page: https://openairdocs.org/ntsb/ERA21FA263 ## Probable cause A partial loss of engine power due to foreign object debris contamination of the left turbocharger wastegate. Contributing to the accident was the pilot’s failure to divert to the nearest airport. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Planning/preparation: flight planning/navigation](https://openairdocs.org/ntsb-findings/02061025): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cirrus Design SR22T, 1 case](https://openairdocs.org/ntsb-findings/02061025/cases.md?model=2130004), [All aircraft, 179 cases](https://openairdocs.org/ntsb-findings/02061025/cases.md) - [Turbocharging (recip only): turbocharger](https://openairdocs.org/ntsb-findings/01058120): Aircraft › Aircraft power plant · Malfunction (probable cause); cases with it: [Cirrus Design SR22T, 1 case](https://openairdocs.org/ntsb-findings/01058120/cases.md?model=2130004), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/01058120/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cirrus Design SR22T, 6 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2130004), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel; cases with it: [Cirrus Design SR22T, 2 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=2130004), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-climb to cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Cirrus Design SR22T, 5 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=2130004), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cirrus Design SR22T, 9 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2130004), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cirrus Design SR22T, 17 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2130004), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis While climbing to cruise altitude during a cross-country flight, the pilot advised the air traffic controller that the airplane was experiencing engine issues associated with manifold pressure and requested to divert to an airport where the airplane was maintained; however, this was not the nearest airport. The pilot further stated that he was not declaring an emergency. The controller cleared the airplane to the requested airport with a descent to 3,000 ft msl at the pilot’s discretion, and subsequently transferred communications to the controller at the diversion airport. The controller advised the pilot that he needed to maintain 2,500 ft msl, which was the minimum vectoring altitude (MVA). The airplane gradually descended below the MVA, and the controller advised the pilot that a closer airport was located on his right side (about 10 nm); however, the pilot continued to the diversion airport (about 27 nm). When the controller asked if the pilot was going to use the airframe parachute, the pilot indicated that he was attempting to land in a field. The airplane impacted trees and came to rest in a field about 10 miles from the diversion airport. Data retrieved from the airplane’s Recoverable Data Module (RDM) revealed that the manifold air pressure (MAP) limit was exceeded about 10 minutes into the flight, reaching a peak recorded value of 53.9 inches. The maximum normal operating range for MAP for the airplane according to the pilot operating handbook (POH) was 36.5 inches. The MAP fluctuated from the time of the exceedance until the end of the data, about 19 minutes later. Examination of the engine revealed that the left turbocharger waste gate contained a small metal fragment wedged between the housing and the valve, which was about 75% closed. Metallurgical examination of the fragment revealed it was consistent with stainless steel. Review of the airplane’s maintenance records revealed that the left turbocharger was replaced 3 months before the accident during the most recent annual inspection. It is likely that the maintenance performed on the airplane during the inspection resulted in foreign object deposited into the exhaust system and jammed the waste gate, resulting in an overboost of the turbocharger and partial loss of engine power. ## Factual narrative Review of the airplane’s maintenance records revealed that the most recent annual inspection was completed on March 3, 2021, at an airframe and engine total time of 1,217.9 hours. During the annual inspection, the left turbocharger was replaced with an overhauled turbocharger. According to the airplane pilot operating handbook (POH), the Cirrus Airframe Parachute System (CAPS) is designed to lower the aircraft and its passengers to the ground in the event of a life-threatening emergency. CAPS deployment is likely to result in damage to the airframe and, possibly injury to aircraft occupants, its use should not be taken lightly…. If a forced landing on an unprepared surface is required CAPS activation is recommended unless the pilot in command concludes there is a high likelihood that a safe landing can be accomplished. If a condition requiring a forced landing occurs over rough or mountainous terrain…CAPS activation is strongly recommended….” On June 21, 2021, about 0930 central daylight time, a Cirrus Design Corporation SR22T, N333LZ, was substantially damaged when it was involved in an accident near Mercer, Tennessee. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to air traffic control communications obtained from the Federal Aviation Administration, the airplane departed Memphis International Airport (MEM), Memphis, Tennessee, about 0900 on an instrument flight rules flight plan with an intended destination of Asheville Regional Airport (AVL), Asheville, North Carolina. The pilot established radio communication with air traffic control while climbing through 3,000 ft mean sea level (msl) to 15,000 ft msl; however, after the airplane climbed to 6,600 ft msl, it began to lose altitude. The pilot advised the controller that the airplane was experiencing engine issues associated with manifold pressure. The pilot then requested to divert to McKellar-Sipes Regional Airport (MKL), Jackson, Tennessee, where the airplane was maintained. The pilot further stated that he was not declaring an emergency. The controller cleared the airplane to MKL with a descent to 3,000 ft msl at the pilot’s discretion. The controller then transferred communications to the MKL controller. The pilot contacted the MKL controller while the airplane was descending through 3,900 ft msl for 3,000 ft msl. He asked for the RNAV RWY20 approach to MKL and requested a descent at pilot’s discretion to maintain airspeed. The controller advised the pilot that he needed to maintain 2,500 ft msl, which was the minimum vectoring altitude (MVA) for the area. The airplane subsequently gradually descended below the MVA and the controller advised the pilot that Bolivar Airport (M08), Bolivar, Tennessee, was located on his right side; however, the pilot continued to MKL (At that time, M08 was located about 10 nautical miles (nm) east, and MKL was located about 27 nm northeast of the airplane’s position;respectively). When the airplane was at 720 ft msl, the pilot reported that he was attempting to land in a field. The controller advised the pilot that radar contact was lost; however, he asked the pilot the altitude of the airplane, and the pilot stated 600 ft msl. The controller also asked the pilot if he intended to use the parachute, and the pilot responded that he was trying for a field. No further communications were received from the pilot. The Office of the Medical Examiner, Nashville, Tennessee, performed an autopsy on the pilot. His cause of death was reported as blunt force injuries. Toxicology testing performed by the FAA’s Forensic Services Laboratory on the pilot’s blood and urine identified no evidence of impairing drugs. The wreckage was located in a field on the edge of a tree line about 10 miles southwest of MKL. The airplane came to rest upright on a magnetic heading of 360°. Several large tree branches were lying beside the wreckage. The left wing leading edge exhibited tree impression marks along its length. All three landing gear were separated but remained under the main wreckage. The empennage remained attached to the fuselage. The horizontal stabilizer remained attached to the empennage and exhibited impact damage. The vertical stabilizer remained attached to the empennage; however, the rudder was separated from the vertical stabilizer at the top and mid-point hinges. Control cable continuity was established to all flight control surfaces from the flight controls to the cockpit. The Cirrus Airframe Parachute System (CAPS) was found intact. The safety pin was out of the handle, but the system was not activated. Both wings remained attached to the fuselage and exhibited impact damage. The engine remained attached to the fuselage; however, the engine mounts were fractured in numerous places. The propeller remained attached to the engine. One propeller blade was fractured and found about 20 ft from the main wreckage. The spinner dome was crushed and creased and contained tree bark. The airplane was recovered to a salvage facility for further examination. The bottom spark plugs were removed and exhibited normal wear. The propeller was rotated by hand through 360° and crankshaft continuity was established through the valvetrain. Thumb compression was attained on all cylinders. A lighted borescope was used to examine the pistons, valves, and cylinder walls and all exhibited normal wear. Both turbochargers rotated smoothly by hand. The left exhaust exhibited cracking and melting at the turbocharger attachment flange. The waste gate was removed, and a small metal fragment was wedged between the housing and the valve, which was about 75% closed. The waste gate controller mounting bracket was fractured and the connecting rod was bent. The metal fragment was sent to the National Transportation Safety Board Materials Laboratory for identification. The metallic section was examined using an x-ray fluorescence (XFR) alloy analyzer. Themetallic section was consistent with stainless steel. The Recoverable Data Module (RDM) was removed from the vertical stabilizer. It was not damaged. The RDM was partially downloaded on scene and the data included the accident flight in its entirety. The manifold air pressure (MAP) limit was exceeded about 10 minutes into the flight. The maximum normal operating range for MAP for the airplane according to the POH was 36.5 inches. The peak recorded value during the exceedance was 53.9 inches. Additionally, the MAP fluctuated from the time of the exceedance until the end of the data about 19 minutes later. ## Aircraft - Registration: [N333LZ](https://openairdocs.org/aircraft/N333LZ), registered now, S/N 0243, built 2011 (OpenAirDocs) - Reported make and model: CIRRUS SR22 (T) - Registry model: [Cirrus Design SR22T](https://openairdocs.org/model/cirrus-design-sr22t) (registry code 2130004) (OpenAirDocs) - Registry engine: [Continental TSIO-550 series](https://openairdocs.org/engine/continental-tsio-550-series) (registry code 17043, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 0243 - Year built: 2011 - Airframe hours: 1217 - Engines: Continental TSIO-550-K1B 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Skylane Partners LLC - Registered owner: Skylane Partners LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 3, 2021, 57 hours before - Departed: MEM, Memphis, TN - Destination: AVL, Ashville, NC - Flight plan: IFR - Equipment: ADS-B, Airframe parachute, Angle of attack indicator, Auto-pilot, Data recorder, Electronic flight bag or handheld device, Electronic multifunction display, Stall warning system, Electronic primary flight display, Onboard weather ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 83; injuries: fatal; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; restraint: 4-point; toxicology performed; flight hours: 6,073 total, 3,568 in this make and model, 5,410 as pilot in command, 38 in the last 90 days, 25 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 230° at 12 knots, gusting 17 - Visibility: 10 statute miles - Lowest ceiling: 2,200 ft overcast - Temperature: 82 °F, dew point 73 °F - Altimeter: 29.87 inHg - Icing: Clear - Observed at: MKL, 10 nm away - METAR: KMKL 211453Z 23012G17KT 10SM OVC022 28/23 A2987 RMK AO2 SLP108 T02780233 51010 ## 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 20210621010339A](https://openairdocs.org/incident/20210621010339A), Jun 21, 2021: Cirrus Design Corp SR22T, Mercer, TN, Substantial damage, 1 fatal. On June 21, 2021, at approximately 0930 central daylight time, N333LZ was substantially damaged and the pilot was fatally injured. The accident occurred near… ## Docket (15 files) The files NTSB released with the investigation on June 22, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103304. 32.3 MB in all. - Pilot logbook excepts (item 1, PDF, 3 pages, 14.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12986585&FileExtension=pdf&FileName=pilot%20logbooks_Redacted-Rel.pdf - Excerpt from POH - engine instrument markings and annunciations (item 2, PDF, 1 page, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12986875&FileExtension=pdf&FileName=excerpt%20from%20POH-Rel.pdf - Maintenance logbook excerpts (item 3, PDF, 2 pages, 4.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12986176&FileExtension=pdf&FileName=Maintenance%20logbooks_Redacted-Rel.pdf - FAA ATC report of aircraft accident (form 8020-6-1) (item 4, PDF, 5 pages, 996 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13010728&FileExtension=pdf&FileName=ATC-Rel.pdf - Investigative photos (item 5, PDF, 6 pages, 7.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12985961&FileExtension=pdf&FileName=Investigative%20Photo%27s-Rel.pdf - Toxicological report (item 6, PDF, 1 page, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12660205&FileExtension=pdf&FileName=TOX1_Redacted-Rel.pdf - Metallurgical email report (item 7, PDF, 1 page, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12660459&FileExtension=pdf&FileName=Email%20report-ERA21FA263%20(Metallic%20debris%20from%20waste%20gate)1-Rel.pdf - Fuel flow and map plot (item 8, XLSX, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12986771&FileExtension=xlsx&FileName=N333LZ-Rel.xlsx - Accident flight plots (item 9, PDF, 3 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15691968&FileExtension=pdf&FileName=Cirrus%20Flight%20Track%20Plts%20Data%20Notes%20-%20Mercer%20TN%20(002)-Rel.pdf - Rdm tabular data (item 10, CSV, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12987158&FileExtension=csv&FileName=log_210621_084433_KMEM-Rel.csv - Statement of party representatives to NTSB investigation (item 11, PDF, 1 page, 772 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12659789&FileExtension=pdf&FileName=Cirrus%20-%20Party%20Form%20(signed)_Redacted-Rel.pdf - Evidence control form (item 12, PDF, 1 page, 140 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13010553&FileExtension=pdf&FileName=Evidence-Control-Form-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 13, PDF, 1 page, 495 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12987148&FileExtension=pdf&FileName=Release-of-Wreckage_Redacted-Rel.pdf - Autopsy memorandum of record (item 14, PDF, 1 page, 167 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13010260&FileExtension=pdf&FileName=Autopsy%20Memorandum%20Of%20Record-Rel.pdf - Cirrus POH excerpts (item 15, PDF, 13 pages, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15690914&FileExtension=pdf&FileName=SR22T%20POH%20Excerpts-Rel.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.