ERA23FA182

NTSB accident investigation · Cirrus Design SR22 · Jesup, GA · April 6, 2023

Accident · FatalClass 3 · FieldFinal report
Date
April 6, 2023, 07:50 local (11:50 UTC)
Place
Jesup, GA · 1,200 ft short of runway 29 threshold
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N911TKCirrus Design SR22
Defining event
Approach: Loss of control in flight
Weather
Instrument (IMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
Cirrus Aircraft, FAA/FSDO
FAA report
20230406013859A
Case key
107019

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 failure to maintain adequate airspeed and his exceedance of the airplane’s critical angle of attack, which resulted in a loss of control while maneuvering for a visual landing in low ceiling and low visibility conditions. Contributing to the accident was the pilot’s decision to attempt a visual landing in low visibility conditions.

Findings · 5

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.

Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedCirrus Design SR22: 24 casesAll aircraft: 1,681 casesProbable cause
Ceiling/visibility/precip: low ceilingEnvironmental issues › Conditions/weather/phenomena · Decision related to conditionCirrus Design SR22: 8 casesAll aircraft: 190 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCirrus Design SR22: 94 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Not attained/maintainedCirrus Design SR22: 14 casesAll aircraft: 990 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 instrument-rated private pilot was commuting to work in his airplane. The pilot did not request any air traffic control services for the 22-minute flight, and the airspace at the destination airport was not tower-controlled. Recorded track data revealed that the pilot began a descent to the destination airport and crossed over the approach end of the runway on a heading perpendicular to the runway heading. He then made two turns of about 180° while flying at airspeeds near the airplane’s published stall speed, and reached about 40° of bank during each turn. Additionally, the post-accident position of the flaps suggested that at least the final phase of this maneuvering was being performed with the wing flaps retracted. The airplane impacted terrain about 1,200 ft short of the runway approach end and about 40 ft north of runway centerline. Although there was an instrument approach procedure for the runway, the track data revealed that there was no attempt by the pilot to execute it. The lowest weather minimums for the approach required at least one mile visibility. Weather at the destination airport at the time of the accident included a 300-ft ceiling, ¼ mile visibility in fog, and calm wind. The weather conditions cleared about an hour after the accident. A postaccident examination of the wreckage did not reveal evidence of a mechanical malfunction or anomaly that would have precluded normal operation. Engine operation was recorded on the onboard avionics and revealed increasing power at impact consistent with the pilot advancing the throttle. Based on this information, it is likely that the pilot attempted to fly under the low overcast while trying to acquire the airport visually. During this attempt, he excessively banked the airplane at slow speed, and with the wing flaps retracted, exceeded the airplane’s critical angle of attack, and lost control of the airplane, resulting in a collision with terrain. His tendency to not be late for appointments may have added self-induced pressure and affected his decision-making during the flight.

Factual narrative

According to the Cirrus Design SR22 Pilot’s Operating Handbook, at the maximum gross weight of 3,400 lbs, stall speed with flaps up and 45° bank was 81 kts indicated airspeed (KIAS) at the most aft center of gravity (G.G.) and was 84 KIAS with flaps up and 45° bank at the most forward C.G. With flaps full down, the stall speeds under the same conditions were 72 and 73 KIAS, respectively. On April 6, 2023, about 0750 eastern daylight time, a Cirrus Design Corporation SR22, N911TK, was substantially damaged when it was involved in an accident near Jesup, Georgia. The private pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to recorded data from the airplane’s primary flight display (PFD) and multi-function display (MFD), the airplane took off from Fernandina Beach Municipal Airport (FHB), Fernandina Beach, Florida, about 0728, climbed to about 1,800 ft, and flew to the north-northwest. About 0746, the airplane began descending. The pilot did not request any air traffic control services during the flight. As the airplane approached Jesup-Wayne County Airport (JES), Jesup, Georgia, from the south, it slowed to an indicated airspeed of about 75 knots (kts) and maintained this airspeed within ±5 kts for the remainder of the recording. Track data showed that the airplane initially crossed over the approach end of runway 29 perpendicular to the runway heading (see Figure 1). At 07:50:03, the airplane began to roll right to an ultimate bank angle of about 40° at 07:50:37, and then immediately rolled left to 40°. The airplane subsequently began to roll slightly back towards wings level before it rolled left and pitched down. The MFD stopped recording at 07:51:00, and the PFD stopped recording at 07:51:09. Figure 1 – Final Flight Track and Wreckage Location There was a published RNAV GPS approach to runway 29; however, the airplane’s recorded flight track was inconsistent with that instrument approach procedure. The lowest weather minimums for the approach required at least one mile visibility. The airport was equipped with an Automated Weather Observing System (AWOS) and the 0750 observation included ¼-mile visibility in fog, calm wind, and a ceiling of 300 ft. Airport personnel who arrived to work about 5 minutes after the accident reported and documented fog on the ramp at the time of their arrival. The AWOS reports issued surrounding the time of the accident indicated that restricted visibilities in mist were first observed at 0615, with dense fog being reported from 0635 through about 0820, then mist at 0821 through 0835 before clearing at 0855. According to the pilot’s flight instructor, the pilot completed an instrument proficiency check on September 29, 2021, in the accident airplane. No record of a current flight review per 14 CFR 61.56 (a) and (c) was found. His most recent logged flight review was completed on September 11, 2019. According to interviews with thepilot’s spouse and the JES airport manager, the pilot owned the airplane and used it to commute between his home in Fernandina Beach, Florida and Jesup, where he owned a chiropractic practice. His wife reported that he was “obsessed with weather” and they had an agreement that he would take “no chances” regarding the weather. If the weather was questionable, he would drive instead. The pilot’s spouse and the airport manager both reported the pilot was never late for appointments. His office opened at 0800; however, his spouse did not know what time his first appointment was. The wreckage came to rest upright, and there was no fire. Ground signatures were consistent with a right-wing-low, nose-low impact with terrain. The wreckage came to rest near to the point of initial ground impact on a heading of 040°. The wing flaps actuator was found in the retracted (up) position. One of the propeller blades fractured during the impact sequence. The blades exhibited chordwise scratching, surface polishing, and “S” bending signatures. The airplane was equipped with the Cirrus Airframe Parachute System (CAPS). The system had not activated, and the parachute was not deployed. The CAPS safety pin was found in place in the CAPS handle holder. The airplane was equipped with electronic multifunction and primary flight displays. The non-volatile memory from those units were forwarded to the National Transportation Safety Board Vehicle Recorders Laboratory for examination and download of the data. Recorded engine data from the Avidyne components revealed that the engine was in operation at the time of impact with the terrain, and the data was consistent with an application of power during the last few seconds. The last recorded engine parameters indicated 2,290 rpm, oil pressure 51 psi, oil temperature 178°F, fuel flow 17.1 gph, and manifold pressure 24.9 inHg. Examination of the airframe, engine and propeller did not reveal evidence of a mechanical malfunction or anomaly that would have precluded normal operation.

Aircraft

Registration
N911TK
Reported as
Cirrus Design SR22
Category
Airplane
Serial number
1001
Built
2004
Airframe hours
977.8
Engine
Continental IO-550-N (27), 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 9, 2022 · 23 hours before
Departed
FHB · Fernandina Beach, FL
Destination
JES · Jesup, GA
Airport
JES · Jesup-Wayne County, runway 29, 5,500 × 100 ft, asphalt
Equipment
Electronic primary flight display, Electronic multifunction display, Airframe parachute, Stall warning system

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
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Left
Restraint
4-point
Flight hours
953 total · 419 in this make and model · 20 in the last 90 days · 2 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
Calm
Visibility
0.25 statute miles
Lowest ceiling
300 ft overcast
Temperature
63 °F, dew point 61 °F
Altimeter
30.23 inHg
Observed at
KJES, 1 nm away
METAR
KJES 061150Z AUTO 00000KT 1/4SM FG OVC003 17/16 A3023 RMK AO2

Docket · 20

The files NTSB released with the investigation on January 29, 2025, on NTSB’s docket system: statements, records, photos and specialists’ reports. 68.5 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.