# NTSB ERA23FA258: Cirrus SR22, Jamestown, NY, June 6, 2023 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: June 6, 2023, 13:52 local (17:52 UTC) - Place: Jamestown, NY - Coordinates: 42.155, -79.263333 - Nearby events: https://openairdocs.org/map.md?lat=42.1550&lon=-79.2633&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: TSB Canada, FAA/FSDO, Cirrus Aircraft - NTSB case key (mKey): 192324 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA23FA258 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192324/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=192324 - Page: https://openairdocs.org/ntsb/ERA23FA258 ## Probable cause The pilots’ failure to maintain airplane control following an anomalous engine indication during the initial climb, which resulted in a loss of control and parachute deployment at an altitude too low for the system to operate effectively. Contributing to the accident was an exceedance of engine manifold air pressure for reasons that could not be determined based on the available evidence. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) - [Performance/control parameters: pitch control](https://openairdocs.org/ntsb-findings/01062022): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [All aircraft, 526 cases](https://openairdocs.org/ntsb-findings/01062022/cases.md) - [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) - [Fuel system](https://openairdocs.org/ntsb-findings/01022800): Aircraft › Aircraft systems · Unknown/Not determined (probable cause); cases with it: [All aircraft, 181 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: 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) - [Initial climb: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The day before the accident, the pilot and the flight instructor brought the airplane to a maintenance facility due to a low engine manifold air pressure (MAP) indication. The owner of the maintenance facility adjusted the MAP via a set screw on the bottom of the slope controller (turbocharger controller), while the instructor performed ground runs to verify it. The instructor then took a facility maintenance technician on a 30-minute post-maintenance flight. There were no anomalies noted during that flight. On the day of the accident, the pilot and instructor flew a cross-country flight to the destination airport. Recorded data indicated that, during the flight, the MAP momentarily exceeded the maximum value of 37.5 in (37.59 in) for 1 second, which activated a red crew alerting system (CAS) message visual warning; however, there were no further exceedances during the flight. After conducting business at the destination, the pilot and instructor boarded the airplane for the return flight. They conducted one uneventful touch-and-go landing when, following the second touch-and-go, about midfield at 200 ft above ground level, the MAP exceeded 38.5 in (39.91 in), which activated an aural CAS warning, and the fuel flow exceeded 41 gph (49.5 gph); however, the engine’s fuel-to-air ratio remained sufficient, and the engine continued to operate. The airplane subsequently pitched up 13° and rolled left 67° just before the Cirrus Aircraft Parachute System (CAPS) was deployed about 293 ft above ground level, which was too low to allow for full deployment of the parachute system. The airplane impacted terrain and was consumed by a postimpact fire. Subsequent examination of the slope controller did not reveal any preimpact mechanical malfunctions; however, it sustained heat damage due to a postcrash fire and its gasket rubber diaphragm were destroyed consistent with heat damage. Examination of the remainder of wreckage also did not reveal any preimpact mechanical malfunctions. Based on the evidence, the pilot(s) likely overreacted to a distracting anomaly in the cockpit (exceedance of MAP, resulting in an aural cockpit CAS warning), lost control of the airplane, and deployed the CAPS at altitude that was insufficient for it to be effective. ## Factual narrative Review of RDM data revealed that during the beginning of the previous flight to JHW, the MAP momentarily exceeded its maximum value of 37.5 in (37.59 in) for one second, which activated a red crew-alerting system (CAS) message visual warning. There were no further exceedances on that flight or the subsequent first touch-and-go at JHW. During the accident touch-and-go, MAP exceeded 38.5 in (39.91 in) which activated an aural CAS warning, and the fuel flow exceeded 41 gph (49.5 gph); however, the fuel-to-air ratio remained sufficient and the engine continued to operate. The airplane subsequently pitched up 13° and rolled left 67° at an indicated airspeed of 76 knots, just prior to CAPS deployment at a pressure altitude of 2,019 ft mean sea level (293 ft above ground level). Review of a pilot’s operating handbook for the airplane make and model revealed that the minimum demonstrated altitude loss from CAPS deployment was 400 ft from level flight, and recommended that 2,000 ft above ground level be kept “in mind as a cut-off decision altitude.” The manufacturer did not specify a minimum altitude for CAPS deployment. The CAPS could be deployed by pulling a handle in the cockpit; the system did not have an auto-deploy feature. The published stall speed (50% flap position) was 70 knots indicated airspeed (KIAS) at 0° bank angle and 92 KIAS at 60° bank angle. According to the owner of a maintenance facility based in Waterloo, Ontario, Canada, the airplane owner/pilot and his instructor arrived at the facility the day before the accident. They reported that the manifold air pressure (MAP) was low. Specifically, it was about 32 in, and the maximum is 37.5 in (minimum in normal operating range is 15 in). The owner of the maintenance facility adjusted the MAP via a set screw on the bottom of the slope controller (turbocharger controller), while the instructor performed ground runs to verify it. The instructor then took a facility maintenance technician on a 30-minute post-maintenance flight and verified that everything was set correctly. There were no anomalies noted during that flight. On June 6, 2023, about 1352 eastern daylight time, a Cirrus SR22T, Canadian registration C-GNMT, was destroyed when it was involved in an accident near Jamestown, New York. The two Canadian-certificated pilots were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to witnesses, the pilot in the left seat owned the accident airplane and brokered other airplanes. Additionally, the pilot in the left seat was preparing for an instrument rating practical examination, scheduled for the following week. The pilot in the right seat was providing instruction for the upcoming examination. The purpose of the accident trip was a combination of training and to work on exporting another airplane for sale in the United States. That airplane was at Chautauqua County/Jamestown Airport (JHW), Jamestown, New York.Earlier during the day of the accident, the pilots flew the accident airplane from Waterloo International Airport (CYKF), Waterloo, Ontario, Canada, to JHW. The accident occurred during the return flight to CYKF. According to ADS-B data and witnesses, the accident airplane departed at 1341 and performed one touch-and-go landing on runway 31. Runway 31 was 4,449 ft-long, 100 ft-wide, and consisted of asphalt. During the initial climb after the second touch-and-go landing on runway 31, about midfield at 100 to 200 feet above ground level, the airplane banked steeply left, leveled, then banked right, followed by deployment of the Cirrus Aircraft Parachute System (CAPS). The airplane subsequently impacted a wooded area on the airport and a postcrash fire ensued. Autopsies were performed on the pilots by the Erie County Office of The Medical Examiner, Buffalo, New York. The cause of death for the pilot was “blunt force trauma of head and torso” and the cause of death for the flight instructor was “multiple blunt injuries.” Toxicological testing of the pilots’ specimens was conducted by the FAA Forensic Sciences Laboratory. The results for the pilot were positive for Rosuvastatin, Amlodipine, and Pantoprazole. Those medications are taken to manage cholesterol and blood pressure, respectively. They are not considered impairing. The toxicological results also noted that methamphetamine was detected in the flight instructor’s urine; however, it was not detected in his blood, and thus likely not impairing at the time of the accident. Logbooks were not recovered for the pilot or the flight instructor. The flight instructor held a Federal Aviation Administration (FAA) first-class medical certificate, issued on April 13, 2023. He reported 9,650 total hours of flight experience on the application for that medical certificate. The wreckage came to rest upright, oriented north, and was mostly consumed by fire. No debris path was observed, and the deployed CAPS was observed next to the wreckage. The empennage remained attached and was partially consumed. The recoverable data module (RDM) sustained thermal damage, but was retained and forwarded to the National Transportation Safety Board Vehicle Recorders Laboratory, Washington, DC, for data download. The forward cockpit section and instrument panel were destroyed. Both wing ailerons and flaps had separated and were partially consumed by postimpact fire. Flight control continuity was confirmed from the cockpit to all control surfaces. Measurement of the flap actuator corresponded to 50% flap position. Measurement of the elevator trim motor corresponded to a neutral trim position. The propeller hub remained attached to the engine. Two composite blades separated, and one remained attached. The wreckage was further examined following recovery to a storage facility. The slope controller was separated from the firewall and sustained heat damage. It remained attached to the engine via two hoses, one to the turbochargerwastegate and one oil return to the engine (just below the left magneto drive). The two hoses were cut for removal of the slope controller, which was retained for teardown examination at the manufacturer’s facility. The pressure relief valve (PRV) remained attached to its front engine mount via four bolts. It also sustained heat damage. The four bolts were removed and the PRV was also retained for examination at the manufacturer’s facility. The turbocharger wastegate shaft tang was found midrange and could be moved by hand, with full travel between the 6 o’clock and 9 o’clock positions. An engine exhaust tube was cut to facilitate visual examination of the turbocharger impeller and the wastegate (via a mirror). No obstructions were observed in the exhaust tube, near the impeller, or the wastegate. Continuity was confirmed from the wastegate to its shaft. Subsequent teardown examination at the manufacturer’s facility revealed that the accident slope controller was comparable to a new exemplar unit. The depth of the slope controller set screw on the accident unit measured .184 in and a new exemplar unit from the factory measured .158 in. Disassembly of the accident slope controller revealed that the gasket and rubber diaphragm were destroyed consistent with heat damage. All internal components were accounted for, and no anomalies were noted other than heat damage from the postcrash fire. The plastic PRV head had melted and the solder bellows had seized, consistent with heat damage. No anomalies were noted that would have precluded normal operation. ## Aircraft - Registration: C-GNMT (not matched to a registry record) - Reported make and model: CIRRUS SR22 (T) - Category: Airplane - Serial number: 1814 - Year built: 2018 - Airframe hours: 344 - Engines: Continental TSIO-550-K 315 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 7, 2023, 75 hours before - Destination: CYKF, Waterloo, WI - Flight plan: VFR - Airport: KJHW, Chautauqua County/Jamestown Airport, runway 31, 4,499 × 100 ft, asphalt - Equipment: ADS-B, Airframe parachute, Angle of attack indicator, Auto-pilot, Data recorder, Electronic multifunction display, Electronic primary flight display, Onboard weather, Satellite tracking device, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3; seat: left; restraint: 4-point; toxicology performed - Flight instructor; age 52; injuries: fatal; private, commercial; airplane ratings: single-engine sea, multi-engine land, single-engine land, multi-engine sea; instrument ratings: airplane; medical: class 1, with waivers/limitations; seat: right; restraint: 4-point; toxicology performed; flight hours: 9,650 total ## Weather - Conditions: Visual (VMC), Day - Wind: 360° at 11 knots, gusting 19 - Visibility: 10 statute miles - Temperature: 66 °F, dew point 46 °F - Altimeter: 29.83 inHg - Observed at: KJHW - METAR: KJHW 061756Z AUTO 36011G19KT 10SM FEW041 19/08 A2983 ## Docket (14 files) The files NTSB released with the investigation on June 24, 2025, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=192324. 11.1 MB in all. - Witness statements (item 1, PDF, 3 pages, 612 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16390802&FileExtension=pdf&FileName=Witness%20Statements_Redacted-Rel.pdf - Memoranda for the record (item 2, PDF, 3 pages, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16391299&FileExtension=pdf&FileName=MFRs-Rel.pdf - Fueling record (item 3, PDF, 1 page, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16391319&FileExtension=pdf&FileName=Fueling%20Record-Rel.pdf - Excerpts from maintenance records (item 4, PDF, 8 pages, 555 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16391405&FileExtension=pdf&FileName=Mx%20Excerpts_Redacted-Rel.pdf - Excerpt from POH (item 5, PDF, 1 page, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18684743&FileExtension=pdf&FileName=SR22T%20POH%20Excerpt-Rel.pdf - Wreckage examination (item 6, PDF, 3 pages, 683 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16162329&FileExtension=pdf&FileName=Wreckage%20Examination-Rel.pdf - Memoranda for the record - component examinations (item 7, PDF, 2 pages, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18682881&FileExtension=pdf&FileName=Component%20MFRs-Rel.pdf - Photo array (item 8, PDF, 5 pages, 4 photos, 888 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16392244&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Recoverable data module - specialist's factual report (item 9, PDF, 23 pages, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16815513&FileExtension=pdf&FileName=Recoverable%20Data%20Module%20-%20Specialist%27s%20Factual%20Report_ERA23FA258-Rel.pdf - Attachment 1 to recoverable data module - specialist's factual report (item 10, CSV, 328 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16815757&FileExtension=csv&FileName=Attachment%201%20to%20Recoverable%20Data%20Module%20-%20Specialist%27s%20Factual%20Report_ERA23FA258-Rel.csv - Attachment 2 to recoverable data module - specialist's factual report (item 11, CSV, 687 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16816736&FileExtension=csv&FileName=Attachment%202%20to%20Recoverable%20Data%20Module%20-%20Specialist%27s%20Factual%20Report_ERA23FA258-Rel.csv - Toxicological reports (item 12, PDF, 2 pages, 332 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16684780&FileExtension=pdf&FileName=Toxes_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 13, PDF, 10 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16391415&FileExtension=pdf&FileName=Party%20Forms_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 & evidence control forms (item 14, PDF, 3 pages, 534 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16460259&FileExtension=pdf&FileName=Signed%20Wreckage%20Release_Redacted-Rel.pdf From the NTSB's public API. 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