GAA19CA074

NTSB accident investigation · Cirrus SR22 · Sand Creek, WI · November 21, 2018

Accident · No injuriesData collectionFinal report
Date
November 21, 2018, 10:45 local (16:45 UTC)
Place
Sand Creek, WI
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N579CPCirrus SR22
Defining event
Enroute: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report September 26, 2019
Report
Approved by Office Director
NTSB office
General Aviation Accidents
Parties
FAA
FAA report
20181121022789A
Case key
98684

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 mechanic's failure to properly secure the air reference line, which resulted in a loss of engine power.

Findings · 6

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.

Engine (reciprocating)Aircraft › Aircraft power plant · Incorrect service/maintenanceAll aircraft: 497 casesProbable cause
Engine fuel and control: fuel press sensorAircraft › Aircraft power plant · Incorrect service/maintenanceAll aircraft: 1 caseProbable cause
MaintenancePersonnel issues › Task performance · Maintenance personnelAll aircraft: 143 casesProbable cause
Inspection: post maintenance inspectionPersonnel issues › Task performance · PilotAll aircraft: 57 cases
Inspection: preflight inspectionPersonnel issues › Task performance · PilotAll aircraft: 551 cases
Object/animal/substanceEnvironmental issues › Physical environment · Contributed to outcomeAll aircraft: 224 cases

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 pilot reported that, during a ferry flight, while climbing the airplane to cruise altitude, the engine temperatures increased quickly and that the engine then surged. The pilot added that he "switched" the boost pump, adjusted the mixture lever, and then deployed the ballistic parachute system at 3,500 ft mean sea level. During the off-airport landing in a field, the airplane impacted an irrigation sprinkler system. The airplane sustained substantial damage to the fuselage. Postaccident examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed that two air lines were disconnected and that there were no torque lines on the lines. According to the FAA inspector, the pilot and a mechanic who had conducted the airplane's last maintenance reported that the airplane had been flown 7 hours since the last maintenance. The mechanic had replaced three cylinders during the maintenance, which required removal of the air lines. It is likely that, during the maintenance, the mechanic did not properly secure the air reference line, which led to a loss of engine power.

Factual narrative

The pilot reported that, during a ferry flight, while in the climb to cruise altitude, the engine temperatures increased quickly, the engine surged and then lost power. He then deployed the Cirrus airframe parachute system (CAPS). The pilot's lawyer further reported that, after the engine surged, the pilot executed a "rapid" descent to get the engine "breathing better". The engine then lost power and the pilot pulled the CAPS. During the off-airport landing, in a field, the airplane impacted an irrigation sprinkler system. The airplane sustained substantial damage to the fuselage. During a postaccident examination of the airplane by the Federal Aviation Administration (FAA) inspector and airplane manufacturer, it was revealed that, the air reference line for the fuel injectors was found disconnected on the right-side bank at cylinder #1 and disconnected at the aft baffling. The FAA inspector further reported that, the airplane had flown 7 hours since maintenance, where 3 cylinders had been repaired/replaced. He added that, this was the first time the mechanic had worked on the airplane for the owner. The airplane was to be flown at 10,000 ft or less for the 1st 10 hours after the maintenance. The pilot reported that the power loss occurred 12 minutes into the flight while passing through 10,000 ft to 15,000 ft. The pilot stated that he applied the boost pump, adjusted the mixer lever, and finally pulled the CAPS chute at 3,500 ft MSL. The pilot added, that he had done a flight 2-3 weeks prior.

Aircraft

Registration
N579CP
Reported as
Cirrus SR22 (Undesignat)
Category
Airplane
Serial number
3291
Built
2008
Airframe hours
1,425
Engine
TCM IO-550-N-51B, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Ferry · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 14, 2018
Departed
UBE · Cumberland, WI
Destination
CAK · Akron, OH
Flight plan
IFR
Equipment
Data recorder, Electronic multifunction display, Electronic primary flight display, Stall warning system, ADS-B, Auto-pilot, Airframe parachute

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
49
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
April 4, 2018
Seat
Left
Restraint
3-point
Flight hours
4,200 total · 3,500 in this make and model · 4,000 as pilot in command · 110 in the last 90 days · 30 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
50° at 8 knots
Visibility
10 statute miles
Temperature
19 °F, dew point 10 °F
Altimeter
30.37 inHg
Observed at
KRPD, 13 nm away

Docket · 6

The files NTSB released with the investigation on April 25, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.0 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.