# NTSB GAA19CA074: Cirrus SR22, N579CP, Sand Creek, WI, November 21, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: November 21, 2018, 10:45 local (16:45 UTC) - Place: Sand Creek, WI - Coordinates: 45.204723, -91.691665 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=45.2047&lon=-91.6917&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report September 26, 2019 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 98684 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA074 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98684/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98684 - Page: https://openairdocs.org/ntsb/GAA19CA074 ## Probable cause The mechanic's failure to properly secure the air reference line, which resulted in a loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) - [Engine fuel and control: fuel press sensor](https://openairdocs.org/ntsb-findings/01057334): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [All aircraft, 1 case](https://openairdocs.org/ntsb-findings/01057334/cases.md) - [Maintenance](https://openairdocs.org/ntsb-findings/02062000): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [All aircraft, 143 cases](https://openairdocs.org/ntsb-findings/02062000/cases.md) - [Inspection: post maintenance inspection](https://openairdocs.org/ntsb-findings/02061515): Personnel issues › Task performance · Pilot; cases with it: [All aircraft, 57 cases](https://openairdocs.org/ntsb-findings/02061515/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot; cases with it: [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Object/animal/substance](https://openairdocs.org/ntsb-findings/03022000): Environmental issues › Physical environment · Contributed to outcome; cases with it: [All aircraft, 224 cases](https://openairdocs.org/ntsb-findings/03022000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing: 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: 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 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 (not matched to a registry record) - Reported make and model: Cirrus SR22 (Undesignat) - Category: Airplane - Serial number: 3291 - Year built: 2008 - Airframe hours: 1425 - Engines: 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. - Pilot; age 49; injuries: none; 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 ## 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 20181121022789A](https://openairdocs.org/incident/20181121022789A), Nov 21, 2018: Cirrus Design Corp SR22, Sand Creek, WI, Substantial damage. N579CP was climbing through 10000 ft MSL, on a day with published weather 9000 ft overcast in the area. At about 10000 ft there was a sudden drop in fuel flow,… ## Docket (6 files) The files NTSB released with the investigation on April 25, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98684. 2.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 790 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472176&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Accident Pictures (item 2, .PDF, 4 photos, 261 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472177&FileExtension=.PDF&FileName=Accident%20Pictures-Master.PDF - Lawyer Statement (item 3, .PDF, 146 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472178&FileExtension=.PDF&FileName=Lawyer%20Statement-Master.PDF - FAA Record of Conversation (item 4, .PDF, 143 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472179&FileExtension=.PDF&FileName=FAA%20Record%20of%20Conversation-Master.PDF - Engine Data from Accident Flight (item 5, .PDF, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472180&FileExtension=.PDF&FileName=Engine%20Data%20from%20Accident%20Flight-Master.PDF - CAPS Guide (item 6, .PDF, 533 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472181&FileExtension=.PDF&FileName=CAPS%20Guide-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. --- 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.