# NTSB GAA19CA142: Cirrus SR22, N381DE, Tulsa, OK, February 20, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: February 20, 2019, 17:00 local (23:00 UTC) - Place: Tulsa, OK - Coordinates: 36.039722, -95.982498 - Nearby events: https://openairdocs.org/map.md?lat=36.0397&lon=-95.9825&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR go-around: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - 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): 99004 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA142 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99004/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99004 - Page: https://openairdocs.org/ntsb/GAA19CA142 ## Probable cause The pilot's failure to maintain a stabilized approach with a tailwind and his subsequent failure to maintain yaw control during an attempted go-around. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cirrus Design SR22, 14 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=2130001), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Performance/control parameters: yaw control](https://openairdocs.org/ntsb-findings/01062024): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cirrus Design SR22, 2 cases](https://openairdocs.org/ntsb-findings/01062024/cases.md?model=2130001), [All aircraft, 149 cases](https://openairdocs.org/ntsb-findings/01062024/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cirrus Design SR22, 94 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2130001), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Wind: tailwind](https://openairdocs.org/ntsb-findings/03034015): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Cirrus Design SR22, 9 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md?model=2130001), [All aircraft, 594 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR go-around: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cirrus Design SR22, 74 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2130001), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Approach-VFR go-around: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cirrus Design SR22, 113 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2130001), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that, while en route, he applied left rudder to stay coordinated and that he alternated his left and right legs due to muscle fatigue. He added that, during landing at the destination airport, the approach was stabilized and "felt normal" with the flaps set at 100%. During the landing flare, he used "very little rudder" to maintain centerline, and about 1 to 2 ft above the ground, the airplane suddenly yawed left about 30° to 45°. He added that there was not enough right rudder to maintain the airplane parallel with the runway, so he decided to go around. He applied power, and the airplane then yawed violently left and impacted the ground, exited the runway to the left, and came to rest in the grass left of a parallel taxiway. The airplane sustained substantial damage to the fuselage. The owner provided flight data from the accident flight. Examination of the data revealed that, within 25 seconds of the accident, the airplane descended from 782 to 619 ft mean sea level (msl) with the descent rate peaking around 1,019 ft per minute and the indicated airspeed decreasing from 86 to 60 knots. About 2 seconds before the accident, the pitch attitude peaked at 7° with a left roll of 16°. The airport elevation was about 638 ft msl. The airplane was also equipped with a crash-hardened recoverable data module (RDM). Examination of the data recovered from the RDM revealed that the airplane veered left, the power and pitch were momentarily increased, and the stall warning horn was on. The airplane manufacturer's recommended landing approach speed with flaps set to 100% was 80 to 85 knots. The aerodynamic stall speed at maximum gross weight was about 60 knots. The pilot reported that the wind was light and variable and not gusting. The RDM data revealed that the wind was from 359° at 5 knots. The pilot was landing the airplane on runway 19L. The Federal Aviation Administration inspector reported that he examined the airplane and verified rudder control continuity and noted that "everything was intact." ## Factual narrative The pilot reported that, while en route, he used left rudder to stay coordinated and alternated his left and right leg due to muscle fatigue. During landing at the destination airport, the approach was stabilized and "felt normal" with the flaps set at 100%. During the landing flare, he used "very little rudder" to maintain centerline, and, about 1 to 2 feet above the ground, the airplane suddenly yawed to the left about 30 to 45°. He added that there was not enough right rudder to maintain parallel with the runway, so he decided to go around. He applied power, the airplane yawed violently to the left, the airplane impacted the ground, exited the runway to the left, and came to rest in the grass to the left of a parallel taxiway. The airplane sustained substantial damage to the fuselage. The owner provided flight data from the accident flight. Examination of the data revealed that, within 25 seconds of the accident, the airplane descended from 782 ft mean sea level (msl) to 619 msl with descent rates peaking around 1019 ft per minute and the indicated airspeed decreased from 86 knots to 60 knots. About 2 seconds before the accident, the pitch attitude peaked at 7° with a left roll of 16°. The airport elevation was about 638 ft. The airplane was also equipped with a crash hardened Recoverable Data Module (RDM), a flight recording device installed in the tail of the airplane. Examination of the data recovered from the RDM and revealed that the airplane veered left, the power and pitch were momentarily increased, and the stall warning horn was on. The airplane manufacturer's recommended landing approach speed with flaps set to 100% was 80 to 85 knots. The aerodynamic stall speed at maximum gross weight was about 60 knots. The pilot reported that the wind was light and variable and not gusting. The RDM data revealed that the wind was from 359° at 5 knots. The pilot was landing the airplane on runway 19L. The Federal Aviation Administration inspector reported that he examined the airplane and verified rudder control continuity and that "everything was intact." ## Aircraft - Registration: [N381DE](https://openairdocs.org/deregistered/N381DE-2020-08-01), registration cancelled 2020-08-01, S/N 4526, built 2017 (OpenAirDocs) - Reported make and model: Cirrus SR22 (Undesignat) - Registry model: [Cirrus Design SR22](https://openairdocs.org/model/cirrus-design-sr22) (registry code 2130001) (OpenAirDocs) - Registry engine: [Continental IO-550-N](https://openairdocs.org/engine/continental-io-550-n) (registry code 17215, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 4526 - Year built: 2017 - Engines: Continental IO-550-N reciprocating - Damage: Substantial damage - Flight: Business, Part 91 - Airworthiness certificate: Standard, Normal - Departed: ELD, El Dorado, AR - Destination: RVS, Tulsa, OK - Flight plan: VFR - Airport: RVS, Richard Lloyd Jones Jr, runway 19L, 4,208 × 100 ft, asphalt - Equipment: Angle of attack indicator, Auto-pilot, Data recorder, Electronic multifunction display, Electronic primary flight display, Onboard weather, Stall warning system, Airframe parachute, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review April 17, 2017; seat: left; restraint: 4-point; flight hours: 1,133 total, 725 in this make and model, 1,063 as pilot in command, 81 in the last 90 days, 35 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 250° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 52 °F, dew point 30 °F - Altimeter: 29.89 inHg - Observed at: KRVS ## 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 20190220010389A](https://openairdocs.org/incident/20190220010389A), Feb 20, 2019: Cirrus Design Corp SR22, Tulsa, OK, Substantial damage. Pilot departed rvs at 1530 CST. At approx 1710 CST pilot was cleared to land at krvs rwy 19L. In the flare about 1 or 2 feet off the ground, the plane suddenly… ## Docket (6 files) The files NTSB released with the investigation on April 4, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99004. 7.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471671&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Airplane Data (item 2, .PDF, 205 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471672&FileExtension=.PDF&FileName=Airplane%20Data-Master.PDF - RDM Data from Cirrus (item 3, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471673&FileExtension=.PDF&FileName=RDM%20Data%20from%20Cirrus-Master.PDF - Record of Conversation - FAA Inspector (item 4, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471674&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20FAA%20Inspector-Master.PDF - POH Excerpt (item 5, .PDF, 474 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471675&FileExtension=.PDF&FileName=POH%20Excerpt-Master.PDF - Accident Photo (item 6, .PDF, 849 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471676&FileExtension=.PDF&FileName=Accident%20Photo-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.