# NTSB GAA19CA570: Cirrus SR22, N1216N, Lexington, NE, September 25, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Data collection · Final report - Date: September 25, 2019, 17:20 local (22:20 UTC) - Place: Lexington, NE - Coordinates: 40.786388, -99.778335 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.7864&lon=-99.7783&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: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed, report March 17, 2020 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 100334 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA570 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100334/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100334 - Page: https://openairdocs.org/ntsb/GAA19CA570 ## Probable cause The pilot's exceedance of the airplane's critical angle of attack during a go around, which resulted in an aerodynamic stall and a hard landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Cirrus Design SR22, 14 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=2130001), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/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: crosswind](https://openairdocs.org/ntsb-findings/03034040): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Cirrus Design SR22, 9 cases](https://openairdocs.org/ntsb-findings/03034040/cases.md?model=2130001), [All aircraft, 1,008 cases](https://openairdocs.org/ntsb-findings/03034040/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot; cases with it: [Cirrus Design SR22, 4 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=2130001), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/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: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Cirrus Design SR22, 19 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=2130001), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/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, during approach to land will full flaps, he decided to perform a go around and applied full power. The airplane started turning left and he applied right rudder. The airplane was "low and slow" and was unable to gain altitude. The airplane continued to drift left then subsequently, landed hard in an adjacent field left of the runway. The pilot further reported that, during the go around, he did not adjust the flap setting to the takeoff setting. The airplane sustained substantial damage to the left wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The pilot added that he did not remember if the stall warning horn was going off, but believed that the airplane aerodynamically stalled before impact. The pilot reported that the wind was from 040° at 20 knots, gusting to 30 knots. The airport's automated weather observation station reported that, about 5 minutes before the accident, the wind was from 050° at 12 knots, 10 statute mile visibility, sky clear, temperature 23°C (73°F), dew point 7°C (45°F), altimeter 29.98" Hg. The airport field elevation was 2412 ft. The pilot was departing on runway 32. The pilot operating handbook checklist titled "Balked Landing/Go-Around" stated in part: 1. Autopilot – DISENGAGE 2. Power Lever – FULL FORWARD 3. Flaps – 50% 4. Airspeed – 75-80 KIAS After clear of obstacles: 1. Flaps – UP The manufacturer published a performance chart titled "Balked Landing Rate of Climb." The calculated rate of climb with full flaps during the balked landing was about 1,168 ft per minute. ## Factual narrative The pilot reported that, during approach to land will full flaps, he decided to perform a go around and applied full power. The airplane started turning left and he applied right rudder. The airplane was "low and slow" and was unable to gain altitude. The airplane continued to drift left then subsequently, landed hard in an adjacent field left of the runway. The pilot further reported that, during the go around, he did not adjust the flap setting to the takeoff setting. The airplane sustained substantial damage to the left wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The pilot added that he did not remember if the stall warning horn was going off, but believed that the airplane aerodynamically stalled before impact. The pilot reported that the wind was from 040° at 20 knots, gusting to 30 knots. The airport's automated weather observation station reported that, about 5 minutes before the accident, the wind was from 050° at 12 knots, 10 statute mile visibility, sky clear, temperature 23°C (73°F), dew point 7°C (45°F), altimeter 29.98" Hg. The airport field elevation was 2412 ft. The pilot was departing on runway 32. The pilot operating handbook checklist titled "Balked Landing/Go-Around" stated in part: 1. Autopilot – DISENGAGE 2. Power Lever – FULL FORWARD 3. Flaps – 50% 4. Airspeed – 75-80 KIAS After clear of obstacles: 1. Flaps – UP The manufacturer published a performance chart titled "Balked Landing Rate of Climb." The calculated rate of climb with full flaps during the balked landing was about 1,168 ft per minute. ## Aircraft - Registration: [N1216N](https://openairdocs.org/aircraft/N1216N), registered now, S/N 0549, built 2003 (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 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 0549 - Year built: 2003 - Airframe hours: 3130.9 - Engines: Lycoming IO-550-N 340 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 16, 2018 - Departed: LXN, Lexington, NE - Airport: LXN, Jim Kelly Field, runway 32, 5,489 × 100 ft, concrete - Equipment: Auto-pilot, Electronic multifunction display, Electronic primary flight display, Onboard weather, ADS-B, Airframe parachute ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: serious; private; airplane ratings: single-engine land; medical: basicmed; last flight review January 16, 2019; seat: front; restraint: 4-point; flight hours: 814 total, 73 in this make and model, 20 in the last 90 days, 14 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 50° at 12 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 45 °F - Altimeter: 29.97 inHg - Observed at: KLXN ## 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 20190925014449A](https://openairdocs.org/incident/20190925014449A), Sep 25, 2019: Cirrus Design Corp SR22, Lexington, NE, Substantial damage. Pilot lost control during a go-around from a cross wind landing. Aircraft banked left, pilot did not climb or stop turn. The aircrafts left wing clipped tree… ## Docket (5 files) The files NTSB released with the investigation on November 26, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100334. 1.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 503 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478393&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation - Pilot (item 2, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478394&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilot-Master.PDF - FAA Interview with Pilot (item 3, .PDF, 127 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478395&FileExtension=.PDF&FileName=FAA%20Interview%20with%20Pilot-Master.PDF - POH Excerpt (item 4, .PDF, 701 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478396&FileExtension=.PDF&FileName=POH%20Excerpt-Master.PDF - Accident Photo (item 5, .PDF, 1 photo, 529 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478397&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.