IAD05FA032

NTSB accident investigation · Cirrus Design SR22 · Coconut Creek, FL · January 15, 2005

Accident · FatalField investigationFinal report
Date
January 15, 2005, 12:23 local (17:23 UTC)
Place
Coconut Creek, FL
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N889JBCirrus Design SR22
Weather
Instrument (IMC) · Day
Status
Completed · report May 30, 2006
Report
Approved by Office Director
Parties
Cirrus Design Corporation, FAA/FSDO, Teledyne Continental
FAA report
20050115000619A
Case key
60866

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 pilot's failure to maintain aircraft control, which resulted in an uncontrolled descent to the ground. Factors included an avionics failure, pilot disorientation, and instrument meteorological conditions. A factor in the severity of the impact was the pilot's failure to deploy the airplane's onboard parachute system.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - in flightManeuvering
Flight/nav instruments - failureFactor
Became lost/disorientedPilot in commandFactor
Aircraft control - not maintainedPilot in commandCause
Weather condition - low ceilingFactor
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - residential area
Procedures/directives - not usedPilot in commandFactor

Analysis

The pilot took off in instrument meteorological flight conditions and shortly thereafter, misinterpreted a series of air traffic control instructions to be for his airplane when they were for another airplane. Subsequent callouts and responses by the pilot indicated confusion, to the point where he stated, "I gotta get my act together here." Less than 1 minute later, the pilot reported "avionics problems," and about 40 seconds after that, during his last transmission, he stated that he was "losin' it." The airplane subsequently descended nose-down, out of clouds, and impacted a house and terrain. The airplane was equipped with a primary flight display (PFD), as well as separate backup instruments in case the display failed. The airplane had approximately 98 hours of operation since being manufactured, and had a history of PFD failures. The pilot had previously practiced partial panel (no PFD) flight. The airplane was also equipped with a parachute system, which was not deployed in flight.

Factual narrative

History of flight

On January 15, 2005, at 1223 eastern standard time, a Cirrus Design Corporation SR22, N889JB, was destroyed when it impacted a house, then terrain, in Coconut Creek, Florida. The certificated commercial pilot was fatally injured. Instrument meteorological conditions prevailed, and the airplane was operating on an instrument flight rules flight plan from Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida, to Naples Municipal Airport (APF), Naples, Florida, and back to Fort Lauderdale Executive. The personal flight was conducted under 14 CFR Part 91.

According to information received from the Federal Aviation Administration (FAA), the airplane departed Fort Lauderdale Executive at 1217.

Radar and transponder data revealed that after the airplane departed Fort Lauderdale Executive, it climbed to the northwest, to 1,600 feet, before beginning a right turn toward the northeast. The airplane then climbed to 1,800 feet, continued the right turn, and once on a southeast heading, descended to 1,000 feet. Subsequently, the airplane turned left, and headed northeast, climbing to 1,900 feet. It then made a right turn to the south, and descended to 400 feet during a 12-second period, followed by a climb to 1,400 feet during the next 12-second period. The airplane subsequently made one more left turn, through north, to the northwest, and its last altitude readout, at 1223:17, was 1,100 feet. The last radar contact was about 500 feet southeast of the accident site.

A review of the voice communication tape revealed:

At 1219:13, the pilot stated: "cirrus november eight eight nine juliet bravo is through a thousand, ah (unintelligible)."

At 1219:59, the controller responded: "eight eight niner juliet bravo you're radar contact, turn left heading two seven zero." The pilot then responded with: "ah, two seven zero, nine zero, ah, nine juliet bravo.

At 1220:07, the controller stated (to another pilot): "seven eight five, turn right, heading zero niner zero."

At 1220:10, an unidentified voice, similar to the accident pilot's, responded: "ah, did you say a right turn to two seven zero?"

At 1220:15, the controller stated: "turn right zero niner zero seven eight five."

The pilot from that airplane did not respond.

At 1220:21, the controller stated: "three six seven eight five, turn right heading zero niner zero."

At 1220:27, there was a sound similar to two pilots blocking each other's transmissions.

At 1220:29, the controller stated: "eight juliet, correction, niner juliet bravo, turn left, two seven zero."

At 1220:32, the pilot responded: "two seven zero for nine juliet bravo"

At 1220:35, the controller stated: "turn now please."

At 1220:39, the controller stated: "november six niner xray, turn left, heading one five zero," and that pilot responded with: "one five zero, six niner xray."

At 1220:43, the controller stated: "november nine juliet bravo, turn left, heading two seven zero, two seventy the heading niner juliet bravo. you've turned the wrong way."

At 1220:49, the pilot responded: "you told me to turn ninety; i'm turning back to two seventy now."

At 1220:52, the controller stated: "negative sir, that was for a seven eight five. november niner juliet bravo, continue in the turn heading of zero niner zero. traffic alert. traffic eleven o'clock, one mile, indicates two thousand, he's southbound."

At 1221:06, the pilot responded: "zero nine zero on the heading, nine juliet bravo."

At 1221:13, the controller stated: "november niner juliet bravo, just continue on a ninety heading. november six niner xray, turn right, heading of zero, correction, turn right, heading two seven zero." That pilot responded: "two seven zero, six niner x."

At 1221:25, the controller stated: "november seven eight kilo, turn left, turn left, heading zero niner zero, maintain three thousand," and the pilot responded: "zero nine zero, seven eight kilo."

At 1221:30, the controller stated: "cirrus niner juliet bravo, climb and maintain two thousand, over."

At 1221:35, the pilot responded: "climbing to two thousand (pause), and you want me (transmission cut off)."

At 1221:40, the controller stated: "november niner juliet bravo, just continue on a ninety heading, heading zero niner zero. i'm trying to get you away from a cessna."

There was no response from the pilot.

At 1221:50, the controller stated: "november niner juliet bravo, fly heading zero niner zero, over."

There was no response from the pilot.

At 1221:59, the controller asked: "november eight eight niner juliet bravo, how do you hear, over?"

At 1222:05, the pilot responded: "i'm hearin' ya. i'm hearin' ya. i'm, i'm, i gotta get, ah, my act together here."

At 1222:11, the controller stated: "november niner juliet bravo, fly heading zero niner zero. i have aircraft off your left, will be on the approach at pompano. just fly a ninety heading, climb and maintain two thousand."

There was no answer from the pilot.

At 1222:30, the controller stated: "seven eight kilo, turn left, three six zero, it's going to be a short vector, i've got a cirrus disorientated out to the of, ah, east of you. i have to get him under control again." That pilot responded: "three six zero, seven eight kilo."

At 0222:39, the controller stated: "thank you. november seven eight five, turn right, heading one eight zero. this will be vectors across the localizer for aircraft that's just going to be coming across pompano at two thousand feet." There was no response from that pilot.

At 1222:52, the controller asked: "cirrus eight eight niner juliet bravo, miami, how do you hear?"

At 1222:55, the pilot responded: "i hear you, but i've got, i've got problems, i've got avionics problems."

At 1223:02, the controller stated: "cirrus niner juliet bravo, roger. do you have a gyro?"

At 1223:07, the pilot responded: "i'm trying to get the plane, ah, level, nine juliet bravo."

At 1223:11, the controller asked: "okay, november niner juliet bravo, do you see the ground?"

At 1223:16, the pilot responded: "negative, I do not see the ground, nine juliet bravo."

At 1223:21, the controller asked: "all right, you have your wings level?"

At 1223:23, the pilot responded: "the wings are level, nine juliet bravo."

At 1223:24, the controller asked: "november niner juliet bravo, roger, do you have a directional gyro?"

At 1223:28, the pilot stated: "i'm losin', i'm losin' it again here."

There were no further transmissions from the pilot.

A witness, an airline transport pilot who was at a park near the accident site, reported that he heard the airplane flying southeast at a very low altitude. He looked up, but couldn't see it through the low overcast and mist. The airplane didn't sound like it had any engine problems, but as it flew farther away, it sounded as if it was maneuvering.

A second witness, who was outside his home near the accident site, stated that he heard an airplane above the clouds that sounded like it was conducting acrobatics, climbing and descending. Suddenly, it descended out of the clouds, then banked and headed back up into the clouds in a northeasterly direction. As it ascended, the witness heard "an rpm change, like it was climbing." The witness then heard the engine get louder, followed by the sound of an explosion. The witness did not see the airplane exit the clouds a second time due to trees in his line of sight.

Another witness, who did see the airplane descend from the clouds the second time, stated that when it did so, the airplane was perpendicular to the ground, "but on a slant."

The accident occurred during daylight hours, in the vicinity of 26 degrees, 15.5 minutes north latitude, 080 degrees, 10.4 minutes west longitude.

Personnel information

The pilot held a commercial pilot certif

Aircraft

Registration
N889JB
Reported as
Cirrus Design SR22
Category
Airplane
Serial number
0949
Airframe hours
98
Engine
Continental IO-550, 310 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Gerald B. Ballard
Registered owner
Jerry Ballard Homes, Inc.
Airworthiness certificate
Standard, Normal
Departed
FXE · Ft Lauderdale, FL
Destination
APF · Naples, FL
Flight plan
IFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
57
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1
Last flight review
March 1, 2004
Seat
Left
Toxicology
Performed
Flight hours
483 total · 405 in this make and model · 418 as pilot in command · 17 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
310° at 5 knots
Visibility
5 statute miles
Lowest ceiling
600 ft overcast
Temperature
68 °F, dew point 66 °F
Altimeter
30.09 inHg
Observed at
FXE, 4 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.