# NTSB LAX01FA145: Cirrus Design SR20, N116CD, Sierra Vista, AZ, April 11, 2001 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 10, 2001, 18:50 local (Apr 11, 2001, 01:50 UTC) - Place: Sierra Vista, AZ - Coordinates: 31.759166, -110.419441 - Nearby events: https://openairdocs.org/map.md?lat=31.7592&lon=-110.4194&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report May 13, 2003 - Report: Approved by Office Director - Parties: Teledyne Continental Motors, Cirrus Design - NTSB case key (mKey): 52070 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX01FA145 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/52070/pdf - Page: https://openairdocs.org/ntsb/LAX01FA145 ## Probable cause the pilot's inadequate weather evaluation and attempted VFR flight into IMC, which resulted in an in-flight collision with mountainous terrain. Factors in the accident included the adverse weather conditions and the dusk lighting conditions. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - light condition - dusk (contributing factor) - weather condition - obscuration (contributing factor) - weather condition - clouds (contributing factor) - weather condition - icing conditions (contributing factor) - preflight briefing service - used, pilot in command - weather evaluation - inadequate, pilot in command (cause) - vfr flight into imc - attempted, pilot in command (cause) - In flight collision with terrain/water, cruise - terrain condition - mountainous/hilly ## Analysis The composite aircraft impacted the side of a mountain approximately 20 minutes prior to sunset after the noninstrument rated private pilot departed on a cross-country flight. The pilot obtained printed weather information via a DUATs system approximately 9 hours prior to the flight's departure. AIRMETS for mountain obscurement, moderate turbulence and moderate rime/mixed icing conditions were in effect, and included the area of the accident site. Previous weather observations from the departure airport reported snow showers located over the mountains in the vicinity of the flight's route. A witness located near the accident site, reported he could not see the base of the mountain throughout the day due to sleet, snow, rain, and wind. Nearby airport weather observations indicated VFR weather conditions; however, forecasts for the flight route indicated there was still a chance of mountain obscurement. No evidence was found that the pilot obtained updated weather information for the route of flight prior to taking off. No anomalies were noted that would have prevented normal aircraft operation. ## Factual narrative HISTORY OF FLIGHT On April 10, 2001, about 1850 mountain standard time, a Cirrus SR20 single engine airplane, N116CD, collided with mountainous terrain and burned northwest of Sierra Vista, Arizona. The airplane was destroyed, and the noninstrument rated private pilot and two passengers received fatal injuries. The airplane was registered to, and operated by, the pilot/owner as a personal flight under the provisions of 14 CFR Part 91. The flight originated from the Tucson, Arizona, International Airport at 1830, with Belen, New Mexico (E80), as the intended destination. Instrument meteorological conditions prevailed at the accident site and no flight plan had been filed. The pilot and two passengers were from Wisconsin, and were in Tucson visiting relatives. According to air traffic control records, the pilot radioed the Tucson Clearance Delivery requesting a visual flight rules (VFR) clearance, with a heading of 100 degrees at 3,800 feet to E80. After takeoff, the pilot was instructed to turn to a heading of 120 degrees and to expect an on course clearance from the next controller, and was then instructed to contact departure control. Departure control instructed the pilot to make a left turn to a heading of 030 degrees. The controller then verified the pilot's requested heading and cleared the flight to turn on course. At 1843, radar service was terminated and the pilot was instructed to squawk VFR (transponder code 1200), to which the pilot acknowledged. Concerned family members reported the aircraft overdue when it failed to arrive as scheduled. Civil Air Patrol initiated a search and personnel located the accident site on April 14, 2001. The burned wreckage was located approximately 150 feet below the crest of a ridgeline in the Whetstone Mountains, at 5,200 feet mean sea level (msl). The accident site was approximately 52 nautical miles southeast of Tucson. Belen is located northeast of Tucson. PERSONNEL INFORMATION The noninstrument rated pilot held a private pilot certificate with an airplane single engine land rating. He was issued a third-class medical certificate on January 24, 2000, with a limitation to wear corrective lenses. According to his last medical application, the pilot reported having accumulated a total of 1,450 hours of flight time. Utilizing the aircraft maintenance records, Safety Board investigators estimated that the pilot accumulated approximately 116.6 hours of flight time in the accident airplane as of February 6. According to Cirrus Design, the pilot received SR20 familiarization training between February 3 and February 6, 2000. The training course consisted of five ground training lessons and four flight training lessons. The flight training consisted of basic flight maneuvers, takeoffs and landings, stalls, global positioning system (GPS), emergency procedures, and instrument flying familiarization. The instrument portion covered procedures for recovery from visual flight rules (VFR) flight into instrument meteorological conditions (IMC). AIRCRAFT INFORMATION The single engine, composite airplane was powered by a 200-horsepower Teledyne Continental IO-360-ES engine and a 3-blade, constant speed Hartzell propeller. The airplane was equipped with an airspeed indicator, attitude indicator, altimeter, turn coordinator, heading indicator, and vertical speed indicator. It was also equipped with two Garmin 430 radio/GPS/COMNAV/moving maps and an ARNAV ICDS-2000 Multi Function Display (MFD) with a 10-inch screen. The ARNAV unit displays navigational waypoints, course line, ground speed and other information, which is fed to the ARNAV screen from the No. 1 Garmin 430 radio. The ARNAV unit also has a separate database, which displays terrain elevations based on position. The Garmin 430 is approved for instrument flight rules (IFR) operation; however, the ARNAV MFD is for reference only, and is not certified for flight in instrument conditions. The accident airplane was equipped with a ballistic recovery parachute system, manufactured by Ballistic Recovery Systems (BRS). According to Cirrus Design, the Cirrus Airframe Parachute System (CAPS) is a ballistic recovery device that will lower the entire airframe to the ground when all alternatives to land the aircraft have been exhausted. The CAPS consists of a parachute, a solid propellant rocket to deploy the parachute, a rocket activation handle, and a Kevlar harness imbedded within the fuselage structure. The pilot activates the system by pulling on a T-handle mounted on the cockpit ceiling. This action activates the firing pin mechanism, which in turn ignites the solid propellant rocket in the parachute canister. The aircraft was manufactured and issued an airworthiness certificate in the beginning of 2000. The only and last annual inspection was conducted at the Cirrus Design factory service center between February 5 and February 16, 2001. At that time, the aircraft and engine had accumulated 116.6 hours total time. According to the annual inspection discrepancy list, the turn coordinator was found to be inoperative and was replaced. All applicable service bulletins were complied with at the time of the annual inspection. It is not known how many hours the aircraft had accumulated after the annual inspection up until the time of the accident. METEOROLOGICAL INFORMATION One of the local sheriff's deputies, who is a pilot and lives approximately 2 miles from the base of the Whetstone Mountains, said the weather the day of the accident was "terrible" with icing, sleet, snow, rain, and wind, and he could not see the base of the mountains from his home. A printed copy of weather information, dated April 10, 2001, was found scattered around the accident site. The printed sheets appeared to be incomplete, and included weather information from Arizona to Wisconsin. The information included winds aloft information, notices to airmen, current weather (METAR), terminal forecasts (TAF), and text weather radar data. It is uncertain whether more of the weather information was burned in the wreckage. A section of the printed weather information found at the accident site concerned a terminal forecast for Albuquerque, New Mexico, (issued at 0535 on the 10th). This TAF indicated between 1800 and 2300 the wind would be from 270 degrees at 20 knots gusting to 30 knots; visibility would be greater than 6 miles; ceilings would be broken at 7,000 feet; and showers may be in the vicinity. According to Flight Service Station archived information, the pilot obtained DUATS weather information at 0709 and 0926 on the morning of the accident. The Safety Board conducted a meteorological study and the following are excerpts of the findings: Surface analysis charts prepared by the National Weather Service (NWS) for 1700 and 2000, on April 10th, showed closely packed isobars over Arizona and New Mexico oriented in a northwesterly-southeasterly direction. The 850 and 700 millibar charts for 1700, showed station plots on both charts that generally indicated westerly winds over Arizona at 20-25 knots. The 700 millibar analysis chart showed narrow temperature-dew point spreads at Albuquerque, Tucson, and Flagstaff, which indicated a nearly saturated atmosphere at these locations. The closest weather reporting facility was located at the Safford Regional Airport (SAD), which was 11 nautical miles south-southeast of the accident site. At 1850, the weather observation facility reported the wind from 290 degrees at 12 knots; visibility 10 statute miles; a few clouds at 6,000 feet agl, and scattered clouds at 8,000 feet agl; temperature 4 degrees Celsius; dew point 1-degree Celsius; and an altimeter setting 29.94 inches of mercury. The remarks section of the 1850 report indicated that the rain began at 1755 and ended at 1834. At 1855, the weather observation facility at the Tucson International Airport ( ## Aircraft - Registration: [N116CD](https://openairdocs.org/deregistered/N116CD-2001-07-17), registration cancelled 2001-07-17, S/N 1017 (OpenAirDocs) - Reported make and model: Cirrus Design Corp. SR20 - Registry model: [Cirrus Design SR20](https://openairdocs.org/model/cirrus-design-sr20) (registry code 2130000) (OpenAirDocs) - Category: Airplane - Serial number: 1017 - Airframe hours: 116.5 - Engines: Teledyne Continental IO-360-ES 300 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Douglas Martin Koehler - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 16, 2001 - Departed: TUS, Tucson, AZ - Destination: ABQ, Albuquerque, NM ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 1,567 total, 167 in this make and model ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 280° at 10 knots, gusting 17 - Visibility: 10 statute miles - Lowest ceiling: 7,500 ft broken - Temperature: 52 °F, dew point 23 °F - Altimeter: 29.98 inHg - Observed at: TUS, 34 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 20010410008969A](https://openairdocs.org/incident/20010410008969A), Apr 10, 2001: Cirrus SR20, Sierra Vista, AZ, No damage. (-23) Mr. Koehler, while acting as pilot in command of a SR-200, N116CD, was enroute to milwaukee, wis. From tucson AZ. The aircraft departed tucson airport at… 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.