# NTSB LAX05FA088: Cirrus Design SR22 G2, N286CD, Norden, CA, February 7, 2005 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: February 6, 2005, 18:20 local (Feb 7, 2005, 02:20 UTC) - Place: Norden, CA - Coordinates: 39.283889, -120.333335 - Nearby events: https://openairdocs.org/map.md?lat=39.2839&lon=-120.3333&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report December 28, 2006 - Report: Approved by Office Director - Parties: Federal Aviation Administration, Teledyne Continental Motors, BRS, Inc., Cirrus Design Corporation - NTSB case key (mKey): 60969 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX05FA088 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60969/pdf - Page: https://openairdocs.org/ntsb/LAX05FA088 ## Probable cause the pilot's in-flight loss of control following an inadvertent encounter with unforecast severe icing conditions. A factor in the accident was the inaccurate icing forecast developed by the NWS Aviation Weather Center. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, climb - to cruise - weather forecast - inaccurate, nws personnel (contributing factor) - weather condition - icing conditions (cause) - Loss of control - in flight, climb - aircraft control - not maintained, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - mountainous/hilly ## Analysis The airplane, while operating under an instrument flight rules (IFR) flight plan, departed from controlled flight after encountering icing conditions, entered an uncontrolled descent, and collided with the ground. The airplane was equipped with an Ice Protection System that when activated supplied deicing fluid to the wings, tail, and propeller. The aircraft was not certified for flight into known icing and the Pilot Operating Handbook reads that, "Flight into known icing conditions is prohibited." The pilot received a preflight weather briefing, which advised that there were no pilot weather reports (PIREP) for the intended route of flight, and that the freezing level in the Reno area was 6,000 feet with no precipitation. There were no valid SIGMET's or AIRMET's for icing conditions along the pilot's route. The pilot filed his IFR flight plan for 12,000 feet, but indicated he might request 14,000 feet once airborne. After takeoff, at 1807:46, the pilot contacted Oakland Air Route Traffic Control Center (ARTCC) and requested to climb to 16,000 feet to try to get above the clouds. At 1813:40, the pilot reported that he was still in the clouds and asked about going lower. At 1815:00, the pilot advised ARTCC that if he could go up another 200 to 300 feet, he could get above the clouds. ARTCC requested clarification if the pilot wanted to go up or down. The pilot responded that he would like to go up first to build up some airspeed. The pilot was cleared for a block altitude between 16,000 to 17,000 feet. About 2 minutes later, the pilot transmitted that he was "coming down" and that he was "icing up." The last transmission from the pilot was at 1817:42, again indicating that he was icing up and coming down. According to investigators from Ballistic Recovery Systems (BRS), following the examination of the ballistic parachute system, they determined the system was deployed outside of the operating envelope of the system, which is 133 knots indicated airspeed. An examination of the airplane wreckage did not reveal any evidence of preimpact mechanical failures or malfunctions. Analysis of the actual weather conditions encountered revealed the likelihood that the pilot encountered severe icing related to super-cooled large water droplets as the aircraft achieved 16,000 feet and above. Review of the weather forecast products available at the time of the pilot's briefing disclosed that the AFSS briefing fully conformed to Federal Aviation Administration standards and adequately covered the observed and forecast weather conditions. Although post accident analysis of the weather conditions showed the clear likelihood of severe icing conditions, the algorithms used by the NWS Aviation Weather Center to predict icing conditions showed only a low probability of icing in the area, and, in the absence of PIREPs to the contrary, an icing forecast was not triggered. ## Factual narrative HISTORY OF FLIGHT On February 6, 2005, about 1820 Pacific standard time, a Cirrus Design SR22 G2, N286CD, impacted mountainous terrain after encountering icing conditions near Norden, California. The owner/pilot was operating the airplane under the provisions of 14 CFR Part 91. The private pilot, the sole occupant, sustained fatal injuries; the airplane was destroyed. The personal cross-country flight departed Reno/Tahoe International Airport (RNO), Reno, Nevada, about 1750, en route to Oakland, California. Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed. The primary wreckage was at 39 degrees 17 minutes north latitude and 120 degrees 20 minutes west longitude. The National Transportation Safety Board investigator-in-charge (IIC) reviewed recorded radar data and noted a secondary 4271 discreet beacon code at a mode C reported altitude of 4,600 feet msl (mean sea level). Recorded radar data indicated that the airplane took off from RNO and executed the Mustang 6 departure (standard instrument departure procedure (SID)). The airplane climbed on a westerly course for about 18 minutes 30 seconds, and obtained a mode C reported altitude of 16,100 feet msl. The radar data indicated the airplane leveled off and maintained 16,100 feet msl for about 3 minutes 40 seconds. Radar data showed the airplane initiated a climb and obtained a mode C reported altitude of 16,700 feet msl. The last 12 seconds of recorded radar data indicated the airplane was in a descent. Radar contact was lost at 18:17:29, at a mode C reported altitude of 15,700 feet msl. During the flight, the pilot reported to air traffic controllers that he was in icing conditions and was not able to maintain altitude. PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records revealed that the pilot held a private pilot certificate with ratings for airplane single engine land and instrument airplane. The pilot held a third-class medical certificate issued on July 13, 2004, with a limitation that the pilot must possess corrective glasses for near vision. An examination of the pilot's logbook indicated an estimated total flight time of 473.2 hours. He logged 100.4 hours in the last 90 days, and 38.9 hours in the last 30 days. He had an estimated 69 hours in the accident airplane make and model. He completed a biennial flight review on December 29, 2004. AIRCRAFT INFORMATION The airplane was a Cirrus Design SR22 G2, serial number 1235. A review of the airplane's logbooks revealed an entry for an annual inspection dated December 20, 2004. A total airframe time of 5.0 hours was reported at the last annual inspection. The Hobbs hour meter read 71.4 at the last maintenance, which was recorded in the logbook as January 23, 2005. The engine was a Teledyne Continental Motors IO-550-N engine, serial number 917485. Total time on the engine at the last annual inspection was 5.0 hours. Fueling records at Mercury Air Center, located at RNO, established that the airplane was last fueled on February 6, 2005. The airplane was refueled to capacity with the addition of 20.6 gallons of 100LL-octane aviation fuel. Examination of the maintenance records revealed no unresolved maintenance discrepancies against the airplane prior to departure. The accident airplane was equipped with an Ice Protection System. This system was designed and certified for the Cirrus SR22 as a "No Hazard" to normal operations, allowing a pilot who inadvertently enters icing conditions to activate the system. Once the system is activated, deicing fluid flows along the wing, horizontal stabilizer, and propeller blades. The Ice Protection System section of the Pilot Operating Handbook (POH) Supplements (Section 9) states in the Limitations Section that flight into known icing is prohibited. The POH further states, "no determination has been made as to the capability of this system to remove or prevent ice accumulation." Section 3, titled Emergency Procedures, under the heading of "Inadvertent Icing Encounter" states: "Flight into known icing conditions is prohibited." The Ice Protection System section of the POH Supplements (Section 9) also states in part: "Flight into known icing is prohibited. The Ice Protection System has not been evaluated in known icing conditions. At the first indication of icing, the most expeditious and safest course of exiting the icing conditions should be taken." METEOROLOGICAL INFORMATION The closest official weather observation station was Truckee-Tahoe Airport (TRK), Truckee, California, which was located 9.3 nautical miles (nm) northeast of the accident site. The elevation of the weather observation station was 5,900 feet msl. An aviation routine weather report (METAR) for TRK was issued at 1810. It read: Winds from 240 degrees at 6 knots; visibility 10 statute miles; skies 3,400 feet broken, 10,000 feet overcast; temperature 03 degrees Celsius; dew point -03 degrees Celsius; altimeter 29.87 inHg (inches of Mercury). The Safety Board staff meteorologist prepared a factual report, which included the following weather for the departure airport (RNO) and the nearest airport to the accident site (TRK): Reno/Tahoe International Airport (RNO), Reno, field elevation 4,415 feet msl, located approximately 067 degrees at 29 nautical miles from the accident location, augmented Automated Surface Observation System (ASOS). Time-1656; type-METAR; wind-calm; visibility 10 statute miles; present weather - none; sky condition - broken 11,000 feet; temperature 06 degrees Celsius; dew point -01 degree Celsius; altimeter setting 29.82 inHg; remarks - none. Time-1756; type-METAR; wind 020 degrees at 6 knots; visibility 10 statute miles; present weather - none; sky condition - overcast 5,500 feet; temperature 06 degrees Celsius; dew point -01 degree Celsius; altimeter setting 29.83 inHg; remarks - none. Time-1856; type-METAR; wind variable at 4 knots; visibility 10 statute miles; present weather - none; sky condition - broken 6,000 feet overcast 8,000 feet; temperature 06 degrees Celsius; dew point -03 degrees Celsius; altimeter setting 29.83 inHg; remarks-none. COMMUNICATIONS The pilot contacted Reno Flight Service Station (FSS) at 1620 on February 6, 2005. The pilot received a standard weather brief and filed an IFR flight plan. The Safety Board IIC reviewed the recorded conversations between the FSS briefer and the accident pilot. The pilot filed his IFR flight plan with a departure from RNO, via the Mustang VOR Very High Frequency Omni-directional Radio-range (FMG), airway Victor 200, to Truck intersection, airway Victor 392 to Sacramento VOR (SAC), then direct to Oakland. The pilot filed for an altitude of 12,000 feet. The briefing included current and forecasted weather for the Reno area, the intended route of flight, and the destination. The briefer advised the pilot that there were no pilot weather reports (PIREP) for the intended route of flight. The freezing level in the Reno area was 6,000 feet with no precipitation. The pilot indicated he might request 14,000 feet once he was airborne. The Safety Board IIC requested from the FAA transcripts of all communications between the accident pilot and any services provided by the FAA. The FAA notified the IIC that the Digital Voice Recording System (DVRS) had malfunctioned at some point after February 3, 2005, and was not discovered until February 6, 2005. The malfunction affected the first eight channels of the DVRS, and its ability to record information on those eight channels. The eight channels included the following positions: Channel 1 Local 1 Channel 2 Cab Coordinator Channel 3 Ground Control Channel 4 Local 2 Channel 5 Flight Data Channel 6 Clearance Delivery Channel 7 CIC Channel 8 Final Radar Due to this malfunction, the recordings ## Aircraft - Registration: [N286CD](https://openairdocs.org/deregistered/N286CD-2008-04-30), registration cancelled 2008-04-30, S/N 1235, built 2004 (OpenAirDocs) - Reported make and model: Cirrus Design Corp SR22 G2 - 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: 1235 - Airframe hours: 100.1 - Engines: Teledyne Continental IO-550-N 310 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Charles W. McGrath - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, January 1, 2005, 47.7 hours before - Departed: RNO, RENO, NV - Destination: OAK, OAKLAND, CA - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review December 1, 2004; toxicology performed; flight hours: 473 total, 69 in this make and model, 347 as pilot in command, 100 in the last 90 days, 39 in the last 30 days ## Weather - Conditions: Instrument (IMC), Dusk - Wind: 240° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: 10,000 ft overcast - Temperature: 37 °F, dew point 28 °F - Altimeter: 29.87 inHg - Observed at: TRK, 9 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 20050206002509A](https://openairdocs.org/incident/20050206002509A), Feb 6, 2005: Cirrus SR22, Norden, CA, Destroyed, 1 fatal. (-23) On February 6, 2005, approximately 1820 pacific standard time, a Cirrus design corporation SR22, N286CD encountered icing conditions and the pilot… 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.