LAX07FA021

NTSB accident investigation · Cirrus SR22 · Meadview, AZ · October 25, 2006

Accident · FatalField investigationFinal report
Date
October 25, 2006, 12:08 local (19:08 UTC)
Place
Meadview, AZ
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N121LDCirrus SR22
Weather
Visual (VMC) · Day
Status
Completed · report January 31, 2008
Report
Approved by Office Director
Parties
Am-Safe, National Transportation Safety Board, Teledyne Continental, CAV Aerospace, Federal Aviation Administration, Cirrus Design, UK Air Accidents Investigation Branch
FAA report
20061025030429A
Case key
64769

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 inadequate weather evaluation and continued flight into forecasted icing conditions. Contributing to the severity of the accident was the pilot's failure to follow proper operating procedures and deploy the CAPS when the airplane entered a spin. The flight service specialist's failure to follow published procedures to provide adverse weather or forecast potential hazardous conditions along the intended route of flight, as well as the air traffic controller's failure to provide the pilot with radar-displayed weather information were factors.

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.

In flight encounter with weatherCruise
Weather condition - icing conditionsFactor
Fss service - information insufficientAtc personnel(fss)Factor
Weather condition - turbulence
Communications/information/atc - information insufficientAtc personnel(artcc)Factor
Weather evaluation - inadequatePilot in commandCause
Flight into adverse weather - continuedPilot in commandCause
Loss of control - in flightCruise
Stall/spin - inadvertentPilot in command
Procedures/directives - not followedPilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The pilot contacted a flight service station (FSS) specialist to file an instrument flight plan. He stated that he had onboard weather and did not need a weather briefing; however, the FSS specialist did not provide information about adverse weather conditions along the route of flight, as required by FAA directives. The pilot then departed on the cross-country flight. While en route to his destination, the pilot told the air traffic controller that he needed to deviate around weather. The air traffic controller was aware of thunderstorms along the pilot's route of flight, as well as an icing report north of his position. The air traffic controller did not advise the pilot of the known weather information, as required by FAA directives. The pilot continued and then stated that they had an emergency due to icing conditions. Meteorological conditions at the time of the accident showed that the pilot encountered rime/mixed icing of at least moderate intensity, in convection. Thunderstorms were in the area and turbulence was also possible. The airplane then stalled and entered a spin. There was no evidence that the pilot attempted to activate the Cirrus Airframe Parachute System (CAPS), although activation of the system is the only approved recovery of the airplane after its entry into a spin. Weather information transmitted to the airplane's onboard weather system contained weather forecasts of icing, turbulence, and thunderstorms. Whether or not the pilot reviewed this information could not be determined. Testing showed that a fluid line of the anti-icing system could disconnect at higher pressure; however, under normal system pressure the line stayed secured. No other mechanical anomalies were identified during the examinations.

Factual narrative

"This case was amended March 5, 2008."

History of flight

On October 25, 2006, at 1208 mountain standard time (MST), a Cirrus SR22, N121LD, reported icing conditions at approximately 12,000 feet mean sea level (msl) and impacted terrain about 24 nautical miles (nm) northeast of Meadview, Arizona. The pilot was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. The instrument rated private pilot and three passengers sustained fatal injuries; the airplane was destroyed. A combination of visual and meteorological conditions prevailed along the route of flight and a pop-up instrument flight rules (IFR) flight clearance was issued at 1150. The pilot departed from Lake Tahoe Airport (TVL), South Lake Tahoe, California, about 1030 Pacific daylight time, and was destined for the Grand Canyon National Park Airport (GCN), Grand Canyon, Arizona.

According to family friend, the pilot met his wife and two children in the San Francisco, California area on October 23. They flew to South Lake Tahoe, spent the night, and then planned to depart for the Grand Canyon to go hiking. The morning of the accident, the pilot was delayed due to an overnight frost accumulation on the airplane. About 1015, the pilot told the family friend that they were going to the Grand Canyon and would call when they arrived. Following the trip to the Grand Canyon, they had plans to travel to Phoenix, Arizona.

Review of flight service station (FSS) data showed that the pilot contacted flight service to file an instrument flight plan. At the conclusion of filing the flight plan, the specialist asked if the pilot needed any additional services. The pilot stated that, "It's beautiful weather so I got weather on board, and we're set." There was no record of the pilot obtaining a weather briefing from FSS or via direct user access terminal (DUAT) service for the accident flight.

A fixed base operator employee at Lake Tahoe Airport stated that the pilot arrived at the airport the day prior from Reno, Nevada. The airplane was secured at the ramp and no fueling services were provided. The pilot returned to the airport the following morning and found frost on the airplane. He and his family waited while the sun rose and melted the frost accumulation. They departed about 1030. The employee indicated that the weather conditions at the Lake Tahoe Airport were "very good" with clear skies.

Personnel information

The pilot held a private pilot certificate with an instrument rating. The pilot's last medical was issued on July 2, 2005, and was a third class. It had no limitations or waivers.

The pilot attended the Cirrus transition course at the Cirrus factory from November 15- 21, 2005. The pilot accrued 20.4 dual hours, 6.0 oral instruction hours, 1.5 dual day hours, 8.4 instrument hours, 34 landings, and 8.7 pre/post flight briefing hours.

The pilot's personal flight logbook was recovered from the accident site. The entries in the logbook were dated from July 1996 to October 2006. Excluding the last four entries that were for future planned flights, the pilot's total logged time was about 892 hours. The pilot obtained an instrument rating in July of 2005 which equated to his most recent flight review as outlined in FAR 61.56 (d). The pilot had accrued about 384 hours in the accident airplane. In the pilot's logbook, he logged almost all flights in the accident airplane under "actual instrument conditions." An accurate estimate of his actual instrument flight time could not be determined.

From April 25 to 29, 2006, the pilot logged a trip from Atlanta, Georgia, round trip via Gulfport and Tunica, Mississippi. In the remarks section he noted that thunderstorms were encountered.

Airplane information

The airplane was a Cirrus SR22 manufactured in 2005. The pilot purchased the airplane from the factory in November 2005. A Teledyne Continental Motors (TCM) IO-550-N equipped with a Harztell PHC-J3YF-1RF powered the airplane. The pilot had previously owned a Cessna 172M, which his logbook indicated was purchased in June 2004. Federal Aviation Administration records showed that the pilot sold the Cessna 172M on April 15, 2005.

The airplane's production flight testing was completed on October 30, 2005, and its airworthiness certificate was issued on November 7, 2005. The first annual inspection was due no later than November 30, 2006. The last maintenance performed on the airplane was on October 12, 2006, at a total time of 406.2 hours.

The airplane was last refueled at a fixed base operator at the Reno/Tahoe International Airport on October 23. The fueling invoice indicated that the right and left fuel tanks were filled with the addition of 24.1 total gallons of fuel. On the invoice, the pilot's estimated departure time from the airport was noted as 1000 on October 24.

Meteorological information

Meteorological Factual Report

A Safety Board meteorologist reviewed weather data surrounding the time and location of the accident. The area forecast issued on October 25, at 0345 MST and valid until 1645 MST reported that the northern half of Arizona was forecast to have cloud layers from 7,000 to 8,000 feet broken, and 11,000 feet broken, with cloud tops at 14,000 feet. After 1300, winds were forecast to be westerly at 17 knots gusting to 27 knots.

The local weather included AIRMETS (Airman's Meteorological Information) for icing, approximately 65 nautical miles northeast of the accident site, and moderate turbulence (within the accident site area).

A convective SIGMET (Significant Meteorological Information) was issued for an area encompassing the accident site. Area thunderstorms were moving from 290 degrees at 20 knots with cloud tops to 28,000 feet mean sea level (msl). A convective SIGMET implies severe or greater turbulence, severe icing, and low-level wind shear.

XM Satellite Weather

The airplane was equipped with an XM Satellite Weather System. According to the supplement in the pilot's operating handbook, the XM Satellite Weather System enhances situational awareness by providing the pilot with real time, graphical weather information depicted on the MFD. The weather information is not an FAA-approved weather source.

The company that supplies weather information for the unit provided data showing that weather data, including the convective SIGMET, was available to the pilot. When the information is displayed to the pilot, it is shown on a specific page of the multi-function display (MFD). Although the unit has non-volatile memory, the page(s) of data that the pilot was viewing during the flight is not a recorded parameter.

Comparison of the weather radar data available to the pilot using the airplane's onboard weather display, with recorded weather radar information obtained following the accident, showed that the images available on the pilot's weather display did not compare exactly with radar images obtained by the Safety Board meteorologist. According to the weather provider, both the recorded radar and pilot's radar display showed similar locations of precipitation, but had the pilot's display lacked some of the lighter precipitation. The data that the pilot had displayed at the time of the accident is not a recorded parameter.

Wreckage and impact

The Safety Board investigator, a Safety Board specialist from the Office of Research and Engineering, and investigators from Cirrus, Ballistic Recovery Systems, AmSafe, and Teledyne Continental Motors, responded to the accident site on October 26, 2007. Two Federal Aviation Administration (FAA) inspectors from the Las Vegas Flight Standards District Office (FSDO) and one investigator from the FAA Aircraft Accident Investigation division also responded to the site.

The airplane impacted 20-degree sloped desert terrain at a terrain elevation of 4,520 feet mean sea level. All of the control surfaces were attac

Aircraft

Registration
N121LD
Reported as
Cirrus SR22
Category
Airplane
Serial number
1670
Airframe hours
436.1
Engine
Textron Lycoming IO-550-N, 310 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Luis A. Castro
Registered owner
Innovative Hospitality Systems LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 1, 2005 · 436.1 hours before
Departed
TVL · S Lake Tahoe, CA
Destination
GCN · Grand Canyon NP, AZ
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
44
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
July 1, 2005
Seat
Left
Toxicology
Performed
Flight hours
892 total · 384 in this make and model · 746 as pilot in command · 110 in the last 90 days · 60 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
220° at 14 knots, gusting 20
Visibility
10 statute miles
Lowest ceiling
4,400 ft broken
Temperature
52 °F, dew point 43 °F
Altimeter
30.03 inHg
Observed at
GCN, 80 nm away

Docket · 25

The files NTSB released with the investigation on December 20, 2007, on NTSB’s docket system: statements, records, photos and specialists’ reports. 36.4 MB in all.

Meteorology 5 - Factual Report of Weather SpecialistItem 1 · .PDF · 2.0 MBCockpit Displays - Factual ReportItem 2 · .PDF · 249 KBCockpit Displays - Attachment 1Item 3 · .CSV · 98 KBGPS 17 - Special StudyItem 4 · .PDF · 255 KBATC 3 - Factual Report of Group ChairmanItem 5 · .PDF · 227 KBATC 3 - Errata 1 ATC Factual Report of Group ChairmanItem 6 · .PDF · 52 KBATC 3 - Attachment 1 - DRI AFSS and ZLA ARTCC Parital TranscriptsItem 7 · .PDF · 334 KBATC 3 - Attachment 2 - DRI AFSS Event ReconstructionItem 8 · .PDF · 140 KBATC 3 - Attachment 3 - DRI AFSS - ZOA - ZLA Controller statementsItem 9 · .PDF · 11.2 MBATC 3 - Attachment 4 - ATC Weather related productsItem 10 · .PDF · 68 KBBaron Services Weather ReportItem 11 · .PDF · 5 photos · 1.1 MBXM Weather TransmissionsItem 12 · .PDF · 628 KBRecord Of Conversation - Line Personnel InterviewItem 13 · .PDF · 22 KBFlight Service ExcerptsItem 14 · .PDF · 226 KBCAV ReportItem 15 · .PDF · 311 KBBRS ReportItem 16 · .PDF · 80 KBStatement of Party Representatives to NTSB InvestigationItem 17 · .PDF · 223 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 18 · .PDF · 80 KBToxicological ReportItem 19 · .PDF · 48 KBImage 1. Aerial view.Item 20 · .PDF · 2.2 MBImage 2. Airplane on scene with parachute (BRS).Item 21 · .PDF · 3.0 MBImage 3. Accident stie.Item 22 · .PDF · 2.5 MBImage 4. Right horizontal test (CAV).Item 23 · .PDF · 3.6 MBImage 5. Propeller (TCM).Item 24 · .PDF · 3.7 MBImage 6. Engine top view (TCM).Item 25 · .PDF · 4.0 MB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.