# NTSB NYC02LA071: Cirrus Design SR-20, N244CD, Lexington, KY, March 16, 2002 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: March 16, 2002, 12:40 local (17:40 UTC) - Place: Lexington, KY - Coordinates: 38.066665, -84.566665 - Nearby events: https://openairdocs.org/map.md?lat=38.0667&lon=-84.5667&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report April 17, 2003 - Report: Approved by Office Director - Parties: FAA FSDO-01 - ADs cited in the narratives: [AD 2002-05-05](https://openairdocs.org/ad/2002-05-05) (OpenAirDocs) - NTSB case key (mKey): 54351 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC02LA071 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54351/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54351 - Page: https://openairdocs.org/ntsb/NYC02LA071 ## Probable cause The pilot's failure to maintain aircraft control. Factors in this accident were the undetermined failure of the turn coordinator, as reported by the pilot, and the instrument meteorological conditions. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, approach - flight/nav instruments,turn and bank indicator - undetermined (contributing factor) - Loss of control - in flight, approach - aircraft control - not maintained, pilot in command (cause) - weather condition - clouds (contributing factor) - spatial disorientation, pilot in command - On ground/water encounter with terrain/water, emergency landing - terrain condition - open field ## Analysis The instrument rated pilot and passenger departed into instrument meteorological conditions (IMC) and intended to practice some instrument approaches. Shortly after takeoff, the pilot reported a turn coordinator failure. The turn coordinator indicated a left bank regardless of control inputs and the pilot became disoriented. The airplane was equipped with a Cirrus Airplane Parachute System (CAPS). The pilot stated he pulled the CAPS activation handle repeatedly; however, the cable did not extend and "nothing seemed to happen." The airplane broke out of the cloud layer, and the pilot performed an emergency landing to a field. Witnesses near the accident site reported that the CAPS parachute deployed after ground contact. Post accident testing of the wreckage did not reveal any pre-impact instrumentation, or autopilot failures. The CAPS system also functioned normally; however, it was noted that the pull forces to activate the CAPS parachute varied significantly. ## Factual narrative On March 16, 2002, about 1240 eastern standard time, a Cirrus Design Corporation SR-20, N244CD, was substantially damaged during an emergency landing in Lexington, Kentucky. The certificated private pilot and a pilot rated passenger sustained minor injuries. Instrument meteorological conditions prevailed and an instrument flight rules flight plan had been filed for the flight that departed the Blue Grass Airport (LEX), Lexington, Kentucky. The personal flight was conducted under 14 CFR Part 91. The instrument rated pilot stated he had intended to perform some practice instrument approaches in actual instrument meteorological conditions. The passenger was a friend of the pilot; and also held a private pilot certificate, with an instrument rating. According to the pilot, after a normal preflight check, the airplane departed from runway 04, at LEX. The pilot maintained runway heading until 1,400 feet, then set the autopilot to fly the "heading bug," and the "VS" to climb. He then initiated a climbing right turn by setting the heading bug to 090 degrees, and entered the overcast layer about 1,600 feet. Air traffic control (ATC) then cleared the airplane to the initial approach fix for the "GPS RW 04" approach. The pilot was in the process of selecting the approach in the airplane's global positioning system (GPS), when he noticed that the turn coordinator was "pegged to the left, with no flag," and that the airplane was losing altitude rapidly. The pilot disengaged the autopilot and attempted to stabilize the airplane. In a written statement, he further added: "...I let [the passenger] know I was disengaging the autopilot. By then we were in a steep dive. At this moment, I had no confidence in the instruments other than airspeed, altimeter and vertical speed indicator. The airspeed was high, perhaps in the yellow arch. When we broke out of the clouds, I pulled up hard and the plane responded. Our momentum carried us back into the clouds and somewhere near 3,000 feet, I had control of the altitude momentarily and thought for a minute we might be able to recover. I tried to fly straight and level, which I believe we did for a short time and then everything started to unravel again. The attitude indicator (AI) was now unreliable. I suspect the AI tumbled during recovery from the previous dive. Next we were climbing and probably turning and generally out of control...." The airplane was equipped with a Cirrus Airplane Parachute System (CAPS). The pilot indicated he pulled the CAPS activation handle repeatedly; however, the cable did not extend and "nothing seemed to happen." He further stated: "...Finally I decided that it must have already deployed, but still we were carrying 120-140 knots of airspeed and descending faster than I expected we would if the chute had deployed. After we broke out [of the cloud layer] we began to search for a suitable landing site. We were still uncertain as to whether or not we were under the canopy, but continued to fly as if we were not..." The airplane touched down in field and struck trees, about 3 miles northeast of LEX. Witnesses near the accident reported that the CAPS parachute deployed after ground contact. With regards to the turn coordinator, the pilot rated passenger stated "... it was banked to the left, and regardless of control inputs, remained in a position indicating a left bank." On site examination of the wreckage by a Federal Aviation Administration (FAA) inspector did not reveal any pre-impact instrumentation, or autopilot failures; however, the turn coordinator, autopilot control box, autopilot roll trim actuator, and the horizontal situation indicator (HSI) were removed from the airplane for further testing. The CAPS system also functioned normally; however, it was noted that the pull forces to activate the CAPS parachute varied significantly during post accident testing. Additional testing conducted by the manufacturer on production line aircraft revealed that the manner in which the activation handle was pulled, made a difference in how easily the CAPS system could be activated. According to the airplane manufacturer, the CAPS system was designed to bring the aircraft and its occupants safely to the ground in the event of a life-threatening emergency. The CAPS system consisted of a parachute, a solid-propellant rocket to deploy the parachute, a rocket activation handle, and a harness imbedded within the fuselage structure. The activation handle was located in the headliner of the cabin between the forward crew seats. The igniter system employed a 25-pound spring, to arm and trigger the igniter. The pilot was required to pull on the handle, and continue to pull for a short period of time to allow the spring to compress, arm and fire the charge. Yanking the handle in short strokes would not allow the spring to compress completely, and would fail to activate the igniter. On February 25, 2002, Cirrus Design Corporation issued Service Bulletin (SB) 22-95-01. The SB was also the subject of FAA Airworthiness Directive (AD) 2002-05-05, which became effective on March 19, 2002. The service bulletin and subsequent AD, entailed the installation of a cable clamp external to the rocket cone adapter which would provide positive retention of the activation cable housing. On February 28, 2002, Cirrus Design Corporation issued SB 20-95-02, after it was discovered that some production airplanes may exhibit a condition where the pull force required to activate the CAPS system may by greater than desired. The SB entailed the installation of a clamp to positively restrain the cable housing at the CAPS Handle Adapter, loosen and straighten the activation cable above the headliner, and to remove an Adel clamp securing the activation cable adjacent to the rocket cone adapter. The accident airplane was purchased new by the pilot in April 2001, and had been operated for about 150 hours since new. On March 4, 2002, maintenance was performed on the airplane which included compliance with SB 22-95-01/AD 2002-05-05. Service Bulletin 20-95-02, had not been complied with at the time of the accident. The pilot reported he had experienced the exact same type of turn coordinator failure on a previous occasion. Maintenance records revealed a turn coordinator was replaced on the airplane on June 25, 2001, after 57 hours of operation. On April 15, 2002, the retained components from the accident airplane were examined at Meggitt S-Tec, Mineral Wells, Texas, under the supervision of a Safety Board investigator. Functional checks of the components both individually and then as a combined system on an engineering test bench did not revealed any malfunctions. The weather reported at LEX, at 1254, was: wind from 360 degrees at 7 knots, visibility 5 miles in mist, ceiling 600 feet overcast, temperature 6 degrees C, dew point 6 degrees C, altimeter 30.18 in/hg. The pilot reported 371 hours of total flight experience, with 110 hours in make and model. He also reported 54 hours of simulated, and 24 hours of actual flight experience in instrument meteorological conditions. As a result of this accident, and the subsequent testing, Cirrus Design Corporation issued SB 20-95-03, which required replacement of the CAPS handle access cover. The new cover incorporated an expanded description for the CAPS activation handle use. Additionally, on July 10, 2002, SB-20-95-05, was issued and required the replacement of the CAPS activation cable in order to further reduce the pull forces required to deploy the CAPS system. Cirrus Design Corporation also issued similar service bulletins for the SR-22 series airplanes, which were also equipped with a CAPS system. ## Aircraft - Registration: [N244CD](https://openairdocs.org/deregistered/N244CD-2004-09-23), registration cancelled 2004-09-23, S/N 1140, built 2001 (OpenAirDocs) - Reported make and model: Cirrus Design Corp. SR-20 - Registry model: [Cirrus Design SR20](https://openairdocs.org/model/cirrus-design-sr20) (registry code 2130000) (OpenAirDocs) - Registry engine: [Lycoming I0360 SER A&C](https://openairdocs.org/engine/lycoming-i0360-ser-a-c) (registry code 41511, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1140 - Airframe hours: 0 - Engines: Teledyne Continental IO-360ES 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Paul A. Heflin - Registered owner: P & S Products Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 6, 2001, 150 hours before - Departed: LEX, LEXINGTON, KY - Destination: LEX, KY - Flight plan: IFR - Airport: LEX, Blue Grass, runway 4, 7,003 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 55; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; last flight review February 3, 2001; seat: left; flight hours: 371 total, 110 in this make and model, 254 as pilot in command, 20 in the last 90 days, 8 in the last 30 days - Other flight crew; age 18; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--no waivers/lim.; last flight review February 19, 2001; seat: right; flight hours: 257 total, 18 in this make and model, 165 as pilot in command, 22 in the last 90 days ## Weather - Conditions: Instrument (IMC), Day - Wind: 360° at 7 knots - Visibility: 5 statute miles - Lowest ceiling: 600 ft overcast - Temperature: 43 °F, dew point 43 °F - Altimeter: 30.18 inHg - Observed at: LEX, 3 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 20020316003019A](https://openairdocs.org/incident/20020316003019A), Mar 16, 2002: Cirrus SR20, Lexington, KY, Destroyed. (-23) Mr. Heflin was on a local IFR flight plan practicing IFR approaches to the Lexington, KY bluegrass airport. Mr. Heflin departed runway 4 and requested an… ## Docket (15 files) The files NTSB released with the investigation on January 27, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54351. 5.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 497 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399191&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Passenger and Witness Statements (item 2, .PDF, 344 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399193&FileExtension=.PDF&FileName=Passenger%20and%20Witness%20Statements-Redacted.PDF - Air Traffic Control Information (item 3, .PDF, 677 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399194&FileExtension=.PDF&FileName=Air%20Traffic%20Control%20Information-Redacted.PDF - Radar Data (item 4, .PDF, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399195&FileExtension=.PDF&FileName=Radar%20Data-Redacted.PDF - Maintenance Records (excerpts) (item 5, .PDF, 658 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399196&FileExtension=.PDF&FileName=Maintenance%20Records%20(excerpts)-Redacted.PDF - Accident Site Diagram (Lexington Police Dept.) (item 6, .PDF, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173311&FileExtension=.PDF&FileName=Accident%20Site%20Diagram%20(Lexington%20Police%20Dept.)-Master.PDF - Pull Force Testing Results (item 7, .PDF, 121 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173312&FileExtension=.PDF&FileName=Pull%20Force%20Testing%20Results-Master.PDF - Meggitt S-TEC Testing Report (item 8, .PDF, 184 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173313&FileExtension=.PDF&FileName=Meggitt%20S-TEC%20Testing%20Report-Master.PDF - Letter from Cirrus Design (item 9, .PDF, 282 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399197&FileExtension=.PDF&FileName=Letter%20from%20Cirrus%20Design-Redacted.PDF - Cirrus Design Service Bulletin SB A20-95-01 (item 10, .PDF, 135 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173315&FileExtension=.PDF&FileName=Cirrus%20Design%20Service%20Bulletin%20SB%20A20-95-01-Master.PDF - Cirrus Design Service Bulletin SB 20-95-02 (item 11, .PDF, 477 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173316&FileExtension=.PDF&FileName=Cirrus%20Design%20Service%20Bulletin%20SB%2020-95-02-Master.PDF - Cirrus Design Service Bulletin SB 20-95-03 (item 12, .PDF, 100 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173317&FileExtension=.PDF&FileName=Cirrus%20Design%20Service%20Bulletin%20SB%2020-95-03-Master.PDF - Cirrus Design Service Bulletin SB 20-95-04 (item 13, .PDF, 380 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173318&FileExtension=.PDF&FileName=Cirrus%20Design%20Service%20Bulletin%20SB%2020-95-04-Master.PDF - Cirrus Design Service Bulletin SB 20-95-05 (item 14, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173319&FileExtension=.PDF&FileName=Cirrus%20Design%20Service%20Bulletin%20SB%2020-95-05-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 15, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399198&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.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.