NYC08FA138

NTSB accident investigation · Cirrus Design SR22 · Front Royal, VA · March 15, 2008

Accident · FatalField investigationFinal report
Date
March 14, 2008, 23:50 local (Mar 15, 2008, 03:50 UTC)
Place
Front Royal, VA
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N141SRCirrus Design SR22
Defining event
Initial climb: Controlled flight into terr/obj (CFIT)
Weather
Visual (VMC) · Night
Status
Completed · report March 5, 2009
Report
Approved by Office Director
Parties
Teledyne Continental Motors, Avidyne Corporation, Cirrus Design Corporation, FAA/FSDO
FAA report
20080314012569A
Case key
67669

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 clearance from rising mountainous terrain, and his failure to turn toward his assigned course during initial climb. Contributing to the accident were the low ceiling, reduced visibility, dark night conditions, and rising mountainous terrain.

Findings · 6

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Ceiling/visibility/precip: low ceilingEnvironmental issues › Conditions/weather/phenomena · Effect on operationCirrus Design SR22: 8 casesAll aircraft: 190 casesProbable cause
Ceiling/visibility/precip: low visibilityEnvironmental issues › Conditions/weather/phenomena · Effect on operationCirrus Design SR22: 4 casesAll aircraft: 175 casesProbable cause
Light condition: darkEnvironmental issues › Conditions/weather/phenomena · Effect on operationCirrus Design SR22: 13 casesAll aircraft: 448 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · PilotCirrus Design SR22: 11 casesAll aircraft: 792 casesProbable cause
Performance/control parameters: heading/courseAircraft › Aircraft oper/perf/capability · Not attained/maintainedCirrus Design SR22: 3 casesAll aircraft: 82 casesProbable cause
Terrain: mountainous/hilly terrainEnvironmental issues › Physical environment · Response/compensationCirrus Design SR22: 9 casesAll aircraft: 329 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot departed from runway 27 on a night instrument flight rules flight in marginal visual meteorological conditions. Rising mountainous terrain was located west of the departure airport. The pilot's first waypoint was located northeast of the airport. There was no record of the pilot previously departing the airport at night. Recorded data from the airplane's primary flight display showed that during controlled flight just prior to impact the airplane was climbing and accelerating, reaching a pressure altitude of approximately 2,200 feet mean sea level (msl) and an indicated airspeed of 140 knots. About 6 seconds before the end of the recording, the airplane began a steep descending turn to the left (roll attitude reached a peak value of 95 degrees left wing down, pitch attitude reached a peak of about 27 degrees nose down). The airplane collided with the rising terrain, about 4 miles west of the airport, at about the 1,200 msl level while on a southerly heading. Recorded weather about the time of the accident included a broken ceiling at 2,400 feet, overcast ceiling at 3,000 feet, visibility 3 miles in rain, and winds from 340 degrees at 4 knots. Examination of the airplane, airplane systems, engine, and propeller did not reveal any preimpact mechanical failures or malfunctions.

Factual narrative

History of flight

On March 14, 2008, at 2350 eastern daylight time, a Cirrus Design Corp. SR22, N141SR, owned and operated by the private pilot, was destroyed when it impacted mountainous terrain during initial climb from Front Royal-Warren County Airport (FRR), Front Royal, Virginia. The personal flight was conducted under 14 Code of Federal Regulations Part 91. Night marginal visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the planned flight to Baltimore Washington International Airport (BWI), Baltimore, Maryland. The certificated private pilot and a passenger were killed. The flight departed from FRR at 2348.

According to the airport manager at FRR, the pilot previously flew IFR from BWI to FRR, and landed uneventfully about 2135. The pilot picked up his son, and departed on runway 27. The airplane subsequently impacted a mountain ridge approximately 3 miles west of FRR.

A National Transportation Safety Board investigator and a Federal Aviation Administration (FAA) inspector viewed video from an airport surveillance camera, with the FRR airport manager. Review of the video revealed that runway lights illuminated about 2348, followed by lights consistent with the accident airplane, rising from runway 27. A fireball was observed on a mountain to the west, about 1 minute 20 seconds after the airplane lights rose from the runway. The airport manager subsequently stated that when he later attempted to download the video, the recording system purged the data.

Review of FAA air traffic control (ATC) data, and Lockheed Martin communication data, revealed that the accident pilot telephoned the Raleigh/Durham, North Carolina flight service station (FSS) at 1930. He requested a standard weather briefing and filed an IFR flight plan from BWI to FRR.

At 2228, the pilot called the Lansing Michigan FSS, to cancel his IFR flight plan. He advised that he landed safely at FRR, but his mobile phone had "died."

At 2319, the pilot called the Kankakee, Illinois FSS, to file an IFR flight plan for his return trip to BWI.

At 2324, the pilot telephoned Potomac Clearance Delivery for his return flight. The ATC specialist then provided the pilot with an IFR clearance, which included initial instructions to fly direct COGAN intersection, climb and maintain 4,000 feet mean sea level (msl), expect 5,000 feet msl 10 minutes after departure. The pilot's release time was 2350, with a clearance void time of 2355. No further communications from the pilot were received by Potomac terminal radar approach control (TRACON).

Potomac TRACON recorded two radar targets, with the accident airplane's transponder code. The first target was recorded at 2348:35, with an indicated altitude of 1,700 feet msl. The second target was recorded at 2348:39, with an indicated altitude of 1,800 feet msl. The targets depicted the accident airplane approaching a mountain ridge, traveling west toward the accident site.

Personnel information

The pilot, age 54, held a private pilot certificate, with ratings for airplane single-engine land and instrument airplane. His most recent FAA third-class medical certificate was issued on October 15, 2007. At that time, he reported a total flight experience of 180 hours. The pilot obtained his instrument rating on September 20, 2006.

The pilot's logbook was not recovered; however, he maintained an aircraft usage log with a partner, for the accident airplane. Review of the usage log revealed that since August 27, 2006, through March 9, 2008, the pilot flew the accident airplane 113 hours. The pilot flew the accident airplane 13 hours since October 15, 2007, when he reported his total flight experience for the third-class medical certificate. The pilot flew 8.5 hours and 4.6 hours during the 90-day period and 30-day period preceding the accident, respectively. The pilot's flight times extrapolated from the usage log assumes that he swapped legs and pilot-in-command time with his partner, when both pilots' initials were listed in the "code" field for a singular entry.

The accident pilot's total experience in actual and simulated instrument meteorological conditions could not be determined. Further review of the usage log did not reveal any previous flights to FRR.

Aircraft information

The four-seat, low-wing, fixed-gear airplane, serial number 1971, was manufactured in 2006. It was powered by a Teledyne Continental Motors IO-550-N, 310-horsepower engine and equipped with a Hartzell propeller.

The pilot owned and operated the accident airplane, which he purchased new in 2006. A review of the maintenance logbooks revealed that the airplane's most recent annual inspection was completed on June 13, 2007. At that time, the airplane had accumulated 157.7 total hours of operation. An airworthiness directive was complied with 9 days prior to the accident. At that time the airplane had accumulated 267.8 total hours of operation.

Meteorological information

Winchester Regional Airport (OKV) was located about 15 miles north of the accident site. The reported weather at OKV, at 0000, was: wind from 340 degrees at 4 knots; visibility 3 miles in rain; broken ceiling at 2,400 feet; overcast ceiling at 3,000 feet; temperature 10 degrees Celsius (C); dew point 8 degrees C; altimeter 29.59 inches of mercury.

Wreckage and impact information

The airport elevation at FRR was 709 feet msl. The wreckage was located on the mountain ridge, about 1200 feet msl. An approximate 100-feet debris path was observed through trees, extending on a 170-degree magnetic course, to the main wreckage. The trees ranged in height from approximately 60 to 80 feet. Portions of the left wing were found near the beginning of the debris path. The left and right ailerons were found toward the end of the debris path, near the main wreckage. The airplane came to rest inverted, oriented about a 340-degree magnetic heading, and had been subjected to a postcrash fire. The cockpit and cabin were consumed by fire, and the only recognizable instrument recovered was the standby attitude indicator. The Cirrus Airframe Parachute System (CAPS) parachute remained stowed and its respective charge had burned, consistent with the postcrash fire.

Portions of the right and left elevator, horizontal stabilizer, and empennage were located several feet to the west of the main wreckage. The wing spar was located in the main wreckage, and the rudder was located a few feet south of the main wreckage. Flight control continuity was confirmed from the rudder pedals and elevator control torque tube, to their respective bellcranks, at the rear of the airplane. Aileron control continuity was confirmed from the cockpit area, to the left and right inboard flap hinges, respectively. The elevator trim was an electric system, and the elevator trim motor was destroyed by fire.

The propeller was partially separated from the engine. All three propeller blades exhibited s-bending, chordwise scratching, and leading edge gouging. The engine sustained impact damage, portions of the No. 5 cylinder were separated, and the crankshaft could not be rotated by hand. The top spark plugs were removed for inspection; their electrodes were intact and light gray in color, except for the No. 5 spark plug, which sustained impact damage. The fuel manifold contained fuel, and its fuel screen was absent of debris. The engine driven fuel pump coupling remained intact, and the engine driven fuel pump moved liquid freely when tested via an electric drill. Both magnetos produced spark at all towers when rotated by hand. The oil pump remained attached to the engine, and oil was noted throughout the engine.

Medical and pathological information

An autopsy was performed on the pilot by the Commonwealth of Virginia, Department of Health, Office of the Chief Medical Examiner, Fairfax, Virginia, on March 18, 2008. According to the autopsy report

Aircraft

Registration
N141SR
Reported as
Cirrus Design SR22
Category
Airplane
Serial number
1971
Airframe hours
158
Engine
Continental Motors IO-550-N, 310 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Hector K Collison
Registered owner
Hector K Collison
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 13, 2007 · 30 hours before
Departed
FRR · Front Royal, VA
Destination
BWI · Baltimore, MD
Flight plan
IFR
Airport
FRR · Front Royal-Warren County, runway 27, 3,007 × 75 ft, asphalt

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
54
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
September 20, 2006
Seat
Left
Toxicology
Performed
Flight hours
193 total · 113 in this make and model · 9 in the last 90 days · 5 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
340° at 4 knots
Visibility
3 statute miles
Lowest ceiling
2,400 ft broken
Temperature
50 °F, dew point 46 °F
Altimeter
29.59 inHg
Observed at
OKV, 12 nm away

Docket · 20

The files NTSB released with the investigation on December 16, 2008, on NTSB’s docket system: statements, records, photos and specialists’ reports. 11.7 MB in all.

FAA reports on this event · 1

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