# NTSB NYC08FA138: Cirrus Design SR22, N141SR, Front Royal, VA, March 15, 2008 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 14, 2008, 23:50 local (Mar 15, 2008, 03:50 UTC) - Place: Front Royal, VA - Coordinates: 38.905555, -78.318885 - Nearby events: https://openairdocs.org/map.md?lat=38.9056&lon=-78.3189&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report March 5, 2009 - Report: Approved by Office Director - Parties: Teledyne Continental Motors, Avidyne Corporation, Cirrus Design Corporation, FAA/FSDO - NTSB case key (mKey): 67669 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC08FA138 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67669/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=67669 - Page: https://openairdocs.org/ntsb/NYC08FA138 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Ceiling/visibility/precip: low ceiling](https://openairdocs.org/ntsb-findings/03035010): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Cirrus Design SR22, 8 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md?model=2130001), [All aircraft, 190 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md) - [Ceiling/visibility/precip: low visibility](https://openairdocs.org/ntsb-findings/03035015): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Cirrus Design SR22, 4 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md?model=2130001), [All aircraft, 175 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Cirrus Design SR22, 13 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=2130001), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cirrus Design SR22, 11 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=2130001), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Performance/control parameters: heading/course](https://openairdocs.org/ntsb-findings/01062047): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cirrus Design SR22, 3 cases](https://openairdocs.org/ntsb-findings/01062047/cases.md?model=2130001), [All aircraft, 82 cases](https://openairdocs.org/ntsb-findings/01062047/cases.md) - [Terrain: mountainous/hilly terrain](https://openairdocs.org/ntsb-findings/03021010): Environmental issues › Physical environment · Response/compensation (probable cause); cases with it: [Cirrus Design SR22, 9 cases](https://openairdocs.org/ntsb-findings/03021010/cases.md?model=2130001), [All aircraft, 329 cases](https://openairdocs.org/ntsb-findings/03021010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Cirrus Design SR22, 12 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=2130001), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## 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](https://openairdocs.org/deregistered/N141SR-2017-05-31), registration cancelled 2017-05-31, S/N 1971, built 2006 (OpenAirDocs) - Reported make and model: Cirrus Design Corp SR22 - Registry model: [Cirrus Design SR22](https://openairdocs.org/model/cirrus-design-sr22) (registry code 2130001) (OpenAirDocs) - Registry engine: [Continental IO-550-N](https://openairdocs.org/engine/continental-io-550-n) (registry code 17215, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1971 - Airframe hours: 158 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; injuries: fatal; 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 ## 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 20080314012569A](https://openairdocs.org/incident/20080314012569A), Mar 14, 2008: Cirrus SR22, Front Royal, VA, Destroyed, 2 fatal. (-23) Pilot departed frr with marginal night visual meteorological conditions. Shortly after take off, the aircraft made contact with trees in a heavily… ## Docket (20 files) The files NTSB released with the investigation on December 16, 2008, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=67669. 11.7 MB in all. - Interview Summaries (item 1, .PDF, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40301494&FileExtension=.PDF&FileName=Interview%20Summaries-Master.PDF - Primary Flight Display Data Plots (item 2, .PDF, 7.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40303508&FileExtension=.PDF&FileName=Primary%20Flight%20Display%20Data%20Plots-Master.PDF - Radar Plot And Data (item 3, .PDF, 199 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40301503&FileExtension=.PDF&FileName=Radar%20Plot%20And%20Data-Master.PDF - First Recorded Communications Between Pilot and FSS (Raleigh/Durham, North Carolina) (item 4, .PDF, 9 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40302305&FileExtension=.PDF&FileName=First%20Recorded%20Communications%20Between%20Pilot%20and%20FSS%20(Raleigh%2FDurham,%20North%20Carolina)-Master.PDF - Second Recorded Communications Between Pilot and FSS (Lansing, Michigan) (item 5, .PDF, 9 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40302306&FileExtension=.PDF&FileName=Second%20Recorded%20Communications%20Between%20Pilot%20and%20FSS%20(Lansing,%20Michigan)-Master.PDF - Final Communications Between Pilot And FSS (Kankakee, Illinois) (item 6, .PDF, 9 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40301504&FileExtension=.PDF&FileName=Final%20Communications%20Between%20Pilot%20And%20FSS%20(Kankakee,%20Illinois)-Master.PDF - Recorded Communications Between Pilot And Potomac Clearance Delivery (item 7, .PDF, 9 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40301506&FileExtension=.PDF&FileName=Recorded%20Communications%20Between%20Pilot%20And%20Potomac%20Clearance%20Delivery-Master.PDF - Aircraft Usage Log (item 8, .PDF, 264 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40301495&FileExtension=.PDF&FileName=Aircraft%20Usage%20Log-Master.PDF - Excerpts From Airframe Logbook (item 9, .PDF, 179 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40301496&FileExtension=.PDF&FileName=Excerpts%20From%20Airframe%20Logbook-Redacted.PDF - Excerpt From Engine Logbook (item 10, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40301497&FileExtension=.PDF&FileName=Excerpt%20From%20Engine%20Logbook-Redacted.PDF - Excerpt From Propeller Logbook (item 11, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40301498&FileExtension=.PDF&FileName=Excerpt%20From%20Propeller%20Logbook-Redacted.PDF - Fuel Receipt (item 12, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40301499&FileExtension=.PDF&FileName=Fuel%20Receipt-Master.PDF - Weather Report (item 13, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40301500&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF - Toxicological Report (item 14, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40301501&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 15, .PDF, 958 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40301502&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 16, .PDF, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305404&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo - Main Wreckage (item 17, .PDF, 453 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40301507&FileExtension=.PDF&FileName=Photo%20-%20Main%20Wreckage-Master.PDF - Photo - Engine (item 18, .PDF, 466 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40301508&FileExtension=.PDF&FileName=Photo%20-%20Engine-Master.PDF - Photo - Propeller (item 19, .PDF, 466 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40301509&FileExtension=.PDF&FileName=Photo%20-%20Propeller-Master.PDF - Photo - View From Airport to Accident Site (item 20, .PDF, 366 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40301510&FileExtension=.PDF&FileName=Photo%20-%20View%20From%20Airport%20to%20Accident%20Site-Master.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.