# NTSB WPR13LA145: Cirrus Design SR20, N427GE, Kernville, CA, March 11, 2013 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: March 11, 2013, 15:01 local (22:01 UTC) - Place: Kernville, CA - Coordinates: 35.728054, -118.419723 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.7281&lon=-118.4197&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-aborted after touchdown: Runway excursion](https://openairdocs.org/ntsb-events/300) - Highest injury: Minor injuries - Injuries: 1 minor, 2 uninjured - Status: Completed, report October 21, 2015 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administratin, Cirrus Aircraft - NTSB case key (mKey): 86400 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR13LA145 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/86400/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=86400 - Page: https://openairdocs.org/ntsb/WPR13LA145 ## Probable cause The pilot’s application of excessive pitch and his failure to achieve adequate airspeed during the go-around attempt, which resulted in an aerodynamic stall. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: pitch control](https://openairdocs.org/ntsb-findings/01062022): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cirrus Design SR20, 6 cases](https://openairdocs.org/ntsb-findings/01062022/cases.md?model=2130000), [All aircraft, 526 cases](https://openairdocs.org/ntsb-findings/01062022/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cirrus Design SR20, 13 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=2130000), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cirrus Design SR20, 47 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2130000), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-aborted after touchdown: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [Cirrus Design SR20, 22 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=2130000), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## Analysis The pilot reported that, while in the landing flare with the flaps configured full down, the airplane drifted right, and he then decided to execute a go-around. After he added power for the go-around, the left main wheel contacted the runway, and the airplane then veered left, continued off the left side of the runway, and impacted a ditch. Flight data from the primary flight display showed that the airplane had a high engine rpm and a 9-degree left bank with a 17-degree nose-up pitch attitude and was at an airspeed of 56 knots during the attempted go-around. The Pilot's Operating Handbook states that, during a go-around, the best angle-of-climb airspeed (between 81 and 83 knots indicated airspeed [KIAS]) should be set and maintained and that the flaps should then be retracted. It also states that, if the airplane is configured with full flaps in a 15-degree bank angle, it will stall between 55 and 57 KIAS. It is likely that the excessive pitch angle and low airspeed during the go-around attempt resulted in an aerodynamic stall. ## Factual narrative On March 11, 2013, at 1501 Pacific daylight time, a Cirrus SR20, N427GE, veered off the left side of the runway and into a ditch at the Kern Valley Airport, Kernville, California. The airplane was registered to East Pole Aviation, and operated by Justice Aviation under the provisions of 14 Code of Federal Regulations, Part 91. The private pilot and two passengers sustained minor injuries, and the airplane was substantially damaged. Visual meteorological conditions prevailed, and no flight plan had been filed. The flight originated at Bakersfield, California, about 1438.The pilot stated that while in the landing flare with the flaps configured full down, the airplane drifted right so that the right main landing gear was no longer over the runway. The pilot decided to execute a go-around. After he added power for the go-around, the left main wheel contacted the runway; the airplane veered left, continued off the left side of the runway, impacted a ditch, and came to rest inverted. The pilot indicated in the NTSB Pilot/Operator Accident Report (Form 6120.1) that there were no mechanical malfunctions or failures prior to the accident. The Avidyne Primary Flight Display (PFD) was removed from the airplane and sent to the NTSB Vehicle Recorders Laboratory for data download and review. The Avidyne PFD unit includes a solid state Air Data and Attitude Heading Reference System (ADAHRS) and displays aircraft parameter data including altitude, airspeed, attitude, vertical speed, and heading. The PFD unit has external pitot/static inputs for altitude, airspeed, and vertical speed information. The PFD has a data logging function, which is used by the manufacturer for maintenance and diagnostics. Maintenance and diagnostic recordings consists of system information, event data, and flight data. The data extracted from the PFD contained the accident flight and other flights on March 11, 2013. The following data was extracted from the Avidyne PFD for the accident sequence of events. At 1501:24, the data indicated that the airplane's roll was 7 degrees left, the pitch was 2 degrees nose down, and the airspeed was 69 knots. At 1501:28, the data indicated that the airplane's roll was 3 degrees right, the pitch was 5 degrees nose up, and the airspeed was 66 knots. At 1501:30, the data indicated that the propeller rpm was 1,350, the airplane's roll was 2 degrees left, the pitch was 2 degrees nose up, and the airspeed was 62 knots. At 1501:30 and 1501:36, the propeller rpm was 1,350 and 2,400, respectively. During this time period, the pitch, roll, and airspeed were sampled at a higher frequency. As such, determining when power was applied relative to pitch increase is limited by the sampling rate differences. However, during this period the pitch increased from 2 degrees nose up to 12 degrees nose up, the roll increased to 9 degrees left, the airspeed decreased to 56 knots, and by 1501:32, the longitudinal acceleration began to increase. Also during this period, themagnetic heading changed left from 351 degrees to 327 degrees. At 1501:38, the pitch reached a maximum value of 17 degrees nose up when the airspeed was about 56 knots. Between 1501:38 and 1501:41, the pitch decreased to 16 degrees nose down, and the aircraft rolled to 31 degrees right, before rolling back to the left through 20 degrees. After 1501:41, the vertical acceleration increased to a full scale value of XYZ, the left roll angle increased to a full scale value of 180 degrees left, and the airspeed decreased to 0 knots. The Cirrus SR20 Pilot Operating Handbook contains stall speeds for a gross weight of 3,000 pounds, flaps configuration, and angle of bank factors. The accident airplane configuration was flaps at 100% (full down), and for this configuration the stall speed at 15 degrees angle of bank is between 55-57 knots indicated airspeed (KIAS). The Pilot Operating Handbook lists the following procedures for a Balked Landing/Go-Around. 1. Autopilot – Disengage 2. Power Lever – FULL FORWARD 3. Flaps – 50% 4. Airspeed – Best Angle of Climb (81-83 KIAS) After clear of obstacles 5. Flaps – Up (0%) ## Aircraft - Registration: [N427GE](https://openairdocs.org/deregistered/N427GE-2014-03-17), registration cancelled 2014-03-17, S/N 1984, built 2008 (OpenAirDocs) - Reported make and model: CIRRUS DESIGN CORP SR20 - Registry model: [Cirrus Design SR20](https://openairdocs.org/model/cirrus-design-sr20) (registry code 2130000) (OpenAirDocs) - Registry engine: [Continental IO-360-ES](https://openairdocs.org/engine/continental-io-360-es) (registry code 17160, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1984 - Airframe hours: 1318 - Engines: CONT MOTOR IO-360-ES 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Justice Aviation - Registered owner: East Pole Aviation LLC - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, February 25, 2013, 37 hours before - Departed: KBFL, Bakersfield, CA - Destination: KL05, Kernville, CA - Airport: KL05, Kern Valley Airport, runway 35, 3,500 × 50 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; injuries: minor; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review July 30, 2012; seat: left; flight hours: 1,532 total, 34 in this make and model, 1,474 as pilot in command, 5 in the last 90 days, 2 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 2 knots - Visibility: 20 statute miles - Lowest ceiling: none - Temperature: 61 °F - Altimeter: 30.23 inHg - Observed at: KIKY, 30 nm away ## Docket (8 files) The files NTSB released with the investigation on September 24, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=86400. 4.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 898 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40432168&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Cockpit Displays Specialist's Report (item 2, .PDF, 4 photos, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40432169&FileExtension=.PDF&FileName=Cockpit%20Displays%20Specialist%27s%20Report-Master.PDF - Cockpit Displays - Attachment 1 - Tabular Data (CSV) (item 3, .CSV, 591 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40432170&FileExtension=.csv&FileName=Cockpit%20Displays%20-%20Attachment%201%20-%20Tabular%20Data%20(CSV)-Master.csv - Record of Conversation - Airport Manager (item 4, .PDF, 191 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40432171&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Airport%20Manager-Master.PDF - Kernville, CA - Cirrus Timeline (item 5, .PDF, 7 photos, 723 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40432172&FileExtension=.PDF&FileName=Kernville,%20CA%20-%20Cirrus%20Timeline-Master.PDF - Evidence Control Form (item 6, .PDF, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40432173&FileExtension=.PDF&FileName=Evidence%20Control%20Form-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 7, .PDF, 227 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40432174&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Accident Photos (item 8, .PDF, 2 photos, 610 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40432175&FileExtension=.PDF&FileName=Accident%20Photos-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.