# NTSB WPR13LA186: Cirrus Design SR22, N205KT, Silver Peak, NV, April 10, 2013 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: April 10, 2013, 09:26 local (16:26 UTC) - Place: Silver Peak, NV - Coordinates: 37.903331, -117.679443 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.9033&lon=-117.6794&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report June 2, 2014 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: FAA FSDO - NTSB case key (mKey): 86627 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR13LA186 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/86627/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=86627 - Page: https://openairdocs.org/ntsb/WPR13LA186 ## Probable cause The pilot’s incapacitation due to sleeping pills, which led to the airplane impacting terrain in an autopilot-controlled descent following a loss of engine power due to fuel exhaustion. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Mental/emotional state](https://openairdocs.org/ntsb-findings/02022500): Personnel issues › Psychological · Pilot (probable cause); cases with it: [All aircraft, 21 cases](https://openairdocs.org/ntsb-findings/02022500/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) (defining event); cases with it: [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) ## Analysis The airplane departed and climbed to a cruise altitude of 16,500 feet. The pilot set the autopilot to continue the flight over an area of sparsely populated desert terrain. He stated that he then took sleeping pills in an attempt to take his life. When the fuel was exhausted in the selected tank, the engine lost power. The airplane's autopilot was equipped with an envelope protection feature, which placed the airplane into a controlled descent that was maintained to ground impact. Local law enforcement personnel who responded to the scene of the accident found the airplane relatively intact with the wings, empennage, and engine still attached to the fuselage and the injured pilot seated in the left front seat. ## Factual narrative On April 10, 2013, about 0926 Pacific daylight time, a Cirrus Design Corporation SR22, N205KT, was substantially damaged when it impacted terrain in autopilot-controlled descent after the pilot became incapacitated during cruise flight near Silver Peak, Nevada. The private pilot, the sole occupant on board, was seriously injured. The pilot/owner was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the personal cross-country flight, which had originated from the Henderson Executive Airport in Las Vegas, Nevada, about 0752. A flight plan had not been filed. Witnesses reported to local authorities that an airplane had crashed in the desert near the Heart of Nature alum mine in Esmeralda County, Nevada. Local law enforcement personnel responded to the accident site and found the airplane relatively intact with the wings, empennage, and engine still attached to the fuselage and the injured pilot seated in the left front seat. The officer asked the pilot what happened, and the pilot was unable to respond coherently and mumbled what sounded like "I fell asleep" or "I just wanted to sleep." The day after the accident two Federal Aviation Administration (FAA) inspectors visited the pilot in the hospital. The FAA inspectors asked the pilot to explain what happened during the accident, and the pilot responded by stating that he made an attempt to take his own life. The pilot said that after takeoff, he flew south, climbed to 16,500 feet msl, and entered a waypoint into the GPS that was about 500 miles away. He explained that he planned the flight to avoid populated areas. He said that he switched the fuel selector to a tank that contained 20 gallons of fuel, and he estimated that the airplane would run out of fuel in slightly more than an hour. The pilot stated that he then took 40 1-milligram sleeping pills. He further stated that his next memory was waking up in the hospital. When the airplane was recovered by salvage personnel, FAA inspectors examined the airplane and reported that the nose landing gear was bent aft, and both main landing gears were bent upward and outboard. The forward lower part of the fuselage was crushed and deformed upward and aft. Several attempts were made to interview the pilot over a 6-month period, and to obtain a completed National Transportation Safety Board Form 6120.1 Pilot/Operator Aircraft Accident/Incident Report from the pilot. The pilot declined to be interviewed, citing legal issues, and a completed Form 6120.1 was not received. According to data retrieved from non-volatile memory in the airplane's Avidyne primary flight display and multi-function display, the airplane flew south for about 22 nautical miles and then turned to a northwesterly heading of about 330 degrees. It climbed to an altitude of about 16,500 feet msl and maintained that altitude for approximately 1 hour 8 minutes. About 0917, when the fuel in the selected wingtank was exhausted, the engine lost power. The envelope protection feature of the airplane's Avidyne DFC90 autopilot placed the airplane into a controlled descent, which was maintained to ground impact. The recorded data showed that the airplane descended at an indicated airspeed that varied from 84 to 103 knots and a descent rate that varied from 1,100 to 1,500 feet per minute. The last data point recorded before ground impact showed that the airplane's indicated airspeed was 84 knots and its descent rate was about 1,500 feet per minute. According to Avidyne, the DFC90 autopilot's envelope protection feature operates whenever the autopilot is active. Envelope protection continuously computes the reserve lift available before stall may be expected, in all flight conditions. If a predetermined reserve lift threshold is violated, the autopilot will reduce the bank angle and/or lower the nose to reestablish operation within limits. The commanded autopilot mode is not cancelled. For example, if the autopilot is in navigation-coupled, altitude-hold mode, the autopilot will continue to follow the flight plan and will make its best attempt at maintaining altitude consistent with maintaining an acceptable stall margin. With wings level and a complete loss of engine power, the reserve lift threshold is maintained at approximately 1.1 times the stall speed; the airplane will descend as necessary to maintain that reserve. ## Aircraft - Registration: N205KT (not matched to a registry record) - Reported make and model: CIRRUS DESIGN CORP SR22 - Category: Airplane - Serial number: 2112 - Year built: 2006 - Airframe hours: 890 - Engines: CONT MOTOR IO-550-N 310 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Unknown, September 17, 2012 - Departed: HND, Las Vegas, NV - Destination: Silver Peak, NV - Flight plan: Unknown - Equipment: Data recorder, Auto-pilot, Angle of attack indicator, Airframe parachute, Stall warning system, Electronic multifunction display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 53; injuries: serious; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; restraint: lap only; flight hours: 1,100 total, 1,100 in this make and model, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 340° at 19 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 52 °F, dew point 10 °F - Altimeter: 30.23 inHg - Observed at: TPH, 29 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 20130410005159A](https://openairdocs.org/incident/20130410005159A), Apr 10, 2013: Cirrus Design Corp SR22, Silver Peak, NV, Substantial damage. Aircraft departed henderson airport (hnd) Nevada to an unknown destination. On site investigation indicated that the right fuel tank of the aircraft was empty… ## Docket (18 files) The files NTSB released with the investigation on May 1, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=86627. 12.7 MB in all. - Request for NTSB Form 6120 - Sent to Attorney (item 1, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411828&FileExtension=.PDF&FileName=Request%20for%20NTSB%20Form%206120%20-%20Sent%20to%20Attorney-Redacted.PDF - Lawyer Refusal for Pilot to Complete Statement (item 2, .PDF, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411829&FileExtension=.PDF&FileName=Lawyer%20Refusal%20for%20Pilot%20to%20Complete%20Statement-Redacted.PDF - FAA Interview of Pilot (item 3, .PDF, 313 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411830&FileExtension=.PDF&FileName=FAA%20Interview%20of%20Pilot-Redacted.PDF - FAA Site Sketch (item 4, .PDF, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411831&FileExtension=.PDF&FileName=FAA%20Site%20Sketch-Master.PDF - Esmeralda County Sheriff Report (item 5, .PDF, 149 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411832&FileExtension=.PDF&FileName=Esmeralda%20County%20Sheriff%20Report-Redacted.PDF - MFD Data Analysis (item 6, .PDF, 121 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411833&FileExtension=.PDF&FileName=MFD%20Data%20Analysis-Master.PDF - Primary Flight Data (item 7, .PDF, 8.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411834&FileExtension=.PDF&FileName=Primary%20Flight%20Data-Master.PDF - Primary Flight Data Log Analysis (item 8, .PDF, 122 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411844&FileExtension=.PDF&FileName=Primary%20Flight%20Data%20Log%20Analysis-Master.PDF - MFD Plot - Descent (item 9, .PDF, 660 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411835&FileExtension=.PDF&FileName=MFD%20Plot%20-%20Descent-Master.PDF - MFD Plot - Initial Climb (item 10, .PDF, 596 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411836&FileExtension=.PDF&FileName=MFD%20Plot%20-%20Initial%20Climb-Master.PDF - MFD Plot - Plan View (item 11, .PDF, 653 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411837&FileExtension=.PDF&FileName=MFD%20Plot%20-%20Plan%20View-Master.PDF - MFD Plot - Turn (item 12, .PDF, 669 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411838&FileExtension=.PDF&FileName=MFD%20Plot%20-%20Turn-Master.PDF - Avidyne PFD, MFD, DFC 90 Data (item 13, .PDF, 174 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411842&FileExtension=.PDF&FileName=Avidyne%20PFD,%20MFD,%20DFC%2090%20Data-Redacted.PDF - DFC 90 Autopilot Envelope Protection Features (item 14, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411843&FileExtension=.PDF&FileName=DFC%2090%20Autopilot%20Envelope%20Protection%20Features-Redacted.PDF - Permission to Download Data (item 15, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411846&FileExtension=.PDF&FileName=Permission%20to%20Download%20Data-Redacted.PDF - Photo 1. Overview of Accident Site (item 16, .PDF, 324 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411839&FileExtension=.PDF&FileName=Photo%201.%20Overview%20of%20Accident%20Site-Master.PDF - Photo 2. Front View Looking Aft (item 17, .PDF, 226 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411840&FileExtension=.PDF&FileName=Photo%202.%20Front%20View%20Looking%20Aft-Master.PDF - Photo 3. Cabin - Panel View (item 18, .PDF, 203 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411841&FileExtension=.PDF&FileName=Photo%203.%20Cabin%20-%20Panel%20View-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.