# NTSB WPR18LA256: Cirrus SR22, N131TX, Kennett, MO, September 7, 2018 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: September 7, 2018, 15:00 local (20:00 UTC) - Place: Kennett, MO - Coordinates: 36.225833, -90.036666 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.2258&lon=-90.0367&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: FAA, Continental Motors, Cirrus Aircraft - NTSB case key (mKey): 98263 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR18LA256 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98263/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98263 - Page: https://openairdocs.org/ntsb/WPR18LA256 ## Probable cause The pilot’s inadvertent activation of the fuel pump control rocker switch, which resulted in a loss of engine power shortly after takeoff. Contributing to the accident was the pilot’s distraction with an entangled headset cord. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fuel system](https://openairdocs.org/ntsb-findings/01022800): Aircraft › Aircraft systems · Unintentional use/operation (probable cause); cases with it: [Cirrus Design SR22T, 3 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md?model=2130004), [All aircraft, 181 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md) - [Attention/monitoring: monitoring equip/instruments](https://openairdocs.org/ntsb-findings/02021525): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cirrus Design SR22T, 1 case](https://openairdocs.org/ntsb-findings/02021525/cases.md?model=2130004), [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/02021525/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cirrus Design SR22T, 2 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=2130004), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Attention/monitoring: attention](https://openairdocs.org/ntsb-findings/02021510): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cirrus Design SR22T, 1 case](https://openairdocs.org/ntsb-findings/02021510/cases.md?model=2130004), [All aircraft, 226 cases](https://openairdocs.org/ntsb-findings/02021510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Cirrus Design SR22T, 2 cases](https://openairdocs.org/ntsb-events/190/sequence.md?model=2130004), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Initial climb: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cirrus Design SR22T, 9 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2130004), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis During the takeoff roll, the pilot realized that his headset active noise reduction (ANR) function was inoperative. He tugged on the headset cord to access the ANR control module, but the module was stuck between his seat and the center console, and he returned his attention to continuing the takeoff. When the airplane was about 200 ft above ground level, the pilot engaged the autopilot, then leaned down to focus on freeing the control module. A few seconds later, and without freeing the module, the pilot noticed a significant decrease in engine noise and power. He sat upright, verified that the engine power and mixture levers were correctly positioned, and began scanning the instrument panel, but was unable to restore engine power. About the same time, the aural "sink rate" warning began sounding. Based on the airplane's low altitude and his evaluation of the surrounding terrain, the pilot chose to deploy the airframe parachute system, even though the airplane’s height above the ground was below the minimum recommended deployment altitude. The airplane impacted the ground under canopy, resulting in substantial damage to the fuselage. It is likely that, during his attempt to free the headset control module, the pilot inadvertently and unknowingly repositioned the unguarded three-position fuel pump control rocker switch, located on the center console, to the HIGH BOOST/PRIME position. This selection resulted in the loss of engine power. ## Factual narrative Cirrus Post-Accident Actions About 4 months before the accident, Cirrus began implementing software changes intended to prevent improper operation of the electric fuel boost pump. The approach consisted of a software-controlled lockout feature that was to be retroactively applied to all SR22T model Cirrus airplanes via service bulletins (SBs). The revised software locks out the high boost function of the pump (when HIGH BOOST/PRIME is selected) until the airplane reaches a pressure altitude of 10,000 feet; this prevents an engine power loss at low altitudes due to improper selection of HIGH BOOST/PRIME. The SBs differed slightly as a function of whether the airplanes were equipped with the "Perspective" or "Perspective Plus" avionics platforms. Perspective Plus-equipped airplanes were first addressed by SB2X-42-14, issued on May 30, 2018. Perspective-equipped airplanes (the accident airplane model) were first addressed by SB2X-42-15, issued on November 14, 2018, about 2 months after the accident. That SB was superseded by SB2X-42-17, issued on March 18, 2019. SB2X-42-16, issued February 1, 2019, addressed a total of 48 new-production model year 2019 airplanes. Although Cirrus categorized all these SBs as "mandatory," compliance was not mandated by the FAA. All subsequent new-production Cirrus airplanes are equipped with the lockout software. Electric Fuel Boost Pump The airplane was equipped with an electrically powered fuel boost pump. A three-position (boost, off, high boost/prime) rocker switch to control the fuel pump was located on the horizontal surface of the center console between the two forward seats, just left of the engine power lever. (see Figure 1.) The fuel pump is unpowered (off) when the switch is in its neutral position. Depressing the forward end of the switch face powers the pump in the BOOST mode, which is used for takeoff, climb, landing, and switching fuel tanks. Depressing the aft end of the switch face powers the pump in the HIGH BOOST/PRIME mode, which is used to prime the engine before engine start, and for suppressing vapor formation in flight above 18,000 ft with hot fuel. The switch was not guarded or otherwise physically protected from inadvertent operation. Figure 1. Fuel Boost Pump Switch The Pilot’s Operating Handbook Systems Description section entitled Fuel Pump Operation stated: "To prevent over-priming during low power settings, the system uses a lockout relay that only allows HIGH BOOST/PRIME fuel pump operation when manifold pressure is greater than 24 in. Hg," and when the engine manifold pressure exceeded 24 in. Hg, "pressing HIGH BOOST/PRIME will turn the pump on in low-speed mode." On September 7, 2018, about 1500 central daylight time, a Cirrus SR-22T airplane, N131TX, was substantially damaged when it was involved in an accident near Kennett, Missouri. The private pilot and passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.During the takeoff roll, the pilot realized that the noise-reduction function of his active noise reduction (ANR) headset was not operating. Because ANR function activation is controlled by a button on a control module located on the headset cord, the pilot tugged on the cord to access and engage the ANR button; however, the pilot could not operate the control module because it was wedged between his seat and the center console. The pilot continued the takeoff with the intention of waiting until he was airborne to free the module. When the airplane was about 200 ft above ground level (agl), the pilot engaged the autopilot, which was set for a capture altitude of 3,000 ft mean sea level (about 2,700 ft agl). He then leaned down and focused on attempting to free the control module. Within a few seconds, and without freeing the module, the pilot sensed a significant decrease in engine noise and power. He sat upright, verified that the engine power and mixture levers were correctly positioned, and then began scanning the instrument panel. About the same time, the aural "sink rate" warning began annunciating. The pilot was unable to discern the cause of the engine power loss. He asked his wife (who was not a pilot but was familiar with the airplane) what their altitude was, and she promptly responded "640" ft. The airplane was equipped with the Cirrus Airframe Parachute System (CAPS). The pilot realized that the airplane height above the ground was very close to, or possibly below, the minimum recommended CAPS deployment altitude, but he decided that, based on the surrounding terrain, CAPS deployment appeared to be his best option for survival. The extraction rocket fired, the parachute opened, and the airplane impacted the ground during its first tail-first swing after the parachute opened and came to rest upright in a field. The fuselage was substantially damaged. The pilot noted that it was possible that he had inadvertently and unknowingly re-positioned the fuel boost pump switch, located on the center console, to the HIGH BOOST/PRIME position when he was attempting to free his headset control module. Examination of the wreckage revealed that the CAPS parachute was still attached to the airplane. The engine and cowling were almost completely fracture-separated from the fuselage. The windshield was fractured into multiple pieces. The headset cord was wrapped around the engine power lever, and the fuel pump switch was in the HIGH BOOST/PRIME position. No other non-impact damage or abnormalities were observed. ## Aircraft - Registration: [N131TX](https://openairdocs.org/deregistered/N131TX-2021-03-06), registration cancelled 2021-03-06, S/N 0230, built 2011 (OpenAirDocs) - Reported make and model: Cirrus SR22 (T) - Registry model: [Cirrus Design SR22T](https://openairdocs.org/model/cirrus-design-sr22t) (registry code 2130004) (OpenAirDocs) - Registry engine: [Continental TSIO-550 series](https://openairdocs.org/engine/continental-tsio-550-series) (registry code 17043, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 0230 - Year built: 2011 - Airframe hours: 2310 - Engines: Continental TSIO-550 315 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 5, 2018 - Departed: TKX, Kennett, MO - Destination: ARB, Ann Arbor, MI - Flight plan: IFR - Airport: TKX, Kennet, runway 18, 3,012 × 75 ft - Equipment: Airframe parachute, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: minor; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review May 1, 2018; seat: front; restraint: 4-point; flight hours: 1,351 total, 1,180 in this make and model, 1,264 as pilot in command, 19 in the last 90 days, 3 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 150° at 7 knots, gusting 12 - Visibility: 8 statute miles - Lowest ceiling: none - Temperature: 86 °F, dew point 75 °F - Altimeter: 29.94 inHg - Observed at: TKX, 2 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 20180907013229A](https://openairdocs.org/incident/20180907013229A), Sep 7, 2018: Cirrus Design Corp SR22T, Kennett, MO, Substantial damage. Pilot and his passenger departed out of ktkx on runway 20 and began to climb. The pilot stated that after he passed 200 ft. he engaged the autopilot. The pilot… ## Docket (17 files) The files NTSB released with the investigation on May 25, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98263. 8.2 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9042804&FileExtension=pdf&FileName=1%20-%20Form%206120_Redacted-Rel.pdf - Metars (item 2, PDF, 1 page, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9042455&FileExtension=pdf&FileName=10%20-%20METARs-Rel.pdf - Roc pilot sept 7 2018 (item 3, PDF, 2 pages, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9042736&FileExtension=pdf&FileName=2%20-%20Record%20of%20Conversation%20Pilot%20Sept%207-Rel.pdf - Roc pilot January 2020 (item 4, PDF, 2 pages, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9042072&FileExtension=pdf&FileName=3%20-%20Record%20of%20Communication%20Pilot%20Jan%202020-Rel.pdf - Copa weblog sept 9 2018 (item 5, PDF, 4 pages, 256 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9042813&FileExtension=pdf&FileName=4%20-%20COPA%20weblog%20Sept%209%202018%20Excerpt_Redacted-Rel.pdf - Copa weblog sept 10 2018 (item 6, PDF, 2 pages, 145 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9042213&FileExtension=pdf&FileName=5%20-%20COPA%20weblog%20Sept%2010%202018%20Excerpt_Redacted-Rel.pdf - Flight plans (item 7, PDF, 2 pages, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9042745&FileExtension=pdf&FileName=6%20-%20Flight%20Plans-Rel.pdf - Flight track (item 8, PDF, 2 pages, 476 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9042222&FileExtension=pdf&FileName=9%20-%20Flight%20Track%20and%20Events-Rel.pdf - Rdm data (item 9, CSV, 254 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9042081&FileExtension=csv&FileName=7%20-%20RDM%20Data%20KTKX-Rel.csv - Event timeline (item 10, PDF, 1 page, 17 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9042610&FileExtension=pdf&FileName=8%20-%20Kennett%20Timeline%20Corrected%20for%20AP%20Mode-Rel.pdf - Sa 18-02 (item 11, PDF, 1 page, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9042123&FileExtension=pdf&FileName=11%20-%20SA18-02-Rel.pdf - SB2X-42-17 (item 12, PDF, 18 pages, 130 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9042822&FileExtension=pdf&FileName=11a%20-%20SB2X-42-17%5B1%5D-Rel.pdf - Certification criteria (item 13, PDF, 3 pages, 782 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9708464&FileExtension=pdf&FileName=11b%20-%20Certification%20Basis%20and%20Revised%20Criteria-Rel.pdf - Statement of party representatives to NTSB investigation (item 14, PDF, 2 pages, 148 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9042619&FileExtension=pdf&FileName=12%20-%20Party%20Forms_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 15, PDF, 1 page, 482 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9042754&FileExtension=pdf&FileName=13%20-%20Wrk%20Rlse%20FULL%20signed%202018-11-16%2012-32_Redacted-Rel.pdf - FAA photographs (item 16, PDF, 3 pages, 4 photos, 880 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9042204&FileExtension=pdf&FileName=1a%20-%20FAA%20Photos-Rel.pdf - AIR-22-04 loss of engine power due to excessive fuel flow in Cirrus SR22T aircraft (item 17, PDF, 8 pages, 304 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13762767&FileExtension=pdf&FileName=AIR-22-04-Rel.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.