# NTSB WPR20FA019: Cirrus SR22, N220MT, Upland, CA, November 7, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: November 7, 2019, 11:00 local (19:00 UTC) - Place: Upland, CA - Coordinates: 34.109722, -117.669723 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.1097&lon=-117.6697&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Continental Aerospace Technologies, Federal Aviation Administration, Cirrus Aircraft - NTSB case key (mKey): 100538 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR20FA019 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100538/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100538 - Page: https://openairdocs.org/ntsb/WPR20FA019 ## Probable cause The pilot's exceedance of the airplane’s critical angle of attack while maneuvering for landing, which resulted in an aerodynamic stall and loss of control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cirrus Design SR22, 94 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2130001), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cirrus Design SR22, 14 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=2130001), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained; cases with it: [Cirrus Design SR22, 24 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=2130001), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Cirrus Design SR22, 19 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=2130001), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Cirrus Design SR22, 74 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2130001), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Approach: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cirrus Design SR22, 113 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2130001), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis Radar data indicated that, when the accident airplane was about 1 nautical mile southwest of the airport, another airplane entered a left downwind leg for the landing runway. The first airplane was on the base leg of the traffic pattern when the accident airplane entered the left downwind. The accident airplane's speed slowly decreased as it continued the downwind leg, and the first airplane landed when the accident airplane was turning toward the base leg at about 69 knots groundspeed. Shortly thereafter, the airplane descended and impacted a residential area about 1/2 mile from the runway threshold. A witness saw the accident airplane enter the traffic pattern shortly behind the first airplane. As the first airplane landed, the accident airplane was on base to final flying “low and very slow,” like it was “waiting for” the first airplane. The left wing dropped, and the airplane descended to the ground. Postaccident examination of the airframe and engine revealed no anomalies that would have precluded normal operation. Based on the available information, the accident is consistent with the pilot’s exceedance of the airplane’s critical angle of attack while maneuvering for landing, which resulted in an aerodynamic stall, loss of control, and impact with terrain. It is possible that the pilot may have been distracted by the airplane landing in front of him, which contributed to his loss of situation awareness regarding the airplane’s speed. ## Factual narrative The logbooks were found within the airplane and were heavily burned. On November 7, 2019, about 1100 Pacific standard time, a Cirrus SR22 airplane, N220MT, was destroyed when it was involved in an accident near Upland, California. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. One witness saw the accident airplane enter the traffic pattern shortly behind another airplane. As the other airplane landed, the accident airplane was on base to final flying “low and very slow” as if it was “waiting for” the other airplane. The left wing dropped, and the airplane descended to the ground. The accident airplane approached the airport from the southwest; when it was about 1 nautical mile from the airport, another airplane entered a left downwind for runway 24. The other airplane made a large traffic pattern and was on base when the accident airplane entered a narrower left downwind for the same runway at about 93 knots. The accident airplane's speed slowly decreased while in the traffic pattern. The first airplane landed on the runway when the accident airplane appeared to be in a left turn toward base at about 69 knots. Shortly thereafter, the accident airplane abruptly descended from 1,800 to 1,600 feet at an average rate of 3,030 feet per minute and radar data was lost. An autopsy was performed on the pilot by the San Bernardino County Sheriff's Department Coroner Division, San Bernardino, California. The pilot's cause of death was listed as thermal injuries with smoke inhalation. NMS Labs performed toxicological testing at the request of the coroner. This testing measured elevated carboxyhemoglobin of 34% in the pilot's heart blood (nonsmokers normally have carboxyhemoglobin levels of less than 1-3%, while heavy smokers may normally have levels as high as 10-15%). The testing also detected caffeine in the pilot's heart blood. The Federal Aviation Administration Forensic Sciences Laboratory measured elevated carboxyhemoglobin of 21% in heart blood, and also detected cyanide in heart blood at 2.13 micrograms per milliliter (µg/mL) The airplane impacted a house in a residential area about 1/2 mile from the runway 24 threshold. A majority of the airplane came to rest in the westernmost rooms of the house, and a large portion of the outboard left wing came to rest on an adjacent brick wall. A postimpact fire ensued, and most of the airframe was consumed by the fire. The engine came to rest in an upright and nose low position. The firewall and instrument panel remained attached to the engine and exhibited extensive thermal damage. All three propeller blades remained attached at the hub but were separated at the blade root. Two blades were completely separated and only the balance tube was present; one of the balance tubes was bent aft at about a 45° angle, and the second balance tube was bent slightly. Only about 1/3 of the blade root remained on the third propeller. The blade rootexhibited heavy thermal damage, and about 2/3 of the outboard blade was not present. The airframe parachute risers and suspension lines were draped over a nearby palm tree and the parachute came to rest in a neighboring yard. The slider was observed at the base of the parachute and the beeswax coating on the vent lines at the apex of the parachute canopy remained stuck together, consistent with a packed state. The postaccident airframe and engine examination did not reveal any anomalies that would have precluded normal operation. Of the remaining airframe structure, the rudder, elevator, left wing root, and left-wing spar exhibited thermal damage. The flight controls were heavily damaged with some fragments consumed by fire; however, continuity was established amongst the remaining control cables. The engine was covered in fire-related debris. The intake system exhibited some thermal damage and fire-related debris was noted within some of the tubing. The spark plugs were removed and exhibited normal operating signatures. The crankshaft was rotated by hand; thumb compression was established throughout, and the valves moved accordingly. The ignition harness was mostly intact but exhibited thermal damage. The right magneto was removed from the engine and produced spark. The left magneto was disassembled, and the timing gear was found melted; the remaining internal components were consistent with normal operation. Borescope examination of the piston heads, cylinder walls, valves, and lower spark plugs revealed normal operating signatures. ## Aircraft - Registration: [N220MT](https://openairdocs.org/deregistered/N220MT-2022-03-05), registration cancelled 2022-03-05, S/N 2748, built 2007 (OpenAirDocs) - Reported make and model: Cirrus SR22 (Undesignat) - 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: 2748 - Year built: 2007 - Airframe hours: 1174 - Engines: Continental Aerospace Technolo IO-550-N reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 11, 2019 - Departed: TOA, Torrance, CA - Destination: CCB, Upland, CA - Airport: CCB, Cable Airport, runway 24, 3,863 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; seat: left; restraint: 3-point; toxicology performed; flight hours: 650 total ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 32 °F - Altimeter: 30.10 inHg - Observed at: CCB, 1 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 20191107020879A](https://openairdocs.org/incident/20191107020879A), Nov 7, 2019: Cirrus Design Corp SR22, Upland, CA, Destroyed, 1 fatal. On the day of the accident flight, the owner of the accident aircraft, N220MT, a Cirrus SR-22, departed from torrance for a 20 minute VFR flight to Cable… ## Docket (11 files) The files NTSB released with the investigation on November 17, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100538. 17.5 MB in all. - Cockpit displays - specialist's factual report (item 1, PDF, 3 pages, 2 photos, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10016821&FileExtension=pdf&FileName=WPR20FA019%20Report-Rel.pdf - Google earth images (item 2, PDF, 3 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9985478&FileExtension=pdf&FileName=google%20Earth%20Images-Rel.pdf - Radar data - google earth (item 3, KMZ, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9986619&FileExtension=kmz&FileName=WPR20FA019%20-%20Google%20Earth-Rel.kmz - Radar playback (item 4, MP4, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12810737&FileExtension=mp4&FileName=WPR20FA019%20-%20Playback%203X%20Speed-Rel.mp4 - Witness statements (item 5, PDF, 4 pages, 158 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9986247&FileExtension=pdf&FileName=Witnesses%20Combined-Rel.pdf - Record of conversation - airplane's mechanic (item 6, PDF, 1 page, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9985488&FileExtension=pdf&FileName=curtis%20ROC-Rel.pdf - On scene observations (item 7, PDF, 9 pages, 4.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10127582&FileExtension=pdf&FileName=On%20Scene%20Notes-Rel.pdf - Postaccident airframe and engine examination observations (item 8, PDF, 13 pages, 5.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9986136&FileExtension=pdf&FileName=Airframe%20and%20Engine%20Examination-Rel.pdf - Statement of party representatives to NTSB investigation (item 9, PDF, 2 pages, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9983749&FileExtension=pdf&FileName=party%20forms_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 10, PDF, 1 page, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10127714&FileExtension=pdf&FileName=WPR20FA019%20Wreckage%20Release_Redacted-Rel.pdf - Toxicological report (item 11, PDF, 1 page, 329 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9984970&FileExtension=pdf&FileName=Tox%20printed_Redacted-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.