WPR21LA068

NTSB accident investigation · Cirrus Design SR22 · Ogden, UT · December 10, 2020

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
December 10, 2020, 15:47 local (22:47 UTC)
Place
Ogden, UT
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N577CPCirrus Design SR22
Defining event
Initial climb: Unknown or undetermined
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Tornado Alley Turbo Inc., Cirrus Aircraft
FAA report
20201210017629A
Case key
102400

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The partial loss of engine power for reasons that cannot be determined due to lack of available evidence.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Turbocharging (recip only): turbochargerAircraft › Aircraft power plant · Incorrect service/maintenanceCirrus Design SR22: 2 casesAll aircraft: 29 cases
Not determinedNot determined › Not determined · Unknown/Not determinedCirrus Design SR22: 25 casesAll aircraft: 2,247 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot reported that during takeoff on runway 17, the engine ran smoothly, and the airplane became airborne “in the usual spot.” During the initial climb, the pilot noticed a loss of power that prevented the airplane from continuing to climb, and he initiated a right turn to land on runway 3. During the landing roll, he realized the airplane would not stop with maximum braking. The pilot added that he tried to pull the parachute handle, but it did not activate during the accident sequence. The pilot further stated that he used his right hand to pull the handle as he was flying with this left and could not recall how much force he was able to pull the handle with. The airplane exited the right side of the runway and came to rest upright beyond the departure end of the runway. Examination of the airframe parachute system revealed no evidence of a mechanical failure or malfunction that would have precluded normal operation. It’s likely that the parachute did not deploy due to the pilot not exerting enough force on the deployment handle. Recorded data from the avionics display showed that during takeoff, the manifold pressure had increased to 34.81 inches, and decreased to 25.55 inches about 7 seconds later. The engine rpm reduced from about 2,650 to about 2,478. The data showed that rpm remained about 2,600, with manifold pressure around 25 inches, throughout the duration of the flight until power was reduced for landing. Postaccident examination of the engine revealed that the sensing line from the left intercooler to the pressure controller was hand tight at the control unit. The right-side turbocharger shaft nut was found in the inlet of the turbine along with significant damage to the turbine inlet housing. Examination of the induction system revealed that one of the induction tubes and clamp were crushed, and the remainder were intact. The increase in manifold pressure during takeoff most likely was the result of the loose sensing line between the left intercooler and pressure controller. Furthermore, while it is possible that a loose induction tube clamp would result in a decrease in manifold pressure, it could not be determined due to post impact damage sustained to the induction system. The right-side turbocharger shaft nut found loose was most likely a result of impact damage to the turbocharger from the accident sequence.

Factual narrative

On December 10, 2020, about 1547 mountain standard time, a Cirrus Design Corp. SR22, N577CP, was substantially damaged when it was involved in an accident at the Ogden Hinkley Airport (OGD), Ogden, Utah. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that during takeoff on runway 17, the engine ran smoothly, and the airplane became airborne “in the usual spot.” During the initial climb, he noticed a loss of power that prevented the airplane from continuing to climb so he lowered the nose to “keep up my airspeed” as he initiated a right turn to land on runway 3. The pilot stated that he landed on runway 3 and realized the airplane would not stop with maximum braking. Subsequently the airplane exited the right side of the runway and came to rest upright beyond the departure end of the runway. Postaccident examination of the airplane revealed the airplane sustained structural damage to the left wing and fuselage. The pilot added that he tried to pull the parachute handle, but it did not activate during the accident sequence. The pilot further stated that he used his right hand to pull the handle as he was flying with this left and could not recall how much force he was able to pull the handle with. He added that his goal was to get down as quick as he could, and he knew the [para]chute wouldn’t give the normal sway down but was “hoping for some drag.” Recorded data was recovered from the onboard avionics display units. The data (see figure 1) showed that the engine power increased around 1545:07. During this time, the left and right turbine inlet temperatures (TIT) began to differentiate, with the right TIT temperatures remaining higher than the left. About 21 seconds later, the manifold pressure had increased to 34.8 inches and an rpm of 2,652.3. About 7 seconds later, the manifold pressure decreased to 25.55 inches and the rpm reduced to 2,478.2. The data showed that the airplane established a positive rate of climb at 1545:37 and entered a right turn 12 seconds later. The airplane continued the right turn and reached a maximum GPS altitude of 4,695 ft mean sea level, before a descent began at 1546:35, while west of runway 17/35 and north of runway 3/21. The data showed that the airplane aligned with runway 3 and touched down about 2,423 ft from the departure end of the runway, at a groundspeed of about 121.84 knots. Throughout the recorded data, engine rpm remained around 2,600, with manifold pressure at about 25 inches, until about 18 seconds before touchdown. The airplane’s avionics features a Crew Alert System (CAS), which under certain conditions, would trigger a warning message. A Cirrus Aircraft representative reported that once the manifold pressure exceeded 34 inches, a CAS warning message “manifold pressure” would be displayed and accompanied by an audible double chime that repeats until acknowledged by the pilot by pressing the warningsoft key. The recorded data showed that the CAS warning message criteria was met about 10 seconds before takeoff. The pilot reported that he did not recall any audible chimes or tones. Figure 1: Plotted avionics display data. The Cirrus Airframe Parachute System (CAPS) handle was out of the handle holder. The handle holder mounting bracket was bent downward about 90°. The CAPS system was not activated. The CAPS activation switch was not triggered. With the rocket removed, the activation handle was actuated, and activation cable continuity was established to the igniter switch. The igniter switch circuit continuity was operationally tested. No evidence of any preexisting malfunction that would have precluded normal operation of the CAPS was found. The pilot operating handbook (POH) states in part that pulling the activation handle will activate the rocket and initiate the CAPS deployment sequence. The POH further states to activate the rocket, pull the activation handle from its receptacle…clasp both hands around the activation handle and pull straight down with a strong, steady, and continuous force until the rocket activates. Additionally, the POH references that 45 lbs of force, or greater, may be required to activate the rocket. Examination of the engine revealed that the sensing line from the left intercooler to the pressure controller was hand tight at the control unit. The No. 1 cylinder spark plug, and No. 4 cylinder spark plug ignition lead were also found hand tight. The right-side turbocharger shaft nut was found in the inlet of the turbine. Significant damage to the turbine inlet housing was observed. Further examination of the induction system revealed that one of the induction tubes and clamp were crushed, consistent with impact. The remainder of the induction tubes were intact and undamaged. Review of the airframe and engine maintenance logbooks revealed that the most recent annual inspection was completed 2 days prior to the accident. The entry stated that the Tornado Alley Turbocharger System Inspection for continued airworthiness was complied with. The Tornado Alley Turbo, Inc., 22-6460004 Continued Airworthiness manual, revision a, states in part that “manifold pressure is high and stays high after engine is warm,” the “absolute pressure control sensing line is broken or loose.” A representative from Tornado Alley Turbo, Inc., reported that pressure outside of the induction tubes is about 5 inches lower than inside, and if the clamps on the couplings are not secure, there is enough of a differential in pressure to produce an air leak at the coupling.

Aircraft

Registration
N577CP
Reported as
Cirrus Design SR22
Category
Airplane
Serial number
3345
Built
2008
Airframe hours
722
Engine
Continental Motors IO-550-N, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Netgenesis Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 8, 2020 · 0 hours before
Destination
VGT · Las Vegas, NV
Airport
OGD · Ogden-Hinckley, runway 3, 8,107 × 150 ft, asphalt
Equipment
Electronic primary flight display, Electronic multifunction display, Electronic flight bag or handheld device, Data recorder, Auto-pilot, Angle of attack indicator, Airframe parachute, Onboard weather, Stall warning system, ADS-B

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
64
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
March 22, 2019
Seat
Left
Restraint
4-point
Flight hours
465.1 total · 442.1 in this make and model · 465.1 as pilot in command · 13.4 in the last 90 days · 2.4 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 5 knots
Visibility
10 statute miles
Temperature
32 °F, dew point 19 °F
Altimeter
2995.00 inHg
Observed at
KOGD

Docket · 22

The files NTSB released with the investigation on September 8, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 179 MB in all.

Cockpit display - recorded flight data - specialist's factual reportItem 1 · PDF · 9 pages · 1.3 MBAttachment 1 to cockpit display - recorded flight data - specialist's factual report - previous flightItem 2 · CSV · 809 KBAttachment 2 to cockpit display - recorded flight data - specialist's factual report - accident flightItem 3 · CSV · 373 KBPilot/operator aircraft accident report, NTSB form 6120.1Item 4 · PDF · 11 pages · 6.6 MBRecord of conversation - pilotItem 5 · PDF · 2 pages · 151 KBMechanic statementsItem 6 · PDF · 5 pages · 4.7 MBNTSB examination summaryItem 7 · PDF · 13 pages · 9 photos · 2.4 MBFAA exam observationsItem 8 · PDF · 2 pages · 221 KBAnnual inspection checklistItem 9 · PDF · 9 pages · 5.1 MBMaintenance work orderItem 10 · PDF · 5 pages · 65 KBExcerpts from maintenance recordsItem 11 · PDF · 2 pages · 12.0 MBEvidence control formItem 12 · PDF · 2 pages · 29 KBUps delivery informationItem 13 · PDF · 1 page · 30 KBStatement of party representatives to NTSB investigation - tornado alleyItem 14 · PDF · 1 page · 277 KBStatement of party representatives to NTSB investigation - Cirrus aircraftItem 15 · PDF · 1 page · 4.3 MBRelease of aircraft wreckage, NTSB form 6120.15Item 16 · PDF · 1 page · 381 KBPhoto arrayItem 17 · PDF · 2 pages · 2 photos · 1.6 MBTornado alley Cirrus 22 continued airworthiness rev aItem 18 · PDF · 41 pages · 1.5 MBCirrus SR22 pilot operating handbookItem 19 · PDF · 346 pages · 136 MBDisplay data google earth plotItem 20 · KML · 628 KBRecord of conversation - tornado alley turbo inc.Item 21 · PDF · 1 page · 64 KBRecord of conversation - CirrusItem 22 · PDF · 1 page · 125 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.