Aviation Accident Summaries

Aviation Accident Summary CHI06FA245

Indianapolis, IN, USA

Aircraft #1

N91MB

Cirrus SR22

Analysis

"THIS CASE WAS MODIFIED ON MARCH 25, 2009." The right seat passenger reported that the takeoff and initial climb were uneventful until the airplane reached about 4,000 feet of altitude. That was when he noticed that the sound of the engine had changed and saw that the pilot was struggling to control the airplane. The airplane went through a series of three quick rolls and the wing dipped down. The airplane entered a counterclockwise spin. The pilot told the right seat passenger to pull the emergency parachute handle, so he pulled the throttle back to idle, and then pulled the parachute handle. The airplane impacted a water retention pond about 4 seconds later. Witnesses observed the airplane descending through the clouds with a partially deployed parachute. The inspection of the engine and airframe revealed no pre-existing anomalies. The engine data obtained from the Multi-Function Display indicated the engine was operating at full power for the entire flight. Instrument meteorological conditions prevailed with variable cloud bases of 400 - 1,100 feet above the ground (agl) and with cloud tops reported at 3,200 feet above mean sea level. The baggage found in the baggage compartment weighed 262 pounds. The weight limit of the baggage compartment was 130 pounds maximum. The calculated takeoff condition weight of the accident airplane was 3,733 pounds. The Maximum Takeoff Weight was limited to 3,400 pounds. The center-of-gravity (CG) position was at fuselage station (FS) 148.7 inches, or 32.8 percent mean aerodynamic chord (MAC). The CG limits at maximum gross weight are from FS 143.8 inches to FS 148.1 inches. The airplane was overloaded and the CG position was aft of the CG limit. An aircraft performance study, which utilized data extracted from accident airplane, indicated that the airplane's airspeed decayed until the stall angle of attack of the wing was exceeded. The airplane was in a stalled condition for about 30 seconds and then entered a spin.

Factual Information

"THIS CASE WAS MODIFIED ON MARCH 25, 2009." HISTORY OF FLIGHT On August 28, 2006, at 1038 eastern daylight time, a Cirrus SR22, N91MB, was destroyed when it impacted a water retention pond located about 2.4 miles from the Eagle Creek Airpark (EYE), Indianapolis, Indiana, after a loss of control during cruise climb. The 14 Code of Federal Regulations Part 91 personal flight departed EYE at 1034 en route to Hilton Head Airport (HXD), Hilton Head Island, South Carolina. The pilot received fatal injuries, and the three passengers received serious injuries. Instrument meteorological conditions prevailed at the time of the accident. The flight was on an instrument flight plan. On Saturday, August 26th, the co-owner of N91MB (the accident pilot was the other co-owner) took ownership of the new airplane, and along with a Cirrus Standardized Instructor Program (CSIP) pilot, flew it from Duluth, Minnesota, where it was manufactured, to EYE. The co-owner of the airplane reported the approximately 500 nautical mile flight took about 3.5 hours to complete. A fuel receipt indicated that 50.9 gallons of fuel were added to the airplane after the flight. On Sunday, August 27th, the accident pilot and the CSIP pilot flew N91MB for 1.7 hours on an instrument proficiency check flight. Instrument meteorological conditions were encountered during the flight and the accident pilot practiced instrument procedures and flew 2 instrument approaches. The CSIP pilot reported that the accident pilot was on the "top of his game" and that he flew a very good check ride. After the flight, the CSIP pilot topped off the airplane with fuel. A fuel receipt indicated that 14.4 gallons of fuel were added to the airplane. Although the accident pilot had recently undergone surgery, the CSIP pilot reported that the accident pilot was feeling good and that he had told the CSIP pilot that he did not feel any side effects and was not taking any medications. The CSIP pilot reported that the engine, navigation, and communication systems on the airplane operated normally. The accident pilot telephoned the Terre Haute Flight Service Station (FSS) at 2131 on Sunday night to get a weather brief for a flight from EYE to HXD. The briefer informed him to expect marginal visual meteorological conditions and temporary instrument meteorological conditions at the departure airport between 0800 - 1200 the next morning. On Monday morning, August 28th, the pilot and the three passengers met at the pilot's hangar prior to the flight. The pilot's 29-year-old son, who was not a pilot, assisted loading the cargo on board the airplane. The pilot's son sat in the right front seat, the pilot's wife sat in the right rear seat, and a friend of the family sat in the left rear seat. The pilot taxied the airplane to the EYE ramp prior to takeoff, but was unable to contact Indianapolis Clearance Delivery, which was located at the Indianapolis International Airport, on his airplane's radio. At 1018, while the airplane's engine was running, he telephoned the Terre Haute FSS with his cellular telephone and requested an IFR departure clearance. The pilot was informed that his IFR flight plan was not in the system and that he would need to re-file the flight plan. The pilot stated to the briefer that he had filed an IFR flight plan the night before using Direct User Access Terminal Service (DUATS), but he re-filed his flight plan over the telephone with FSS. At 1030, he received his takeoff clearance, which included the following information: N91MB was cleared from the Eagle Creek Airport to the Hilton Head Airport via radar vectors as filed. He was cleared to climb and maintain 3,000 feet and expect 9,000 feet 10 minutes after departure. Contact departure control on 119.05, squawk 4004, and when able, fly heading 270 degrees. Void time was 1040. The transcript of radio communications between the pilot and Indianapolis Airport Traffic Control (ATC) indicated the following: At 1034:38, the pilot stated, "Indianapolis Departure, Cirrus, uh, Nine One Mike Bravo is off Eagle Creek, uh, turning to heading two seven zero, passing through fifteen hundred." At 1034:48, ATC responded, "Cirrus Niner One Mike Bravo, Indy Departure, ident. What is your on course heading?" At 1034:53, the pilot responded, "Uh, on course is going to be, uh, standby." At 1035:03, the pilot stated, "Uh, we're with you at one five one." At 1035:07, ATC stated, "Cirrus One Mike Bravo, roger. Radar contact one mile southwest of Eagle Creek. Climb and maintain six thousand." At 1035:11, the pilot responded, "Up to six thousand, Niner One Mike." About 1035, track data, which was derived from Airport Surveillance Radar (ASR) and the airplane's Avidyne Entegra EXP5000 Primary Flight Display (PFD), indicated that the airplane was on about a 270 degree heading at about 1,670 feet mean sea altitude with an indicated airspeed of about 117 knots. For about the next 30 seconds, the airplane's heading remained about 270 degrees. About 1035:50, the airplane's heading turned about 30 degrees left to about 240 degrees. The airplane's altitude was about 2,500 feet msl and the indicated airspeed was about 97 knots. At 1036:12, ATC stated, "Cirrus One Mike Bravo, turn left on course." At 103614, the pilot responded, "Uh, thank you, Nine One Mike Bravo, on course." At 1036:19, ATC stated, "And still one fifty?" At 1036:21, the pilot responded, "Uh, that's correct, sir." There were no further radio transmissions recorded from N91MB. At 1036:21, track data indicated that the airplane's altitude was about 3,000 feet msl and the indicated airspeed was about 87 knots. For about the next 20 - 25 seconds the airplane turned left to a heading of about 105 degrees and remained on that heading for about the next 60 seconds. At 1037:52, ATC stated, "One Mike Bravo, you say your on course heading is one five zero." At 1037:52, the airplane's heading was about 105 degrees, the altitude was about 3,800 feet msl, and the indicated airspeed was about 75 knots. Track data indicated that the airplane's heading turned to the northeast on about a 075-degree heading and the airplane lost altitude. The last radar return recorded at 1038:22 indicated that the airplane's altitude was about 1,600 feet msl. The pilot's son reported that the takeoff and initial climb were uneventful until the airplane reached about 4,000 feet of altitude. That was when he noticed that the sound of the engine had changed and saw that the pilot was struggling to control the airplane. The airplane went through a series of three quick rolls and the wing dipped down. The pilot was still attempting to control the airplane when he made an emergency call over the radio but there was no response. The pilot's son reported that the airplane entered a counterclockwise spin. The pilot told him to pull the parachute so he pulled the throttle back to idle and then pulled the parachute handle. An officer of the Indianapolis International Airport Police Department interviewed the pilot's son. The officer's report stated that the pilot's son observed the pilot "pulling backwards on the control yoke of the aircraft trying to keep the aircraft's nose up." The report stated that the pilot's son "grabbed the right sided yoke and attempted to help his father keep the aircraft nose elevated." The family friend who was sitting in the left rear seat reported "everything seemed normal" until "just to the point where we could be leveling off, just to the top of the clouds." She stated, "I remember hearing a different sound. I would call it the engine sounded differently, but something sounding differently. Kind of feeling and hearing something underneath of me." She stated, "The only thing I have to compare it to is when the wheels on a commercial flight are put down or up. And feeling two dips to the side, to the right, and definitely hearing [the pilot] talking to the tower at this time." She later stated, "It was like a rumble to me, you know. That the only thing I had to compare it to was the wheels going up and down, or I don't know, flaps, sometimes, on the wings of bigger planes." She stated that she heard the different noise and felt the rumble maybe 30 seconds before the pilot's son raised his arm to pull the parachute. She did not remember seeing him pull the parachute handle since she lost consciousness or blacked out. Numerous witnesses on the ground reported hearing and seeing the airplane prior to the impact. One witness reported that she "heard the plane's engine stop and start and stop again. Then an explosion and it fell out of the sky with the parachute falling behind but it did not deploy all the way. The airplane fell nose first into the water." Another witness heard a loud "pop" and saw the airplane "falling through the clouds" with the parachute deployed about "3/4 open by the time it hit the water." The airplane impacted a water retention pond in a residential neighborhood. People from the neighborhood went into the pond and assisted the pilot and passengers. Emergency rescue personnel arrived and all four occupants were transported to local hospitals. PERSONNEL INFORMATION The pilot was a 66-year-old private pilot with single-engine and multi-engine land limited to center thrust, and instrument airplane ratings. He held a third-class medical certificate that was issued in June 2005, with the limitations, "must have available glasses for near vision" and "not valid for any class after." He had a total of about 2,570 hours of flight time. Pilot logbook records indicated the pilot had logged about 365 hours of flight time in Cirrus SR22 airplanes. The pilot had owned N48RE, a Cirrus SR22 that was equipped with conventional pilot cockpit instrumentation, and he logged about 308 hours in it. He had flown about 50.2 hours in Cirrus SR22 airplanes equipped with "glass" cockpit instrumentation, which included the Avidyne Entegra EXP5000 PFD and the Avidyne EX5000 Multi-Function Display (MFD), prior to the accident flight in N91MB. Pilot logbook entries indicated that he flew 46.8 hours of actual IFR time and 21.3 hours of simulated IFR time in all Cirrus SR22 airplanes prior to the accident flight. According to the University of North Dakota training records, the pilot attended the Cirrus Factory Training Course December 9 - 11, 2002, when he purchased N48RE. The records indicated that he received 6.8 hours of flight training, and he was awarded a course completion certificate and an instrument proficiency check. The pilot's son reported that the pilot had owned a Cessna 210 from 1979 until the time he purchased his first Cirrus SR22, N48RE. The pilot's son had taken "pinch-hitters" courses in the Cessna 210, and had flown with the CSIP pilot for about 2 hours in N48RE. He reported that the pilot routinely instructed his passengers about the purpose of the airplane's parachute, and how to deploy the parachute in case of an emergency. AIRCRAFT INFORMATION The airplane was a single-engine Cirrus SR22, serial number 1973, with a Continental 310-horsepower IO-55N engine. It received its standard airworthiness certificate on May 25, 2006. According to sales records, Cirrus Design used it as a demonstrator airplane from May 31, 2006, to August 17, 2006. On August 25, 2006, the airplane Hobbs time was listed as 150.3 hours. At the time of the accident, the Hobbs meter indicated 156.0 hours. According to the Delivered Weight and Data Equipment List, the airplane was equipped with: Air conditioning, S-TEC 55X autopilot, dual Garmin GNS 430's, Avidyne PFD and MFD, TKS, EMax Engine Monitoring, Sky Watch, Stormscope, E-TAWS, and XM Satellite Weather and Radio. The airplane was equipped with a Cirrus Airframe Parachute System (CAPS), which is a whole airplane emergency parachute system. Federal Aviation Administration (FAA) inspectors checked the Weight and Balance of the accident airplane. The baggage found in the airplane was collected and weighed twice, but it was determined that the contents needed to be professionally dried to get an accurate weight since they were water soaked. After the baggage was dried, the contents were weighed a third time on calibrated scales. The baggage found in the baggage compartment weighed 262 pounds. The weight limit of the baggage compartment is 130 pounds maximum. The calculated takeoff condition weight of the accident airplane was 3,733 pounds. The Maximum Takeoff Weight is limited to 3,400 pounds. The center-of-gravity (CG) position was at fuselage station (FS) 148.7 inches, or 32.8 percent mean aerodynamic chord (MAC). The CG limits at the Maximum Gross Weight (3,400 pounds) are from FS 143.8 inches to FS 148.1 inches. The airplane was overloaded on the accident flight, and the CG position was aft of the limit described for the maximum gross weight. METEOROLOGICAL INFORMATION At 0953, the Automated Surface Observing System (ASOS) at EYE indicated the following: Wind 180 degrees at 4 knots, visibility 4 miles, mist, overcast 500 feet, temperature 23 degrees Celsius (C), dew point 22 degrees C, altimeter 29.89 inches of Mercury (Hg), ceiling variable between 400 and 800 feet. At 1053, the ASOS at EYE indicated the following: Wind 160 degrees at 4 knots, visibility 9 miles, overcast 700 feet, temperature 23 degrees C, dew point 2 degrees C, altimeter 29.90 inches of Hg, ceiling variable between 400 and 1,100 feet. Pilot reports in the Indianapolis area indicated low overcast stratiform clouds with bases 900 feet and tops to 3,200 feet. COCKPIT DISPLAY - RECORDED FLIGHT DATA System Information The Avidyne Entegra EXP5000 PFD and the Avidyne EX5000C Multi-Function Display (MFD) units were sent to the NTSB's Vehicle Recorder Laboratory for readout. The compact flash memory was removed from the MFD, and the Avionics Computing Resource (ACR) circuit card was removed from the PFD. The MFD compact flash card functioned normally in a standard card reader. A binary copy of the MFD compact flash card was successfully completed. However, the flight data could not be accessed with a standard PC operating system. The card was sent to the manufacturer for data extraction and decoding. The PFD ACR circuit board was sent to the manufacturer for data recovery as well. The manufacturer decoded the downloaded files and the results were returned to the NTSB lab. The PFD unit includes a solid state Air Data and Attitude Heading Reference System 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. Each PFD contains two flash memory devices mounted on a riser card. The flash memory stores information the PFD unit uses to generate the various primary flight data displays. The PFD samples and stores several data streams in a sequential fashion; when the recording limit of the PFD is reached, the oldest record is dropped and a new record is added. Data from the attitude and heading reference system (AHRS) is recorded at a rate of 5Hz. Air data information such as pressure altitude, indicated airspeed, and vertical speed are recorded at 1Hz. GPS and navigation display and setting data are recorded at a rate of .25Hz, and information about pilot settings of heading, altitude, and vertical speed references are recorded when changes are made. The MFD unit is able to display the pilot checklist, terrain/map information, approach chart information and other aircraft/operational information depending on the specific configuration and options that are installed. One of the options available is a display of comprehensive engine monitoring and performance data. Each MFD contains a compact flash memory card located in a slot on the side of the unit. This memory card contains all of the software that the MFD needs to operate. Additionally, this card contains all of the checklist, approach charts, and map information that the unit uses to generate the various cockpit displays. During operation, the MFD display receiv

Probable Cause and Findings

The pilot's failure to maintain sufficient airspeed, which resulted in a stall and subsequent spin. Contributing to the accident were the pilot's inadequate preflight planning, the overloaded condition of the airplane, and the CG aft of the CG limit.

 

Source: NTSB Aviation Accident Database

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