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DEN06FA131
HISTORY OF FLIGHT
On September 15, 2006, at 1332 mountain daylight time, a Cirrus Design Corp SR20, N787SL, owned by East End Aviation LLC,
and piloted by a private pilot, was destroyed when it impacted terrain 50 nautical miles (nm) north northwest of Maybell,
Colorado. Visual meteorological conditions prevailed at the time of the accident. The personal flight was being conducted
under the provisions of Title 14 Code of Federal Regulations Part 91 on an instrument flight rules flight (IFR) plan. The
private pilot and private pilot rated passenger were fatally injured. The cross-country flight departed Bolinder Field - Tooele
Valley Airport (TVY), Tooele, Utah, approximately 1150 and was en route to Lincoln, Nebraska (LNK).
The pilot and his passenger were returning from a business meeting in California and had departed Metropolitan Oakland
International Airport (OAK) approximately 0640 Pacific daylight time. A flight log found within the wreckage indicated that
they landed at TVY. According to a receipt from Tooele Valley Airport, the passenger paid for 36.26 gallons of fuel at 1120.
At 1221:13, the pilot contacted Cedar City radio with a request to file an IFR flight plan from his present position (10
miles east of FFU VOR) to LNK. The flight plan was filed for 14,000 feet. Afterwards, the briefer mentioned Airman's Meteorological
Information (AIRMETS) along the route of flight for mountain obscuration, turbulence, and icing, and advised them to contact
Flight Watch if they needed further weather information.
At 1320:20, the pilot reported to Denver (DEN) Air Route Traffic Control Center (ARTCC) that they were at 13,800 feet
and "need a (unintelligible) altitude… [they] picked a little bit of ice." The controller issued an altimeter
setting of 29.65. At 1323:29, the controller asked about the flight's assigned altitude. The pilot responded 14,000 feet and
stated that he was unable to maintain that altitude. Several altitude assignments were issued by the controller and ultimately
a block altitude from 12,000 feet to 13,000 feet was assigned.
At 1330:51, the pilot reported to ARTCC that they were having "serious" icing issues and were unable to maintain
12,000 feet. The controller asked the pilot if he had terrain in sight and the pilot responded in the affirmative. The controller
cleared the pilot to descend to 11,000 feet and maintain his own terrain separation. At 1331:57, the controller asked the
pilot what type of icing he was encountering. No further transmissions were received from the pilot.
National Track Analysis Program (NTAP) radar data depicted the airplane on a northeasterly heading at an encoded altitude
of 12,500 feet mean sea level (msl). At 1329:40, the airplane reversed course to a northerly direction and continued to descend.
Radar contact was lost at 1332:13. No encoded altitude was available for this time stamp.
An Alert Notification (ALNOT) was issued at 1349 and search and rescue operations were initiated. The wreckage and debris
path were located approximately 1440 by law enforcement personnel from the Sweetwater County Sheriff's office. A witness in
the area observed a portion of the fuselage being drug by the aircraft recovery parachute. They did not witness the actual
impact.
PERSONNEL INFORMATION
The pilot, age 48, held a private pilot certificate with airplane single and multi-engine land, and instrument ratings,
initially issued on October 30, 2004. He had been issued a second class airman medical certificate on May 24, 2006. The certificate
contained no limitations.
According to the Cirrus Factory Training Course records, the pilot attended aircraft familiarization training from September
16 through September 19, 2005. The pilot logged 12.2 hours of flight training and 8.0 hours of ground school during this time.
All areas of training were completed with a satisfactory rating.
A copy of the pilot's logbook was provided to the National Transportation Safety Board (Safety Board) investigator-in-charge
(IIC) for review. The pilot had logged no less than 583.6 hours; 88.3 in multi-engine airplanes and 495.3 hours in single
engine airplanes. A total of 275.8 hours had been logged in a Cirrus SR-20, all but 1.2 hours of which were in the accident
airplane. In addition, the pilot had logged 95.8 hours of instrument time; 35.7 of which were in actual instrument conditions,
and 28 hours of which were in the accident airplane. The pilot successfully completed the requirements of a Flight Review
on July 4, 2005.
The passenger, age 46, held a private pilot certificate with an airplane single engine land rating which was issued on
May 2, 2005. He had been issued a third class airman medical certificate on September 10, 2003. The certificate contained
no limitations.
According to a flight log located within the wreckage, the passenger had flown the previous leg from California. There
was no record that the passenger had attended the Cirrus Factory Training Course.
AIRCRAFT INFORMATION
The accident airplane, a Cirrus Design Corp (serial number 1556), was manufactured in 2005. It was registered with the
FAA on a standard airworthiness certificate for normal operations. The airplane was equipped with a Teledyne Continental Motors
IO-360-ES engine rated at 210 horsepower at 2,800 rpm. The engine was equipped with a Hartzell 2-blade, constant speed propeller.
The pilot purchased the airplane in September of 2005. The airplane was registered to and operated by East End Aviation,
LLC., and was maintained under an annual inspection program. A review of the maintenance records indicated that a 100-hour
inspection had been completed on April 4, 2006, at an airframe total time of 259.9 hours. The airplane had flown approximately
243.5 hours between the last inspection and the accident and had a total airframe time of 503.4 hours.
METEOROLOGICAL CONDITIONS
On September 15, 2006, a Surface Analysis chart, prepared by the National Weather Service (NWS), National Center for Environmental
Prediction, depicted a stationary front that extended from a low pressure area, located in southwest North Dakota, diagonally
through Wyoming and into northern Utah and Nevada. A high pressure ridge extended from western Colorado into northern New
Mexico. The accident site was located to the south of the stationary front and near the ridge of high pressure.
The NWS Freezing Level chart issued on the day of the accident depicted the freezing level along the route of flight ranging
from 11,600 feet to 14,200 feet msl. Doppler weather radar (approximately 120 miles south-southeast of the accident location)
scanned the accident area at 1322. Data indicated reflectivity values of 25 to 34 dBz, or moderate intensity precipitation,
in the accident area around the accident time. According to NTAP data, the accident airplane was in the immediate vicinity
of a 35 dBz cell when the pilot first reported icing conditions.
An Aviation area forecast was issued for eastern Utah, southern Wyoming, and northern Colorado by the Aviation Weather
Center (AWC) in Kansas City, Missouri, the day of the accident, at 0445. The forecast for the route from Utah into Colorado
and Wyoming was for scattered to broken clouds at 10,000 feet, broken to overcast clouds at 15,000 feet, southerly winds gusting
to 30 knots, widely scattered light rain showers with scattered thunderstorms, and rain showers, thunderstorms possibly severe,
cumulonimbus cloud tops to 40,000 feet.
Multiple pilot reports (PIREPS) had been issued for the Colorado/Wyoming area regarding icing. Reports given for icing
included light to moderate clear and rime icing from 8,500 feet msl to 19,000 feet msl. The NWS Current Icing Potential chart
valid at the time of the accident depicted a 90 percent chance of icing conditions at 14,000 feet, 70 percent chance of icing
conditions at 13,000 feet, and less than 40 percent chance of icing below 12,000 feet, all in the vicinity of the route of
flight.
AIRMETs for mountain obscuration (SIERRA), turbulence (TANGO), and icing (ZULU) were all issued by AWC for areas in Utah,
Colorado, and Wyoming, including the accident airplane's route of flight. AIRMET SIERRA stated to expect mountains occasionally
obscured by clouds, precipitation, mist, and fog. AIRMET TANGO stated to expect occasional moderate turbulence below flight
level (FL) 180. AIRMET ZULU stated to expect occasional moderate rime and mixed icing between the freezing level and FL 260.
Convective Significant Meteorological Information (SIGMET) 34W was issued for Wyoming, Colorado, and Utah for an intensifying
area of thunderstorm moving northeastward at 35 knots with tops to 38,000 feet. The NWS Severe Storm Prediction Center also
issued a Weather Watch number 766 for the potential for severe thunderstorms. The watch area extended over the flight route
from Utah to the accident site.
The closest official weather observation station was Rock Springs, Wyoming (RKS), located 50 nautical miles (nm) north
of the accident site. The elevation of the weather observation station was 6,760 feet msl. The routine aviation weather report
(METAR) for RKS, issued at 1254, reported, winds 180 degrees at 24 knots, gusting to 29 knots; visibility 10 statute miles;
sky condition clear; temperature 15 degrees Celsius (C); dewpoint 7 degrees C; altimeter 29.65 inches.
The METAR for RKS, issued at 1354, reported, winds 170 degrees at 23 knots, gusting to 28 knots; visibility 10 statute
miles; sky condition, ceiling broken a 7,500 feet; temperature 15 degrees C; dewpoint 6 degrees C; altimeter 29.64 inches;
remarks, peak wind from 190 degrees at 31 knots measured at 1341; lightning distant west and northwest.
The METAR for Vernal, Utah, issued at 1312, reported, winds 260 degrees at 9 knots, gusting to 18 knots; visibility 2
½ miles in thunderstorm and heavy rain; sky condition, few clouds at 2,800 feet, ceiling broken at 4,900 feet, overcast at
7,000 feet; temperature 10 degrees C; dewpoint 6 degrees C; altimeter 29.69 inches. Remarks: peak wind from 310 degrees at
29 knots recorded at 1301, wind shift at 1255, lightning distant all quadrants, and rain began at 1304.
FLIGHT RECORDERS
The accident airplane was equipped with an Avidyne Primary Flight Display (PFD) (part number 700-0004-0008) and an Avidyne
Multi-Function Display (MFD) (part number 700-0006-000). The avionics computing resource from the PFD and the flash memory
device from the MFD were removed and sent to Avidyne for extraction of flight data associated with this accident. The information
was downloaded on September 25, 2006, under the auspices of the NTSB.
The PFD contained seven fault codes and no flight parameters. The first two fault codes were not related to this event.
An "Attitude Heading Reference System (AHRS) invalid" message was recorded at 1931:48 Universal Time Coordinated
(UTC). According to Avidyne, this message could indicate any of the following conditions - the value of the calculated pitch,
roll, magnetic heading, or rate of turn is considered invalid, or the AHRS has ceased sending data for one second. A cluster
of four fault codes was recorded at 1932:12. According to Avidyne, these fault codes were consistent with a loss of power
to the unit.
The MFD was capable of receiving XM satellite weather information. The MFD does not store the weather information; however,
the message type and time received is stored in the Compact Flash Card. No engine or other parameters were recorded.
WRECKAGE AND IMPACT INFORMATION
The National Transportation Safety Board investigator-in-charge (IIC) arrived on scene approximately 1400 on September
16, 2006. The accident site was located in uneven terrain vegetated with sagebrush. Several ravines and gullies were located
between the initial impact point and the last portion of the airplane wreckage. A global positioning system (GPS) receiver
recorded the coordinates of the initial impact point as 40 degrees, 59 minutes, 04.9 seconds north latitude, and 108 degrees,
48 minutes, 00.2 seconds west longitude. A GPS receiver recorded the coordinates of the last portion of the airplane wreckage
as 41 degrees, 00 minutes, 16.6 seconds north latitude, and 108 degrees, 47 minutes, 11.7 seconds west longitude. The accident
site elevation varied from 7,120 feet to 6,900 feet msl and the airplane impacted on a magnetic heading of 015 degrees.
The Safety Board IIC identified the initial impact point 1.07 miles south of the Colorado/Wyoming border. Fragments from
the nose wheel pant were located within the north most portion of the ground scar. A debris path extended, in a north-northeast
direction from the initial point of impact, for 500 feet. The engine cowling, fuselage doors, main landing gear assemblies,
the propeller assembly, various engine components, the Kevlar Cirrus Airframe Parachute System (CAPS) strap covers, fragmented
composite material, and various personal effects were located within the initial debris path.
A periodic ground scar and debris path extended from this point, across rough uneven terrain, down a 100-foot embankment,
to the wing assembly. The ground scars varied in length and width and were consistent with an object being drug. Sagebrush
was bent and crushed in a north-northwesterly direction. The CAPS deployment system (including the rocket housing, and parachute
cover), the CAPS fuselage cover, the engine assembly, the right aileron, and various personal effects were located within
the second debris path.
The wing assembly was located 1,542 feet from the initial impact point at an elevation of 7,072 feet msl. It consisted
of both the left and right wing, both flaps, the right aileron, both front seats, and portions of the instrument panel. The
leading edges of both wings were crushed aft and exhibited broken composite material. The trailing edges of both flaps were
wrinkled and the aileron separated from the right wing. The leading edges of both wings were clean and the airfoil just aft
of both leading edges exhibited aft particle streaking consistent with structural icing. Control continuity to both ailerons
was confirmed.
A periodic ground scar and debris path extended from the wing assembly over rough, uneven terrain, across several gullies
and ravines, over several barbed wire fences, and across highway 430, into the state of Wyoming. Portions of the elevator,
rudder, and horizontal stabilizer were located within the debris path. An 8.5-foot section of the aft fuselage and portions
of the empennage came to rest 1.55 miles north northwest of the initial impact point. The CAPS canopy remained partially attached
to the fuselage and was tangled in a barbed wire fence.
The CAPS activation handle, the rudder pedals, the rudder and elevator control cables, and an aft seat remained with this
portion of the fuselage. The CAPS activation handle was in the stowed position. An on scene examination of the handle revealed
mud impacted within the securing pinhole and around the handle groove. The safety pin was not located. Control cable continuity
was established through the rudder and elevator cables.
MEDICAL AND PATHOLOGICAL INFORMATION
The autopsy was performed on the pilot and passenger in the Jefferson County Coroner's office on September 20, 2006, as
requested by the Moffett County Coroner's office. The autopsy revealed the cause of death for the pilot due to "head
and internal injuries secondary to blunt force trauma sustained in the airplane crash." The cause of death for the passenger
was due to "exsanguination secondary to lacerations involving the heart and aorta secondary to blunt force trauma sustained
in the airplane crash."
During the autopsy, specimens were collected for toxicological testing to be performed by the FAA's Civil Aerospace Medical
Institute (CAMI), Oklahoma City, Oklahoma (CAMI Reference #200600218001 and 200600218002). Tests for carbon monoxide, cyanide,
ethanol, and drugs were all negative.
TESTS AND RESEARCH
The airplane wreckage was recovered on September 17, 2006, and relocated to a hangar in Greeley, Colorado, for further
examination. The Safety Board IIC, Safety Board survival factors investigators, the FAA AAI-100 IIC, and representatives from
Am Safe Aviation, and Teledyne Continental Motors, examined the wreckage on September 19, 2006. The Safety Board IIC and a
representative from Ballistic Recovery Systems (BRS) examined portions of the wreckage on September 21, 2006.
Engine and Propeller
The engine was separated from the airframe. Three of the four engine mounts remained attached to the engine assembly.
The top sparkplugs were removed and exhibited normal signs of wear. The cylinders were examined using a lighted borescope
and exhibited normal operational signatures. The engine was rotated through using an accessory drive tool from the mount pad
on the back of the starter adapter. Engine continuity was established from the rear of the engine to the front. Tactile compression
was confirmed on all six cylinders. The left magneto was rotated through by hand, producing spark on all of the leads. The
right magneto was rotated, with the use of a magneto test bench, resulting in a spark on all of the leads.
The propeller assembly, to include both blades and the spinner, separated from the engine just aft of the crankshaft propeller
flange. The propeller blades were arbitrarily labeled A and B for identification purposes only. Both blades exhibited chordwise
scratching and leading edge polishing. The spinner was crushed aft, exhibiting rotational signatures.
Seats and Seat Restraints
The Cirrus SR20 is equipped with dynamically certified seats per CFR 23.562. The seat bottoms have an integral aluminum
honeycomb core, designed to crush at impact to absorb downward loads. The seat back of the left seat was pushed aft. The forward
half of the aluminum honeycomb core was crushed. The seat back of the right seat was found bent forward. The forward two thirds
of the aluminum honeycomb core were crushed. The crushing on both cores initiated centrally and the degree of crushing increased
towards the forward portion of the core. According to Cirrus, this crushing is consistent with a forward motion during impact
as opposed to a vertical impact.
The two front seats were equipped with a 4-point harness and an airbag. The left seat harness was found buckled and taught
around the seat. The airbag was deployed. The right seat harness was not buckled and the airbag was deployed. The inertia
reels were fully functional.
Cirrus Airframe Parachute System
The CAPS was examined by a representative from BRS under the auspices of the Safety Board IIC. The aluminum inspection
panel mounted on the airframe, forward of the CAPS unit, exhibited oil canning and was covered in dry mud. The panel was removed,
revealing an 8-inch witness mark that initiated 2.5 inches from the top of the panel and extended down diagonally. The mark
was consistent with the fiberglass cover that housed the igniter. The panel also exhibited burn marks at the top.
The two primers located at the end of the igniter assembly displayed a circular indentation at the center of each primer,
consistent with impact from the respective firing pins. The ball bearings within the igniter assembly were not present. The
CAPS rocket powder was fully spent which is consistent with deployment by tension in the cable. The Teflon covered stainless
steal lines attached to the rocket pick-up collar exhibited discoloration of the Teflon. The CAPS fuselage cover exhibited
a slight impact witness mark with a corresponding spider like paint fracture on the opposite side. This mark is consistent
with impact from the rocket as it exits the airplane.
ADDITIONAL INFORMATION
According to the Cirrus SR 20 Pilot Operating Handbook (POH), Section 2: Limitations -
"Flight into known icing conditions is prohibited." In the event that icing is inadvertently encountered the
POH states to activate the pitot and cabin heat, and the alternate induction air, and either reverse direction of flight or
change altitude in order to exit icing conditions.
The POH states "the Cirrus Airframe Parachute System (CAPS) should be activated in the event of a life-threatening
emergency where CAPS deployment is determined to be safer than continued flight and landing." According to the POH, these
scenarios include mid-air collision, structural failure, loss of control, and landing in inhospitable terrain. Loss of control,
according to the POH, "may result from many situations, such as: a control system failure (disconnected or jammed controls);
severe wake turbulence, severe turbulence causing upset, severe airframe icing, or sustained pilot disorientation caused by
vertigo or panic; or a spiral/ spin." According to the POH, "No minimum altitude for deployment has been set."
The POH goes on to state, "it might be useful to keep 2,000 feet AGL in mind as a cut-off decision altitude."
According to the POH, the CAPS is activated by pulling on the T-handle, installed on the cabin ceiling on the airplane
centerline, just above the pilot's right shoulder. The POH states that both hands should be used with a straight "downward"
continuous force to activate the CAPS. "Up to 45.0 pounds (20.4 Kg) force, or greater, may be required to activate the
rocket."
Finally, the POH states "if it is known or suspected that ground gusts of approximately 30 knots or more are present
in the landing zone, there is a possibility that the parachute could drag the airplane after touchdown, especially if the
terrain is flat and without obstacles."
The wreckage was released to a representative of the insurance company on February 14, 2007.
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