Cirrus NTSB Database
N837CD 20020424
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N254SR 20071230
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N108GD 20071121
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N457S 20061218
N665CD 20061130
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N799TM 20051229
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N286CD 20050206
N6057M 20050120
N889JB 20050115
N1159C 20041204
N1223S 20040910
N8157J 20040419
N100BR 20031012
N9523P 20030118
N566T 20021103
N901CD 20020528
N837CD 20020424
N893MK 20020123
N116CD 20010410

NYC02FA089

HISTORY OF FLIGHT

On April 24, 2002, at 1906 eastern daylight time, a Cirrus SR-22, N837CD, was destroyed when it impacted terrain in Parish, New York. The two certificated private pilots were fatally injured. Visual meteorological conditions prevailed at the time of the accident. No flight plan was on file for the flight, which originated at Syracuse Hancock International Airport (SYR), Syracuse, New York, and was destined for Greater Rochester International Airport (ROC), Rochester, New York. The personal flight was conducted under 14 CFR Part 91.

The two pilots were co-owners of the airplane, which, according to the manufacturer's records, was delivered on April 18, 2002. A brother of one of the pilots reported that they had intended on flying to Rochester to show the airplane to a friend.

During an initial radio call to Syracuse Clearance Delivery, at 1821, one of the pilots stated that they would depart VFR for Oswego County Airport (FZY), Fulton, New York, at 5,500 feet. The crew was given an altitude restriction of 2,000 feet within 5 miles of Syracuse International, the departure frequency, and a transponder code of 4626.

At 1822, one of the pilots contacted Syracuse Ground Control. He requested, and was cleared for, taxi to runway 10.

At 1829, one of the pilots contacted Syracuse Local Control (tower), and requested takeoff clearance. He was then cleared for takeoff.

At 1830, the crew was advised to turn left, to a heading of 360, and contact departure control, which was acknowledged.

One of the pilots then contacted Syracuse Departure Control, and stated that they were passing through 1,200 feet. The departure controller advised the pilot that he was in radar contact, to proceed on course, and to climb to 5,500 feet, which the pilot acknowledged.

At 1836, the controller asked if they were still going to make a VFR practice approach into Oswego County. One of the pilots answered to the affirmative, that they were going to do a practice GPS RWY 24 approach. The pilot and the controller then discussed whether or not to cancel VFR flight following. The pilot requested cancellation, which the controller acknowledged. The controller then advised the pilot to set 1200 as a transponder code, and approved a change of radio frequency.

There were no additional transmissions recorded from the accident airplane.

A radar track confirmed that the airplane proceeded to Oswego County Airport.

A flight instructor, who was on the ground at Oswego County, watching his student pilot conduct a solo traffic pattern flight, reported seeing a Cirrus, "Charlie Delta" touch down on runway 06 about 1840. He recognized the airplane as being a new hangar tenant at the FBO where he worked. The flight instructor knew that there were two owners, but did not notice who was flying or how many people were on board the airplane.

The airplane touched down in the first 1,000 feet of runway. The flight instructor observed all three wheels on the ground, then heard a sudden application of power. Rotation occurred quickly, and the airplane made a steep climb. The climb was "well underway" by the time the airplane reached the intersection of runway 15/33, (about 2,000 feet from the approach end of the runway). The airplane reached pattern altitude by the end of runway 06, and pitched forward "abruptly" to arrest the climb, while simultaneously entering the left crosswind. Power appeared to be reduced as the pitch angle was decreased.

The flight instructor lost sight of the Cirrus in the crosswind. He turned his attention to the final approach area, and shortly thereafter observed his student making a full stop landing. As the student was taxiing the airplane to the ramp, the flight instructor saw the Cirrus on final. "The plane made another well-stabilized approach and smooth touchdown. Again there was a sharp application of power, another steep climbout, a quick transition to level flight at pattern altitude, and a simultaneous left crosswind turn."

The flight instructor did not see the airplane return to the airport.

Radar data indicated that a target departed Oswego Airport, and climbed to 5,500 feet, then headed southeast, toward the accident area, maintaining between 5,200 feet and 5,700 feet. En route, it made a left, 90-degree turn, followed by a right 90-degree turn. It then continued southeast, and made a right, approximately 360-degree turn, followed by a left 360-degree turn. The target then continued the left turn, until it was transiting east-southeast, and making smaller left and right turns, until it reached the airspace over the accident site.

Target altitude readouts in the vicinity of the accident site included: 5,600 feet at 1906:14; 5,700 feet at 1906:23; 5,300 feet at 1906:28; 4,400 feet at 1906:32; 3,800 feet at 1906:37; and 3,200 feet at 1906:42.

A witness to the accident was outside his home, about 1/2 mile to the north. The witness was accustomed to airplanes performing maneuvers in the area due to its sparse population. He saw the airplane, and noticed that the pilot would "cut the engine," then descend the airplane, and pull up, recovering with full power. The airplane performed the maneuvers for about 5 minutes, and the witness saw the maneuver repeated "three or four times." The witness stated that he was fairly sure the airplane "probably did a turn" at the end of the pull-ups, but he wasn't sure which direction the airplane may have turned.

After the airplane completed its last pull-up, the witness noticed that it entered another dive. The airplane "suddenly went into a spiral and he went straight down. He seemed to keep a constant speed on his descent and it looked like he was in slow motion spinning. He continued nose down to the tree line and continued straight down to the ground. I did not hear his engine on at all once he went into the spiral. I did not think he had an engine problem and was intentionally cutting the power of his plane and then giving it full power on the climbout."

A second witness was also outside his home, about 1 mile west-northwest of the airplane. When he saw the airplane, it was traveling in an easterly direction. The airplane was "pretty small" and had "plenty of altitude." The airplane "peeled off to the left," and the witness "remembered seeing the bottom of the aircraft." The airplane passed through about 180 degrees of turn, then leveled off, "and right after it came back to level flight it stalled." The airplane "went into a nose dive spin and then a flat spin into the ground." It "tumbled in a downward spiral, which turned into a flat spin because it was basically flat, spinning on its own axis, slightly nose down, like a turning top." The witness believed the engine was running the entire time, and expected the pilot to add power to pull up. He did not hear any sputtering from the engine.

A third witness, who observed the airplane with the second witness, noted that the airplane "rolled over once and then twisted, which looked to be intentional. Suddenly, the plane began doing a nose spin, which turned into a flat spin. It appeared as though the pilot lost control of the plane."

A fourth witness heard a "strange plane noise. It sounded like 'wah, wah, wah." He looked up to see the airplane "spiraling nose first, straight towards the ground." As it was descending, he heard "a couple of 'pop' 'pop' noises."

The accident occurred during the hours of daylight, and the accident site was located at 43 degrees, 21.86 minutes north latitude, and 76 degrees, 02.25 minutes west longitude.

PILOT INFORMATION

One of the pilots held a private pilot certificate, with ratings for single engine and multi-engine land airplanes, and instrument airplane. He was also an Aviation Medical Examiner. His latest Federal Aviation Administration (FAA) second class medical certificate was dated December 12, 2000.

According to logbook excerpts provided by a family member, as of April 20, 2002, the pilot had recorded 337 hours of total flight time, of which, 250 hours were in single engine airplanes, 87 hours were in multi-engine airplanes, and 31 hours were in make and model. The excerpts documented four training flights in another SR-22 prior to the acquisition of the accident airplane, and three training flights in the accident airplane. There was no evidence of the pilot previously flying with the other accident pilot.

Post mortem medical examination confirmed that the pilot had been sitting in the airplane's left front seat at the time of the accident.

The other pilot also held a private pilot certificate, with ratings for single engine land airplanes and instrument airplane. His latest FAA third class medical certificate was dated June 8, 2001. A contract flight instructor, who conducted SR-22 flight training with him, estimated that the pilot had about 20 hours in make and model, and believed the accident flight was the first one in which he had flown with the other accident pilot.

The pilot's logbook was not recovered; however, on his Cirrus client profile sheet, dated April 22, 2002, he stated he had 475 hours of flight time, all in single-engine airplanes.

Post mortem medical examination confirmed that the pilot had been sitting in the airplane's right front seat at the time of the accident.

There was no evidence as to which pilot was "pilot in command," or which pilot was at the controls leading up to, or during the accident sequence.

AIRCRAFT INFORMATION

The airplane, serial number 0192, was constructed primarily of composite materials. The two-piece elevator and the rudder were aluminum.

The airplane had fixed landing gear, and electrically controlled, single-slotted flaps.

Pilot controls included conventional rudder pedals, and "single-handed side control yokes" (side sticks) for elevator and aileron control.

The airplane was powered by a Teledyne Continental IO-550-N, six-cylinder, normally aspirated, fuel-injected engine, capable of developing 310 horsepower at 2,700 rpm. The engine drove a three-bladed, Hartzell constant-speed, aluminum-alloy propeller.

The airplane was also equipped with a Cirrus Airplane Parachute System (CAPS).

According to the SR-22 Pilot's Operating Handbook:

"CAPS [is] designed to bring the aircraft and its occupants to the ground in the event of a life-threatening emergency. The system is intended to save the lives of the occupants but will most likely destroy the aircraft and may, in adverse circumstances, cause serious injury or death to the occupants.

The CAPS consists of a parachute, a solid-propellant rocket to deploy the parachute, a [manually-activated] rocket activation handle, and a harness imbedded within the fuselage structure. A composite box containing the parachute and solid-propellant rocket is mounted to the airplane structure immediately aft of the baggage compartment bulkhead. The box is covered and protected from the elements by a thin composite cover.

The parachute is enclosed within a deployment bag that stages the deployment and inflation sequence. The deployment bag creates an orderly deployment process by allowing the canopy to inflate only after the rocket motor has pulled the parachute lines taut. The parachute itself is a 2400-square-foot round canopy equipped with a slider, an annular-shaped fabric panel with a diameter significantly less than the open diameter of the canopy. A three-point harness connects the airplane fuselage structure to the parachute.

CAPS is initiated by pulling the activation T-handle installed in the cabin ceiling on the airplane centerline just above the pilot's right shoulder. A placarded cover, held in place with hook and loop fasteners, covers the T-handle and prevents tampering with the control. The cover is removed by pulling the black tab at the forward edge of the cover. Pulling the activation T-handle removes it from the o-ring seal that holds it in place and takes out the approximately six inches of slack in the cable connecting it to the rocket. Once this slack is removed, further motion of the handle arms and releases a firing pin, igniting the solid-propellant rocket in the parachute canister."

The airplane's new logbook did not contain time-in-use information. A work order, dated April 19, 2002, listed airframe total time as 19.3 hours. The work order reported a deformation of the landing light housing, and noted that the airplane would be returned to the factory so the light could be repaired under warranty.

The airplane's usable fuel capacity was 81 gallons. The latest refueling occurred on April 22, 2002, when the airplane was "topped off" with 58 gallons of 100-octane low lead avgas. After the accident, the fuel truck and a fuel sample were examined by FAA inspectors, with no discrepancies noted. There were also no problems noted with aircraft subsequently fueled from the truck.

There were no flight data or cockpit voice recording devices installed on the airplane.

METEOROLOGICAL INFORMATION

Weather, recorded at Oswego County Airport at 1854, included winds from 060 degrees true at 6 knots, visibility 10 statute miles, clear skies, a temperature of 54 degrees F, and a barometric pressure of 30.10 inches Hg.

Weather, recorded at Syracuse Hancock International Airport at 1854, included winds from 070 degrees true at 8 knots, visibility 10 statute miles, a few clouds at 24,000 feet, a temperature of 56 degrees F, and a barometric pressure of 30.12 inches Hg.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located on hilly, forested terrain, at an elevation of about 600 feet. With the exception of some broken branches above the wreckage, and a small tree that was cut off next to it, there was no wreckage path through the trees.

Except for the vertical stabilizer and rudder, the airplane was upright, and substantially consumed in a post-impact fire. Remaining airframe material was charred and brittle.

The nose of the wreckage was pointing toward 030 degrees magnetic. The engine came to rest slanted about 20 degrees nose-down, with dirt and roots bulldozed forward, about 1 foot.

The airplane's right aileron, and the trailing outboard edge of the right wing were crushed against a tree. The wing was cocked forward of its normal 90-degree position relative to the fuselage, and the outboard end pointed toward 090 degrees magnetic.

The empennage was burnt and bent to the left side of the airplane, and pointed toward 230 degrees magnetic. The vertical stabilizer and rudder were bent, and broken over the left horizontal stabilizer. The left elevator was separated from the empennage, and not burned. The right elevator was also separated from the empennage, and the right horizontal stabilizer was in a tree almost directly above the empennage.

The left wing was cocked aft of its normal 90-degree position relative to the fuselage, and the outboard end pointed toward 270 degrees magnetic.

All flight control surfaces were accounted for at the accident scene. Control continuity was confirmed from the cockpit area to all flight controls. The flap motor screw position correlated to the flaps being up.

One of the propeller blades was not damaged. Another propeller blade was bent back about 20 degrees, and exhibited leading blade tip damage and rotational scoring. The third propeller blade, which was bent back, and buried beneath the engine, had severe damage, including a large piece broken out of the leading edge, and rotational scoring to the outboard 8 inches.

The engine was burned, and the number 1 cylinder exhibited melting. Crankshaft continuity was confirmed from the front to the rear of the engine. Both magnetos were broken from their mounts, and exhibited severe burning. Neither magneto would turn. The throttle body was burned, and the butterfly valve was jammed in the half-opened position. The alternate air "Y" was partially melted, and the alternate air door was in the "direct" position. The induction tubing was burnt and partially melted. The starter was broken at the mount. Ignition leads were burnt. The fuel manifold (spider) was fire-damaged, but the fuel screen was clean. The fuel pump was burned. The pump was removed, and the pump drive would not turn. The mixture lever was about 1/4 inch above idle cutoff. The exteriors of the spark plugs were burned. The top plugs were removed and internally appeared new. The propeller governor lever was full aft. The engine was retained for further examination.

The cockpit area was consumed by fire. All gauges and switches were destroyed. Throttle, mixture, and propeller control positions could not be determined. All of the seats were destroyed, except the left pilot seat cushion, which exhibited leading edge compression.

The CAPS parachute was found outside the airframe, in its deployment bag, in front of the right wing. The composite CAPS cover was found about 20 feet in front of the airplane, with no damage to its interior (kick plate) face. The solid propellant rocket was located on the ground, aft of the right wing, with cables leading to the wreckage. The propellant was expended. The "maintenance safety pin," which, when installed, ensured that the CAPS activation T-handle could not be pulled, was not located.

On June 18, 2002, the engine was disassembled and examined under Safety Board supervision at the Teledyne Continental Motors facility, Mobile, Alabama. No pre-impact anomalies were found.

MEDICAL AND TOXICOLOGICAL INFORMATION

On April 27, 2002, autopsies were performed on both pilots by the Onondaga County Medical Examiner's Office, Syracuse, New York. Toxicological testing was subsequently performed at the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma.

ADDITIONAL INFORMATION

- SR22 Spins -

According to the SR-22 Pilot's Operating Handbook:

"The SR22 is not approved for spins, and has not been tested or certified for spin recovery characteristics. The only approved and demonstrated method of spin recovery is activation of the Cirrus Airframe Parachute System (See CAPS Deployment, this section). Because of this, if the aircraft 'departs controlled flight,' the CAPS must be deployed.

While the stall characteristics of the SR22 make accidental entry into a spin extremely unlikely, it is possible. Spin entry can be avoided by using good airmanship: coordinated use of controls in turns, proper airspeed control following the recommendations of this Handbook, and never abusing the flight controls with accelerated inputs when close to the stall. If, at the stall, the controls are misapplied and abused accelerated inputs are made to the elevator, rudder and/or ailerons, an abrupt wing drop may be felt and a spiral or spin may be entered. In some cases it may be difficult to determine if the aircraft has entered a spiral or the beginning of a spin.

If time and altitude permit,...determine whether the aircraft is in a recoverable spiral/incipient spin or is unrecoverable and, therefore, has departed controlled flight.

WARNING

In all cases, if the aircraft enters an unusual attitude from which recovery is not expected before ground impact, immediate deployment of the CAPS is required. The minimum demonstrated altitude loss for a CAPS deployment from a one-turn spin is 920 feet. Activation at higher altitudes provides enhanced safety margins for parachute recoveries. Do not waste time and altitude trying to recover from a spiral/spin before activating CAPS.

- CAPS Enhancements -

On February 28, 2002, Cirrus Design Corporation issued Service Bulletin (SB) 20-95-02, which became effective on March 19, 2002. According the service bulletin, "some production airplanes may exhibit a condition where the pull force required to activate the CAPS may be greater than desired."

The service bulletin also described means of compliance, which included: "install a cable clamp to positively restrain the cable housing at the CAPS Handle Adapter, loosen and straighten the activation cable above the headliner, and remove [an] Adel clamp securing the activation cable adjacent to the rocket cone adapter."

According to the manufacturer's production records, the accident airplane was in compliance with SB 20-95-02.

On March 16, 2002, a Cirrus SR-20 was substantially damaged, and the pilot and pilot-rated passenger sustained minor injuries during an emergency landing in Lexington, Kentucky. According to the factual report, NYC02LA071, the pilot reported that he had pulled the CAPS activation handle repeatedly; however, the cable did not extend, and "nothing seemed to happen." The airplane struck trees, and witnesses reported that the CAPS parachute deployed after ground impact. The airplane was not in compliance with SB 20-95-02.

On October 3, 2002, a Cirrus SR-22 was substantially damaged, and the pilot was uninjured during a forced landing, after separation of the left aileron following maintenance. According to the preliminary report, FTW03LA005, the day before the accident, SB 20-95-05 and SB A22-27-03, trim cartridge self-locking nut replacement, were incorporated. Compliance with SB A22-27-03 would have required removal and reinstallation of the left aileron.

During the first flight after the maintenance, with the airplane at 2,000 feet, the pilot felt a pull to the left, and saw that the left aileron was "separated at one hinge attach point." The pilot declared an emergency, climbed the airplane to 2,500 feet, headed it into the wind, shut down the engine, and deployed the CAPS. The airplane subsequently descended to the ground by parachute, and came to rest upright, in a field of mesquite trees.

- Roll and Yaw Trim Cartridge Shaft Retention -

According to Cirrus Design Corporation Director of Safety, on September 16, 2002, a company pilot reported an in-flight loss of right rudder control during a production test flight. After landing, the company discovered that the yaw spring self-locking rod-retaining nut had backed off, and released spring tension, creating a "potential of control loss and/or jamming."

The director also stated that the roll trim cartridge utilized the same shaft and self-locking nut as the yaw trim cartridge, and that "the root cause was attributed to the run down torque being below minimum tolerance on certain production spring cartridges. A 100 percent sampling of stocked items showed an occurrence of 20 percent."

As a result of the incident, the company issued SB A22-27-03, which provided "instructions on replacing current self-locking nuts on roll and yaw trim cartridges with new self-locking nuts with a higher axial load capability."

On September 28, 2002, Safety Board and Cirrus personnel reexamined the wreckage at a storage facility. Both trim cartridges were located, and both retaining nuts were found installed on their respective cartridge shafts. Although the cartridges exhibited impact and fire damage, there was no evidence of jamming.

On April 26, 2002, the wreckage, with the exception of the engine, was released to a representative of the owners' insurance company. The engine was released on June 18, 2002, following disassembly and examination.

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