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NTSB investigation record

CEN12FA251

Completed

Cirrus design corp Sr22· N110EB

Date
April 21, 2012
Location
Newcomerstown, OH
Conditions
IMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot’s loss of airplane control in instrument meteorological conditions due to his distraction by electrical system anomalies, which resulted in an uncontrolled descent. The reason for the electrical system anomalies could not be determined.

Investigator assessment

Analysis narrative

About 5 minutes before the accident, when the airplane was in cruise flight in instrument meteorological conditions (IMC), at 8,000 ft mean sea level (msl), and at 156 knots ground speed, an air traffic controller updated the altimeter setting via the radio. The pilot acknowledged the call, and his voice sounded normal. No other radio transmissions were received from the pilot, and he made no distress calls. Radar data showed that the airplane then began a descending right turn, that the airspeed increased slightly through the turn, and that the airspeed then suddenly decreased to 61 knots as the turn radius decreased. The airplane had turned about 270 degrees and descended to an altitude of 4,900 ft msl before radar contact was lost. A witness reported seeing the airplane coming out of the low clouds (the cloud ceiling was about 700 to 800 ft above ground level) in a nose-down descent with the wings about level before it disappeared behind a tree line. Examination of the airframe and engine did not reveal any preimpact anomalies. Data from the on-board recoverable data module (RDM) showed an anomaly in the electrical bus voltages, autopilot mode changes, and a momentary dropout of the pilot transmission frequency. Specifically, the RDM data showed that the airplane was flying at 8,000 ft pressure altitude at an airspeed of 148 knots with the autopilot on when alternator 1 dropped offline followed by alternator 2 dropping offline; the airplane is equipped with a two-alternator, two-battery, 28-volt direct current electrical system. About 3 seconds later, the autopilot disengaged. The RDM data confirmed that the airplane then entered a descending right turn with the airspeed increasing slightly and then suddenly decreasing. The data further showed that the airplane then rolled right and that the pitch attitude sharply decreased. The airspeed then increased, and both the roll and pitch reversed back toward wings level before the data ended. The bolster switches for alternator 1, alternator 2, battery 1, battery 2, and the avionics were cycled "on" and "off" on an exemplar airplane to determine what may occur in the cockpit when the bolster switches are manually moved. Seven sets of various electrical bolster switch activations and deactivations were documented. During the tests, bolster switch operation on the exemplar airplane yielded recorded data similar to the accident flight data; however, the reason for the recorded electrical anomalies could not be determined because the RDM does not record the physical position of either the bolster switches or circuit breakers. The data did reveal that the airplane began its deviation off course and its subsequent descending right turn in IMC conditions a few seconds after the alternators went offline and that the pilot was likely attempting to troubleshoot the electrical anomaly with bolster switch activations and deactivations as the airplane descended and turned through the clouds. The electrical anomalies likely distracted the pilot and led to his subsequent loss of airplane control. The witness's statement that the airplane came out of the low clouds with the wings about level and the RDM data indicate that the pilot may have been able to recover from the turn and rapid descent to some degree but that there was insufficient altitude for a full recovery.

Source record

Factual narrative

On April 21, 2012, approximately 1220 eastern daylight time, a Cirrus Design Corp SR22, N110EB, registered to Photopheresis INC., of Morristown, New Jersey, was substantially damaged when it impacted heavily wooded terrain in the vicinity of Newcomerstown, Ohio. The private pilot, who was the sole occupant, sustained fatal injuries. Instrument meteorological conditions prevailed in the vicinity and an instrument flight rules (IFR) flight plan was filed. The flight was being operated under the provisions of 14 Code of Federal Regulations Part 91 as a personal cross country flight. The flight originated at 1013 from the Somerset Airport (SMQ), and its intended destination was Ohio State University Airport (OSU), Columbus, Ohio. According to radar data and recorded radio communications provided to the NTSB by the FAA, approximately 5 minutes prior to the accident, the airplane was in cruise flight at 8,000 feet msl at 156 knots ground speed, when Indianapolis Air Route Traffic Control Center (ARTCC) updated the altimeter setting via radio. The pilot acknowledged the call and his voice sounded normal. No other radio transmissions or distress calls were from received from the pilot after the altimeter setting acknowledgment. Radar data showed the airplane begin a descending right turn with airspeed increasing slightly through the turn and then suddenly decreasing to 61 knots as the radius of the turn decreased. The airplane had turned approximately 270 degrees of heading and descended to an altitude of 4,900 feet msl before radar contact was lost. There were no eye-witnesses to the accident, however, a boy who was a passenger of a car reported that he thought that he saw the airplane coming out of the low clouds in a descent, about wings level before it disappeared out of sight behind a tree line. The boy stated that he then saw black smoke. Recovered data from the on-board data module (RDM) showed an anomaly in the electrical bus voltages, autopilot mode changes, a momentary drop out of the pilot transmit frequency, and a descending right turn with a decreasing radius until impact. Detailed information is provided in the TESTS AND RESEARCH section of this report. PERSONNEL INFORMATION According to FAA records, the pilot held a valid private pilot certificate with Airplane Single Engine Land (ASEL) and Instrument Airplane ratings. He held a valid third class medical certificate, issued April 28, 2010. At the time of his most recent medical exam, the pilot reported about 1,200 hours total flight time, of which 100 hours were within the preceding 6 months. The pilot attended and completed the Cirrus Standard Perspective Differences and Cirrus Turbo Differences Course on April 14, 2009. Additionally, he completed the Cirrus Icing Awareness Course on October 5, 2009. According to information provided by a flight instructor who had flown about once a month with the pilot in recent years, the pilot completed a successful bi-annual flight review in the SR22 on February 17, 2012. Remnants of the pilot's logbook were found at the accident site, but the contents were damaged from impact and could not be documented. AIRCRAFT INFORMATION Cirrus SR22-3423, registration number, N110EB, received its standard airworthiness certificate on April 13, 2009. Cirrus records indicate that the pilot purchased the airplane new and took delivery on April 13, 2009. According to the records on file at Cirrus Aircraft, the airplane was equipped with: Garmin Perspective avionics with dual AHRRS and a single air data computer, Chartview, a GFC 700 autopilot with yaw dampener, Enhanced Vision System (EVS), Synthetic Vision, air conditioning, a Tornado Alley turbo-charging system, supplemental oxygen, engine monitoring, traffic alerting system, terrain awareness system (TAWS-B), XM weather/radio, FIKI, a Tanis heater, and a recoverable data module (RDM). The cover for the airframe, engine, and propeller logbooks were found at the accident site, but the pages were not located. The airplane was equipped with a two-alternator, two battery, 28-volt direct current (VDC) electrical system designed to reduce the risk of electrical system faults. The system provides uninterrupted power for avionics, flight instrumentation, lighting and other electrically operated and controlled systems during normal operation. The electrical system also provides automatic switching from either battery or alternator to the Essential Bus in the event of an electrical system failure by the opposing alternator or battery. The bolster panel contains the pilot switches for operating ALT 1, ALT 2, BAT 1, and BAT 2. The switches are mounted adjoining so that a pilot can control all four switches with a single hand. Power generated from the alternators is fed into the Master Control Unit (MCU). The MCU regulates and distributes the power to the batteries and the system loads. Each alternator provides constant charging current for the corresponding battery and primary power to the aircraft electrical system during normal system operation. The flight instructor who had given the pilot his most recent bi-annual flight review reported that there had been one instance whereby the autopilot had disengaged during a flight sometime in the fall of 2011. He recalled that the problem may have been associated with a battery issue, but could not recall all of the details. METEOROLOGICAL INFORMATION The closest weather reporting location to the accident site was from Zanesville Municipal Airport (ZZV), Zanesville, Ohio, located approximately 24 miles southwest of the accident site at an elevation of 900 feet. The airport had an un-augmented ASOS and reported the following conditions at the approximate time of the accident: Zanesville (ZZV) special weather observation at 1222 EDT, automated, wind from 340º at 5 knots, visibility 7 miles in light rain, ceiling broken at 800 feet agl, overcast at 1,200 feet, temperature 6º C, dew point 4º C, altimeter 29.89 inches of Hg. Remarks - automated observation system, ceiling 600 variable 1,000 feet, hourly precipitation 0.01 inch. The pilot of N110EB contacted the Washington, DC, Federal Aviation Administration (FAA) contract Automated Flight Service Station (AFSS) at 0745 EDT (1145Z) on April 21, 2012 and obtained a weather briefing and filed an IFR flight plan. A copy of the event reconstruction for that briefing was obtained and is included as Attachment 1 in the NTSB Meteorology Group Chairman's Factual Report. An audio file was also reviewed and documented to evaluate the accuracy and content of that briefing, which follows: The pilot initially contacted the AFSS for an outlook briefing for the flight departing at 0800 EDT on April 22, 2012. A complete meteorological factual report prepared by a NTSB meteorology specialist is available in the supporting docket for this report. FLIGHT RECORDERS The Recoverable Data Module (RDM) was located in the debris field and sent to the NTSB Vehicle Recorder Laboratory in Washington DC for evaluation and download. WRECKAGE AND IMPACT INFORMATION General The airplane's main wreckage was located on a heavily wooded hillside at 40°14'58.32" North latitude, 81°32'44.95" West longitude at an approximate elevation of 1,060 feet msl. The direction of energy was about 093 degrees magnetic. The hillside had a 10-degree up slope. The initial point of impact consisted of two trees about 31 feet apart. One tree had missing bark and tree scars on one of its large branches approximately 44 feet above the ground. The second tree's trunk was broke off approximately 34 feet above the ground. Three more tree trunks in the direction of energy ranging in size from 4-8 inches were freshly broken off. About 80 feet from the initial point of impact there was a 3-4 foot deep crater that measured approximately 11 feet long. Within the crater, the propeller hub remained attached to a portion of

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