Back to Search

NTSB investigation record

CEN13FA456

Completed

Cirrus design corp Sr22· N225CD

Date
August 3, 2013
Location
Chesterfield, MO
Conditions
IMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot’s failure to establish and maintain a positive climb rate during the initial climb in night instrument meteorological conditions.

Investigator assessment

Analysis narrative

The instrument-rated pilot departed with a reported cloud ceiling of 400 feet above ground level and 3 miles visibility. A witness, who was about 0.3 nautical mile (nm) west of the departure end of the runway, observed seeing the accident airplane's navigation lights for about 3 to 5 seconds as it traveled west. The airplane appeared to be traveling at a high rate of speed and in a descent. He saw a fireball as the accident airplane impacted the trees and terrain. He reported that the weather conditions were "very foggy" and that he could only see the accident airplane's navigation lights due to the fog and dark light conditions. Approach control radar data indicated that the airplane did not climb more than 200 feet above ground level before impacting the trees. The examination of the wreckage debris field indicated that the airplane was in a shallow descent at impact. The postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

Source record

Factual narrative

The NTSB Vehicle Recorders laboratory examined the MFD memory card. The examination revealed that the memory chip was cracked and no data was recovered. The examination of the GoPro Hero 3 and the Drift HD camera/recorder memory cards revealed that the files contained on the memory cards were not pertinent to the accident flight. The NTSB Materials laboratory disassembled the gyro assembly of the directional gyro to look for indications of rotation on the gyro housing and rotor. The examination of the inner surface of the housing revealed circumferentially oriented scratches where the housing material had been exposed. The surface of the rotor exhibited circumferentially oriented areas where the surface finish had been disturbed to reveal the underlying metal. The NTSB Materials laboratory examination of the horizon reference indicator (attitude gyro) revealed that the interior surface of the gyro assembly had dark, circumferentially oriented marks and circumferentially oriented scratches where the housing materials had been exposed. The gyro's rotor also had circumferentially oriented marks on its surface. An autopsy of the pilot was performed at Saint Louis County Health in St. Louis, Missouri, on August 4, 2013. The "Cause of Death" was listed as craniocerebral blunt trauma. A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aerospace Medical Institute. No carbon monoxide was detected in the blood (cavity). The test for cyanide was not performed. The following substances were identified in the toxicology report: 39 mg/dL ethanol detected in blood (cavity), 38 mg/dL ethanol detected in muscle, 38 mg/dL ethanol detected in kidney, ephedrine detected in liver, ephedrine detected in blood (cavity), pseudoephedrine detected in liver, pseudoephedrine detected in blood (cavity), trimethoprim detected in liver, and trimethoprim detected in blood (cavity). Pseudoephedrine is used to relieve nasal congestion caused by colds, allergies, and hay fever. It is also used to temporarily relieve sinus congestion and pressure. Trimethoprim may be used for cold symptoms as well. The ethanol levels found in this case were consistent with putrefaction, since the recovery of the body was delayed. The SUS weather surface observation at 0454 was: wind 010 at 4 knots; visibility 3 miles in mist; overcast ceiling at 400 feet above ground level (agl), temperature 22 degrees Celsius (C); dew point 21 degrees C; altimeter 29.95. The SUS special weather surface observation at 0512 was: wind 020 at 7 knots; visibility 1 3/4 miles in mist; overcast ceiling at 400 feet agl, temperature 22 degrees C; dew point 21 degrees C; altimeter 29.95; ceilings variable from 200 to 600 feet. The examination of the accident site revealed that the accident airplane impacted the woods located west of SUS on a 250 degree magnetic heading from the departure end of runway 26R. The wreckage path was about 350 feet in length, also on about a 250 degree magnetic heading, from where the initial impact occurred at the edge of the woods to the nose landing gear, which was the part of the accident airplane found furthest from the initial impact point. A piece of the right wingtip was observed embedded in the trunk of a 70 to 80 foot tall tree located near the edge of the woods. The piece was embedded about 30 feet up from the base of the tree. Another tree about 96 feet from the initial impact point also was struck. The tree was about 32 inches in diameter at the base of the tree. The impact occurred near the tree's mid-span and the impact toppled the top of the tree in the direction of travel. A piece of the tree trunk was found at the base of the tree that had a 13 inch by 18 inch diagonal slash with gray paint transfer, which was consistent with a propeller slash mark. The left wing and the wing spar were located about 150 feet from the initial impact point and had extensive fire damage. The aft cabin and cargo compartment were found near the left wing. The Cirrus Aircraft Parachute System (CAPS) rocket motor had fired. The parachute was found deployed, although the parachute canopy had not opened and was found in a packed condition and still in the deployment bag. The airplane's empennage was found about 200 feet from the initial impact point. The elevator and rudder control cables remained attached to the control surfaces and exhibited continuity. The aileron cables to the left wing remained attached to the left aileron actuation pulley, and the left wing aileron control cable continuity was confirmed. The right wing received extensive damage and control cable continuity to the right aileron could not be confirmed. The flap actuator was found in the flaps up position. The instrument panel and avionics were separated from the cockpit and located at various locations in the debris field. The pilot-side attitude gyro remained attached to the instrument panel, but the other instruments were dislodged from the panel. The pilot-side attitude gyro displayed about a 4 degrees nose down with a 3 degrees right wing down attitude. The on-site examination of the engine revealed that the crankcase had impact damage and the forward top portion of the crankcase was found separated in the debris field. The crankshaft was fractured in the area of the nose seal, and the crankshaft propeller flange separated with the propeller hub. The fracture features were consistent with the application of combined torsion and bending. The fracture surface of the crankshaft exhibited 45-degree cracks to both the internal and external surfaces, which were consistent with torsional loading. The cylinders exhibited impact and thermal damage. The cylinders were examined with a lighted borescope. The combustion chambers were a light color. The top and bottom spark plugs exhibited "worn out–normal" operating signatures when compared to a manufacturer's wear diagram. The thee-bladed, variable-pitch propeller had separated from the engine and exhibited impact damage. The propeller blade marked "A" was loose in the hub and had multiple bends. Mid-span of blade A leading edge nicks and gouges were observed as well as chord wise scratches to the chambered face. Blade B was bent forward at mid-span. Blade C exhibited a gradual bend aft from the hub to the tip. The airplane's directional gyro and horizon reference indicator were sent to the National Transportation Safety Board's (NTSB) Materials laboratory for examination. A Go-Pro video camera, a Drift Innovation video camera, and the accident airplane's MFD's memory card were sent the NTSB Vehicle Recorder's laboratory for examination. The airplane was a single-engine Cirrus SR22, serial number 0031. The engine was a Continental 310-horsepower IO-550N engine. The airplane seated four and had a maximum gross weight of 3,400 pounds. The last annual maintenance inspection was conducted on September 11, 2012, with a total time of 1800.8 hours on the airframe and engine. The last oil change was completed on July 21, 2013, with an engine time of 2,067.4 hours. An engine oil analysis indicated normal values at the last inspection. On July 18, 2013, an Avidyne EX5000 Multifunction Display (MFD), part number 700-00004-006, serial number 2055, was installed on the airplane. The original ARNAV MFD was providing erroneous information and required replacement. The total airframe time was 2,058.1 hours. On July 31, 2013, the pilot altimeter, static pressure system, transponder, and altitude encoder were tested and certified. The total airframe time at the time of the inspection was 2,074.8 hours. One of the partners who owned the airplane reported that he flew the airplane to Joplin, Missouri, and back to SUS on the day before the accident. He encountered some IMC conditions during the flight and used the autopilot for the entire flight, except for the takeoffs and landings. He stated that all the instruments were working properly for the flight,

Continue research

Find similar accidents

Continue with the strongest shared characteristics.