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NTSB investigation record

CEN16FA111

Completed

Cirrus design corp Sr20· N477TC

Date
February 28, 2016
Location
Navasota, TX
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The flight instructor's delayed remedial action to prevent a stall at an altitude that was too low to recover. Contributing to the accident was the owner/non-certificated pilot's failure to maintain control of the airplane, which resulted in an accelerated aerodynamic stall.

Investigator assessment

Analysis narrative

The flight instructor and the airplane owner, who did not hold a pilot certificate, were practicing takeoffs and landings in the airplane at an uncontrolled airport. Based on logbook records, this was most likely an instructional flight and the owner was most likely flying the airplane. Air traffic control radar and primary flight display data showed that they had performed two touch-and-go landings followed by two full stop landings before the accident. Shortly after taking off following the second full stop landing, while climbing through 550 ft mean sea level (msl) at an indicated airspeed of about 92 knots, the airplane entered a left bank and began to decelerate. The airplane began to descend, and the airspeed subsequently decreased below 75 knots before it began to increase. The airplane reached a 61° left-wing-down attitude at an airspeed of about 79 knots before entering a rapid roll to the right, through an inverted position. At about the same time, the airplane began a rapid pitch down, reaching a 69° nose-down attitude. The airplane briefly recovered to nearly wings level but again began to pitch down until the final recorded data point, which showed the airplane in a 65° nose-down and 45° right-wing-down attitude, at 268 ft msl, and 89 knots indicated airspeed. The airplane impacted terrain about 0.43 miles from the departure end of the runway. Postaccident examination of the airplane did not reveal any mechanical malfunctions or failures that would have prevented normal operation. Calculations based on the airplane's weight at the time of the accident indicated that, at 1g with flaps up, the aerodynamic stall speed would have been 75 to 78 knots calibrated airspeed. The stall speed in a 60° turn (2 g) would have been 105 to 109 knots. Therefore, it is likely that the combination of a steep left bank and low airspeed resulted in an accelerated aerodynamic stall.

Source record

Factual narrative

The Central Texas Autopsy LLC, Lockhart, Texas, completed autopsy examinations for both the flight instructor and the airplane owner. The autopsy report for both listed the cause of death as multiple blunt force injuries. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, conducted toxicological testing for both the flight instructor and the airplane owner. The tests conducted on the instructor were negative for alcohol and tested drugs. Toxicology testing for the airplane owner detected diphenhydramine in cavity blood at 69 ng/ml and in urine. Naproxen was detected only in urine. Diphenhydramine is a sedating antihistamine used to treat allergy symptoms and as a sleep aid. It is available over the counter under the trade names Benadryl and Unisom and carries the following FDA warning: "may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery)." Naproxen is an anti-inflammatory analgesic available over the counter and by prescription with the names Aleve and Naprosyn, respectively. The flight instructor's logbook(s) were not located during the investigation. On the application for his last Federal Aviation Administration (FAA) medical dated January 15, 2016, he reported having a total of 6,550 hours of flight time; 120 of those hours were flown within the previous 6 months. It is unknown how much experience he had in SR-20 airplanes before flying with the airplane owner. The airplane owner, who was receiving flight instruction, did not hold a student pilot or medical certificate. He had taken a FAA medical examination on October 20, 2015. Due to the pilot's history of arrests, the aviation medical examiner deferred issuing a medical certificate. The FAA requested additional information, which the owner did not supply. On January 20, 2016, the FAA sent a letter to the owner notifying him that they could not determine his eligibility for a medical certificate. According to the owner's pilot logbook, he had a total of 106 hours of flight time of which 57.1 hours were in SR-20 airplanes. The owner had previously flown with the flight instructor on 11 dual instructional flights, which totaled 25.7 hours. The accident site was located about 0.43 mile southeast of the departure end of runway 17 at 60R in a lightly wooded area that was surrounded by open pasture. The airplane came to rest in the middle of a field that was bordered by three large trees spaced about 60 ft apart forming a triangular shape around the wreckage. The terrain at the accident site was wet and muddy. The main wreckage consisted of the entire airplane with a minor amount of airplane debris scattered in the immediate surrounding area. The airplane came to rest upright on a magnetic heading of 60°. Although it sustained impact damage, the empennage was relatively intact. The elevator remained attached to the horizontal stabilizer, which remained attached to the empennage. The rudder remained attached to the vertical stabilizer, which remained attached to the empennage. A 6 to 8-inch-deep ground scar was located under the tail tie down and rudder. The bottom of the rudder was crushed upward. Both elevator and rudder control continuity were verified. The elevator trim motor was positioned to slightly nose down trim. The spar cover, wing spar, and wings were angled downward, and the floor under the cabin seats exhibited impact damage. There was a ground impact scar correlating to the leading edge of both wings. The entire leading edge of the left wing was crushed rearward. A 45° tear was present midspan in the top skin of the wing. The left aileron sustained impact damage, and it remained attached to the wing by its inboard hinge. The position of the roll trim motor was between neutral and full left trim. The left flap remained attached to the wing and was fully retracted. The leading edge of the right wing was crushed aft. The outboard section of the upper wing skin was mostly separated from the torque box structure, and spar damage was observed. The right aileron and flap both exhibited impact damage; however, they remained attached to the wing. The right flap was fully retracted. The right aileron cable was separated about 2 ft away from the cross-over turnbuckle. The separated ends of the cable showed signatures consistent with an overload separation. Aileron control continuity for the rest of the cable circuit was verified. The flap actuator was extended about 4 inches, which correlated to a fully retracted flap position. Both wing fuel tanks were compromised, and there was no fuel present in the tanks. However, first responders reported there was a strong odor of fuel near the wreckage. The four seats remained attached to their respective seat tracks and floor mounts. Both the left rear seat and the right front seat showed deformation to the left. All seat belt inertial reels functioned except for the left front seat. The left front seatbelt could be pulled out, but did not retract due to damage. The CAPS activation handle was observed in its handle holder. The activation handle holder mounting bracket was bent downward and aft with an S-shaped bend. The rocket motor was expended and found on the ground near the airplane. The partially packed parachute bag was on the ground near the wreckage. The harnesses, risers, and a portion of the suspension lines had deployed. The three-ring release mechanism remained loosely interlocked. The break-away cover for the parachute enclosure was located on the ground near the rudder, indicating that the system had deployed during the ground impact. An external examination of the engine was conducted at the accident site. The engine remained attached to the engine mounts, which remained attached to the firewall. The forward portion of the engine was buried at an angle of about 25° with only the top of the propeller spinner remaining above ground level. The firewall had impacted the rear of the engine with some of the engine accessories making an imprint on the firewall. All engine cylinders displayed varying degrees of impact damage and remained attached to the crankcase. The crankcase sustained impact damage but was intact. The oil cooler remained attached to the engine. The oil filter and filter adapter had separated from the engine. Both magnetos had separated from the engine. Both magneto impulse coupling engaged when the magneto drives were turned by hand. The ignition harness sustained impact damage. The top spark plugs were in place and undamaged. The bottom spark plugs were not removed during the on scene examination. The fuel pump sustained impact damage. The fuel line going to the pump inlet remained secured at both the pump and the fuel bowl. The fuel line was removed from the fuel bowl, and no fuel was present in the line; however, there was fuel present in the fuel bowl. The throttle and fuel metering assembly remained attached to the engine. The throttle control arm remained secured to the shaft, and the throttle cable rod end remained secured to the throttle arm. The throttle position was observed at idle. The fuel manifold valve was intact, and it remained attached to the engine. All of the fuel nozzles were intact. The exhaust system sustained impact damage with bent exhaust risers and flattened exhaust outflow pipes. The induction system sustained impact damage. The propeller remained attached to the propeller flange. Both propeller blades remained intact within the propeller hub. One blade displayed forward bending, and the other propeller blade was bent aft. During the on scene examination, there were no anomalies identified with the airframe, engine, or propeller that would have precluded normal operation of the airplane. The airplane, serial number 1378, was a four-place, low-wing, single-engine airplane with fixed landing gear. The airplane was manufactur

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