Primary finding
Probable cause
The reduction in fuel flow and subsequent partial loss of engine power after takeoff for reasons that could not be determined.
Investigator assessment
Analysis narrative
During a familiarization flight, the pilot configured the airplane at an airspeed of 80 knots, with full flaps extended, in preparation for a touch-and-go landing. The mixture was set to full rich and the fuel boost pump was set on “Low Boost.” According to the flight instructor, the approach altitude was slightly high, so he instructed the pilot to perform a forward slip. The pilot decreased the engine power to idle and performed the forward slip as instructed. The flight instructor reported that, as they crossed the runway threshold, the pilot allowed the airspeed to get too slow and he did not stop the descent rate, which resulted in a “noticeable bounce” on the main landing gear. The flight instructor told the pilot to initiate a go-around and the pilot added power, reduced the flaps to 50%, and established a normal climb attitude. The flight instructor reported that the airplane began to climb very slowly. He stated the airspeed increased to 80 knots, at which time he instructed the pilot to raise the flaps. The flight instructor confirmed the airplane’s flaps were up, but the airplane continued to climb about 300 ft per minute. He stated that he expected an increase in airspeed but was surprised that the airspeed was slightly above 85 knots. In addition, he felt a “shudder of an irregular vibrational tick.” He stated it was a noticeable “clunky” sound that resonated through the fuselage every few seconds. The airplane continued to climb at a slower-than-normal rate. Upon reaching 500 ft above ground level the flight instructor stated, “CAPS [Cirrus Airframe Parachute System] available.” At this time, the pilot turned over control of the airplane to the flight instructor. The airplane’s performance continued to decrease so the flight instructor aligned the airplane for an open field and the pilot deployed the airplane parachute system. The flight instructor secured the airplane before it impacted an open snow-covered field. The airplane sustained substantial damage to the forward fuselage, both wings, and the rudder. The fuel selector valve shaft was fractured between the valve handle and the valve shaft housing and the valve was positioned between the right fuel tank and the off position. The fuel selector valve was moved by first responders after the accident from the right fuel tank to the off position. Investigators were unable to determine if the fractured valve shaft was a result of the accident or due to movement of the handle by first responders after the accident. Testing performed by the manufacturer indicated that engine performance and fuel flow would not be impacted with the fuel selector valve handle between the two tanks and partially open. The engine fuel lines were secure. The fuel servo and boost pump fuel inlet lines were absent of fuel and a small amount of fuel was present in both the left and right wing header tanks. The left fuel tank was compromised and fuel staining was observed directly beneath the wing. There was no visible fuel in the right wing fuel tank. Investigators were unable to determine how much fuel was on board at the time of the accident because of the compromised fuel tank. Recorded parameters from the onboard data module were consistent with the training flight described by the flight instructor. About 1254 the recorded parameters were consistent with the go-around initiated by the pilot with an increase in engine rpm, fuel flow, and manifold pressure. However, the increase in fuel flow was not equivalent to the increase seen during the initial takeoff and at several points earlier in the flight. At that time the exhaust gas temperature and cylinder head temperatures for cylinder Nos. 2, 4, and 6 diverged; cylinder No. 2 increased in temperature and cylinder No. 6 decreased in temperature. Two postaccident engine runs confirmed the function of the engine but were limited in duration due to impact damage. An examination of the engine, airframe, and related systems revealed no mechanical anomalies that would have precluded normal operations. The recorded engine parameters and the description from the flight instructor are consistent with a loss of engine power, likely due to a reduced fuel flow; however, investigators were unable to determine the reason for the reduced fuel flow and subsequent loss of engine power. The pilot’s postmortem toxicology testing indicated that he had used the antidepressant medication citalopram. It is unlikely that effects of this medication or an associated underlying condition contributed to the crash; the pilot’s actions as reported by the surviving instructor appeared appropriate to the situation.
Source record
Factual narrative
An autopsy of the private pilot was conducted by the Hennepin County Medical Examiner’s Office. The cause of death was listed as multiple blunt force injuries, and no significant natural disease was identified. The Federal Aviation Administration (FAA) Forensic Sciences Laboratory performed toxicological testing of postmortem specimens from the pilot. Citalopram was detected in cavity blood, with inconclusive citalopram testing in urine. The citalopram metabolite n-desmethylcitalopram was detected in cavity blood and urine. Citalopram is a prescription antidepressant medication. Pilots on citalopram may be approved by the FAA for medical certification on a case-by-case basis, depending on the underlying condition and response to treatment. The pilot had reported no medication use at his last aviation medical examination in June 2020. He had a history of prior Special Issuance medical certification for generalized anxiety disorder in 2018 and 2019, with a July 2020 letter from the FAA stating that Special Issuance was no longer required. The pilot’s postmortem toxicological testing also detected minoxidil in urine and carvedilol in cavity blood and urine. Minoxidil is available as an over-the-counter topical treatment for hair regrowth; it is also available as a prescription oral medication used to treat high blood pressure. Carvedilol is a prescription medication that may be used to treat high blood pressure, heart failure, and to manage heart failure after a heart attack. Minoxidil and carvedilol are not generally considered impairing medications. Other substances (ketamine, the ketamine metabolite norketamine, and famotidine) detected by the pilot’s postmortem toxicological testing were attributable to medications that were administered to the pilot after the crash, as verified from post-crash medical records. The airplane was fueled with 29.5 gallons of 100LL aviation fuel before the flight. The flight instructor stated that they verified the fuel level was up to the tabs, which would have been about 30 gallons of fuel in each fuel tank or 60 gallons total fuel. On January 31, 2022, about 1256 central standard time, a Cirrus SR22 airplane, N227BD, was substantially damaged when it was involved in an accident near Hutchinson, Minnesota. The flight instructor was seriously injured, and the private pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The purpose of the flight was to familiarize the pilot with the newly purchased airplane. The flight instructor reported that they performed a thorough airplane prefight, checked the weather, calculated the weight and balance, reviewed takeoff and landing airplane performance, and talked through the flight briefing before they departed Flying Cloud Airport (FCM) for the practice area. The flight instructor stated that the airplane was fueled up to the tabs. He reported that en route to the practice area, they discussed engine failure and Cirrus Airframe Parachute System (CAPS) deployment procedures. After practicing maneuvers, they proceeded to the Hutchinson Municipal Airport – Butler Field (HCD) to practice a touch-and-go landing. They entered the traffic pattern, and the pilot aligned the airplane on final approach at an airspeed of 80 knots with full flaps extended. The flight instructor stated that the mixture was set to full rich and the fuel boost pump was set on “Low Boost.” He stated that the approach was slightly high, so he instructed the pilot to perform a forward slip. The pilot decreased the engine power to idle and performed the forward slip as instructed. The flight instructor reported that as they crossed the runway threshold, the pilot allowed the airspeed to get too slow and he did not stop the descent rate, which resulted in a “noticeable bounce” on the main landing gear. The pilot initiated a go-around as instructed by the flight instructor. The pilot added power, reduced the flaps to 50%, and established a normal climb attitude for the go-around. The flight instructor reported that the airplane began to climb, but very slowly. He stated the airspeed increased to 80 knots, at which time he instructed the pilot to raise the flaps. The flight instructor confirmed the airplane’s flaps were up, but the airplane continued to climb about 300 ft per minute. He stated he expected an increase in airspeed but was surprised that the airspeed was slightly above 85 knots. In addition, he felt a “shudder of an irregular vibrational tick.” He stated it was a noticeable “clunky” sound that resonated through the fuselage every few seconds. The airplane continued to climb but at a slower than normal rate. Upon reaching 500 ft above ground level (agl) or 1,500 ft above mean sea level (msl), the flight instructor stated “CAPS available.” The pilot turned over control of the airplane to the flight instructor. The flight instructor took over the controls and ensured the throttle was full forward. He made a gradual turn to align the airplane with an open field then leveled the wings, noting that the altimeter indicated 1,600 msl and that the airspeed had decreased into the “70s.” The flight instructor told the pilot to deploy the parachute, and the flight instructor kept the airplane level until the forward parachute straps tightened. He then reduced the throttle to idle, turned off the mixture, and made a mayday call. The flight instructor reported that he does not recall the impact sequence. The airplane touched down in a field about 2 miles southeast of HCD. The airplane touched down in an open snow-covered field and the debris field was contained to the immediate area. The furthest piece of wreckage was a propeller blade located about 400 ft from the main wreckage. The main wreckage came to rest upright. The lower portion of the forward fuselage and the engine compartment were compressed and crushed upward. The sides of the fuselage were cracked between the instrument panel and front seats. The left wing remained attached to the fuselage, and the aft fuselage remained intact. The empennage remained attached except for the rudder, which was separated at all but its lowest attach point. A postaccident examination confirmed flight control continuity from the wing roots to the ailerons and from under the aft seats to the rudder and elevator. The cockpit control stick and rudder pedals were not able to be manipulated due to impact damage. All the flight control fractures were consistent with impact damage. The flap handle was in the up position and the flap actuator screw was fully extended, which was consistent with the flaps in the retracted position. The fuel caps were present on both the right and left wings. No fuel was visible in the right fuel tank. The underside of the left wing exhibited cracking and a small area of blue staining consistent with 100LL aviation fuel was visible with no corresponding staining noted on the snow below the wing. The fuel selector valve shaft was fractured between the valve handle and the valve shaft housing. The valve was removed from the airframe and opened. The valve was positioned between the right fuel tank and the off position. The engine fuel lines were secure. The fuel servo and boost pump fuel inlet lines were removed and both lines were absent of fuel. Engine control continuity was confirmed. According to the fire chief, the fuel selector valve was moved after the accident from the right fuel tank to the off position. A small amount of fuel was present in both the left and right wing header tanks. The fire chief reported a strong smell of fuel while on scene. No other anomalies were noted with the fuel system that would have precluded normal operations. The CAPS system was examined, and the parachute deployment appeared to have been normal. The airplane was equipped with a Heads-Up Technologies Recoverable Data Module