CEN22FA405

The flight instructor’s inadequate supervision of the flight, which allowed for an unintentional movement of the mixture control to the cutoff position that remained unnoticed until the airplane lost engine power due to fuel starvation and descended below the minimum altitude required for a normal deployment of the airframe parachute system. Contributing to the accident was the impairment of the pilot due to his illness, the flight instructor being distracted by his physiological distress, and the apparent lack of communication between the pilot and flight instructor about who was responsible for the safety of the flight, all of which created a situation where neither individual was adequately monitoring the engine operation during a critical phase of flight.

The pilot was in the process of receiving transition flight training after he accepted delivery of his factory-new airplane earlier in the week. On the morning of the accident, the pilot told his factory flight instructor that he did not feel well, and the decision was made to fly cross-country to the pilot’s homebase instead of continuing his transition training at the delivery center. The flight approached the intended destination when about 1 minute before the accident, about 988 ft above ground level (agl) and 2.26 nautical miles (nm) from the runway displaced threshold, there was a total loss of fuel flow and subsequent loss of engine power. About 15 seconds later, 860 ft agl and 1.8 nm from the displaced threshold, the automatic flight control system (AFCS) was turned off and remained off for the remainder of the flight. With the AFCS disengaged, the flight crew continued the descent toward the runway under manual flight control and in visual meteorological conditions. The position of the power (throttle) lever and mixture control were not recorded parameters. However, based on recorded manifold pressure indications, the throttle was decreased once and then increased twice after the total loss of engine power. The first, partial, increase of throttle occurred about 31 seconds after the loss of engine power as the airplane descended through 602 ft agl about 1.49 nm from the runway displaced threshold. This first throttle increase was likely when the pilot attempted to increase engine power to increase the airplane’s airspeed at his flight instructor’s request. The second throttle increase, likely to the full throttle position, occurred about 42 seconds after the loss of engine power as the airplane descended through 407 ft agl about 1.23 nm from the runway displaced threshold. The airplane impacted trees and terrain about 20 seconds after the second throttle increase and came to rest in a wooded mobile home neighborhood. The second throttle increase likely was when the flight instructor became aware of the loss of engine power and assumed control of the airplane from the pilot. However, when the flight instructor advanced the throttle to full forward, the airplane was at least 200 ft below the minimum altitude threshold (600 ft agl) for a normal Cirrus Airframe Parachute System (CAPS) deployment. CAPS training documentation and pilot operating handbook (POH) guidance recommend the immediate deployment of CAPS if no other survivable alternative exists. At no point after the total loss of engine power did the airplane have sufficient altitude to glide to the runway. Based on recorded data, there was ample fuel in both fuel tanks at the time of the accident. A postaccident examination revealed no evidence of obstructions or debris in the fuel system. The 90° elbow inlet fitting to the electric fuel pump was found separated at the accident site. Based on a laboratory analysis, the 90° elbow inlet fitting separated during ground impact and, as such, did not contribute to the sudden loss of fuel flow to the engine. Examination of the engine and related systems did not reveal any mechanical malfunctions or failures that would have precluded its normal operation. Although residual fuel dye was observed on the external surface of the elbow fitting adjacent to its socket-side opening and suggested the possibility of a preexisting fuel leak, the laboratory examinations determined that this likely was not due to a fuel leak, but rather fuel dye that soaked into and was retained by a residual silicone film on the socket-side of the fitting postaccident. Although the silicone film covered both the tube and socket sides of the joint, the blue fuel dye was only observed on the socket-side. The lack of fuel staining on both sides of the joint further supports that the 90° elbow inlet fitting separated during ground impact. Review of the recorded engine data did not reveal erratic engine operation typically associated with a loss of engine power due to fuel starvation or exhaustion. Postaccident flight testing revealed that when the mixture control was moved full aft to the idle cutoff position with the electric fuel pump off, the decrease in fuel flow closely matched the recorded data from the accident flight. The flight testing also revealed that if the mixture control was moved full aft to the idle cutoff position with the fuel pump on, the engine would have continued to operate but with noticeable roughness. In the absence of any mechanical failure or obstruction of the fuel system, and with ample fuel onboard, it is likely the mixture control was inadvertently moved to idle cutoff during the descent with the electric fuel pump off, which resulted in the sudden and total loss of fuel flow to the engine. The investigation focused on how two appropriately certificated pilots, one of which was a factory flight instructor, did not adequately identify the total loss of engine power for the nearly one minute it took from the loss of fuel flow to impact, despite being visible on the airplane cockpit instrumentation, and detectable as a decrease in airplane performance. The investigation determined it is likely that both pilots were distracted and unaware of the loss of engine power for different reasons including inexperience in the airplane make/model, illness and physiological distress, and a lack of effective communication between the pilot and the flight instructor. The flight instructor was a new employee who had recently completed the transition training and obtained his Cirrus Standardized Instructor Pilot (CSIP) qualification. The flight instructor had no previous experience in Cirrus airplanes before he was hired as a factory flight instructor about 4 months before the accident. The consensus from all the factory instructors interviewed was that while the accident flight instructor did require additional time and performed slightly below average in comparison to other new hires in training, he did ultimately perform to a satisfactory level and was proficient enough to work with customers. The flight instructor was likely in physiological distress during the flight, which distracted him from maintaining situational awareness as the flight approached the destination. According to the pilot and the passenger, shortly after departing on the accident flight, the flight instructor stated that he had to urinate. It was the pilot’s perception that the flight instructor was in discomfort during the latter stages of their flight for this reason. Being under any sort of physiological stress would have diminished the flight instructor’s ability to perceive the environment around him and would have diverted his attention away from the task at hand. Divided or diverted attention makes it difficult to detect and correctly interpret stimuli, which in turn affects the decision-making process. Additionally, distraction can prevent a person from either identifying or properly attending to important information. The pilot was inexperienced in the airplane and was operating under the assumption that the flight instructor was the one who was ultimately responsible for the flight, thereby shedding some of the heightened level of awareness typically required to safely fly the airplane. The pilot was also not feeling well (he was diagnosed with COVID-19 after the accident), which was the primary reason that they were returning to his homebase and not continuing his training at the delivery center. Numerous studies have been conducted on how being sick might affect cognitive performance, and how fatigue (a common side effect of being sick) affects performance. Researchers liken both to a level of impairment similar to what one might expect from being intoxicated. Common results are loss of memory, inattention, lack of alertness, and poor judgment and decision-making. When interviewed, the pilot was not aware that there was a los

Flight Instructor A comprehensive flight record for the flight instructor was not located during the investigation. On March 17, 2022, the flight instructor reported 697 total flight hours when he submitted his application for employment with Cirrus Aircraft. Based on Cirrus Aircraft’s flight records, on April 20, 2022, the flight instructor flew 1.2 hours in a Cirrus SR22 airplane in conjunction with his interview for a Cirrus Factory Flight Instructor position. Besides the interview flight, the flight instructor did not have any flight time in a Cirrus airplane nor was he qualified as a Cirrus Standardized Instructor Pilot (CSIP) before he was hired by Cirrus Aircraft in May 2022. While employed by Cirrus Aircraft, the flight instructor flew 109.4 hours, of which 44.9 hours were dual-instruction-received in conjunction with his Cirrus SR22 transition training and CSIP qualification. On July 1, 2022, the flight instructor received his CSIP qualification following a successful 1.7-hour checkride administered by another Cirrus Factory Flight Instructor. While employed by Cirrus Aircraft, the flight instructor flew 14.2 hours as pilot-in-command in support of internal company flight operations and provided 48.6 hours of dual-flight-instruction to four customers, including the accident pilot. The investigative team interviewed several factory flight instructors who were responsible for training the accident flight instructor to perform his duties with Cirrus Aircraft’s customers. The training included three phases; transition training in the Cirrus SR22, an intermediate phase to gain additional flight experience in the SR20/22 airplane while supporting internal company flight operations, and finally the completion of CSIP training. The primary instructor pilot responsible for the training noted that the accident flight instructor had difficulties in progressing through the Cirrus SR22 transition training program. Documented in training records were concerns about the accident flight instructor maintaining situation awareness while operating in areas of high traffic (Class B airspace), maintaining positive control (i.e. “staying ahead”) of the airplane in dynamic situations, and decision-making regarding CAPS deployment. The primary instructor pilot stated that after 23.9 hours of dual instruction completed over a 9-day period, he felt the accident flight instructor was not ready to fly solo and required additional training once a relocation to the Cirrus Aircraft Vision Center in Knoxville, Tennessee, could occur and before the trainee would be ready to transition to the company’s CSIP training. The accident flight instructor’s training records also listed difficulties with managing airplane automation and airplane handing. The consensus from the instructors interviewed was that while the accident flight instructor did require additional time and performed slightly below average in comparison to other new hires in training, he did ultimately perform to a satisfactory level and was proficient enough to work with customers as a Cirrus Factory Flight Instructor. Pilot The pilot was unable to provide a comprehensive record of his flight experience. The pilot’s current flight logbook reflected his total time flown in his Cessna 182 that he purchased new in September 2005. As of August 20, 2022, he had flown 1,686.2 hours in his Cessna 182. The pilot reported additional flight time in a Pilatus PC-12 and a Cessna 414, but most of his pilot-in-command flight experience was flown in his Cessna 182. On his last Federal Aviation Administration (FAA) medical application, dated March 8, 2022, the pilot reported 1,535 hours total flight time, of which 82 hours were flown in the last 6 months. According to a pilot history questionnaire he provided to Cirrus Aircraft before beginning his Cirrus SR22 Transition Training, the pilot had flown about 2,039 hours, of which 1,925 hours were flown as pilot-in-command. Besides a 30-minute demonstration flight completed about 1.5 years before the accident, the pilot did not have any flight time in a Cirrus airplane before he accepted delivery of his new airplane. According to his flight logbook and recorded data from the airplane, the pilot had received 12 hours of dual-flight-instruction in the accident airplane at the time of the accident. Before he arrived at the Cirrus Aircraft Vision Center Campus in Knoxville, Tennessee, the pilot communicated with the person responsible for his airplane delivery experience, and the person responsible for scheduling his training. The pilot stated that he was unable to access the Cirrus Approach Learning Portal before he traveled to Knoxville to accept delivery of his airplane. He reported his inability to access the training portal to the training manager who told the investigation team in a subsequent interview that the issue was elevated to Cirrus Aircraft’s IT department for resolution; however, for unknown reasons, the pilot remained unable to access the training portal. As an interim solution, before he traveled to accept delivery of his airplane, the pilot contacted his Cirrus Aircraft sales representative who provided a copy of the airplane’s POH. The pilot was already in the Knoxville area and began his transition training when his access issue to Cirrus Approach Learning Portal was finally resolved. When interviewed, the pilot repeatedly stated that he had no experience with Cirrus airplanes and believed Cirrus Aircraft would provide a syllabus for his transition training. The pilot stated that, given his lack of flight experience in the Cirrus SR22, his training expectations were to be taught how to fly his new airplane and, as such, was “relying on them to teach me, not me [to] tell them what to teach me.” A postaccident review of the available maintenance records found no unresolved airworthiness issues. According to the Cirrus SR22 POH, the airplane’s maximum glide ratio was 8.8 to 1. During a forced landing with no wind, the airplane flown at 92 KIAS with the flaps fully retracted would glide 1.45 nm laterally for every 1,000 ft of altitude loss. The POH does not provide glide performance data for the airplane with flaps extended to 50% or 100%. The Cirrus Perspective+ integrated avionics system, built by Garmin for Cirrus Aircraft, presents flight instrumentation, position, navigation, communication, and identification information to the pilot through large-format displays. The automatic flight control system (AFCS) provides the flight director, autopilot, yaw damper, and manual electric trim functions. The system features two 12-inch, high resolution display units. The left display is configured as a primary flight display (PFD). The right display is configured as a multi-function display (MFD). Flight Instructor The flight instructor experienced cardiac arrest while being treated by emergency medical services (EMS). He was transported to a hospital, but resuscitation efforts were unsuccessful and he was declared dead by emergency department (ED) personnel. According to the flight instructor’s autopsy, conducted by the Montgomery County Forensic Services Department, the cause of death was multiple blunt force injuries, and the manner of death was accident. The flight instructor sustained injuries to the head, chest, ribs, pelvis, legs, and lumbar vertebra. The urinary bladder was lacerated and empty. The autopsy did not identify significant natural disease. At the request of the Montgomery County Forensic Services Department, NMS Labs performed postmortem toxicological testing of femoral blood from the flight instructor. No tested-for substances were detected. The FAA Forensic Sciences Laboratory also performed postmortem toxicological testing of specimens from the flight instructor and no tested-for substances were detected. Pilot The pilot was alert and walking when EMS personnel arrived. He was