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NTSB investigation record

WPR19FA103

Completed

Cirrus Sr22· N173CT

Date
March 31, 2019
Location
Farmington, NM
Conditions
VMC
Record
Published September 29, 2021

Primary finding

Probable cause

The noninstrument-rated pilot's continued visual flight rules flight into an area of forecast instrument meteorological conditions, which resulted in spatial disorientation and a subsequent loss of control.

Investigator assessment

Analysis narrative

The noninstrument-rated pilot departed on a visual flight rules (VFR) cross-country flight. About 25 minutes after takeoff, the airplane reached its highest altitude of 17,300 ft mean sea level (msl) and was approaching a line of precipitation and thunderstorms. About 20 minutes later, the airplane entered a descent at a rate of about 1,000 ft per minute. The airplane then leveled off at an altitude of about 8,575 ft msl (about 3,000 ft above ground level), about 1,000 ft below the predicted cloud base, and a short time later, the airplane transitioned to a right descending turn that continued until ground contact, reaching a descent rate of about 5,175 ft per minute. The debris field and fragmentation of the airplane was consistent with a high-speed, right-wing-low impact. Examination of the wreckage did not reveal any anomalies with the airframe or engine that would have precluded normal operation, and there was no evidence of an inflight breakup. The airplane’s airframe parachute system was not deployed. Analysis of weather information indicated that the airplane likely encountered a line of developing and expanding rain showers, with updraft and downdraft conditions, precipitation, and reduced visibility as the pilot likely descended to fly under the cloud bases. Due to the developing and expanding rain shower line, outflow boundaries and low-level wind shear conditions were likely present in the area at the accident time. A convective SIGMET as well as AIRMETs for instrument flight rules conditions, mountain obscuration, and moderate icing were valid for the route of flight and in the area of the accident site at the accident time. When activating his flight plan, the pilot indicated to the weather briefer that he was aware of the AIRMETs; however, whether he was aware of the SIGMET was not determined based on the available information. Although the pilot did not receive an official weather briefing, records suggest that he downloaded weather imagery three days before the flight. He had an active subscription to a commercial satellite weather service for the airplane, which was also equipped with multiple avionics devices capable of receiving and displaying weather information. Whether or to what extent the pilot accessed weather imagery in-flight could not be determined. The reduced visibility and the pilot’s lack of experience in flight by reference to instruments provided conditions conducive to the development of spatial disorientation, and the airplane’s descending turn, rapid descent, and high-speed impact with the ground were consistent with the known effects of spatial disorientation. Given the available information, it is likely that the noninstrument-rated pilot encountered instrument meteorological conditions as he continued toward and subsequently attempted to fly below an area of rain shower and thunderstorm activity, and experienced spatial disorientation that resulted in a loss of airplane control.

Source record

Factual narrative

The pilot held a private pilot certificate with a rating for airplane single-engine land, issued in September 2015. The pilot’s flight logbooks were not recovered; however, at the time of his last FAA medical examination, dated March 28, 2017, he reported 270 total hours flight experience, 64 of which occurred in the previous six months. Between August 27, 2017, and September 3, 2017, the pilot attended a Cirrus transition training course in Abilene, Texas. The training included 10.9 hours of flight experience in a Cirrus SR22TN equipped with an Avidyne Entegra avionics suite, and 8.5 hours of ground instruction. The pilot purchased the airplane on July 25, 2017. It was certified for instrument flight rules (IFR) operation, and equipped with Avidyne FlightMax primary and multifunction displays, a Garmin GNS 430, and a set of conventional backup instruments. Additionally, a satellite weather data receiver was included, and the pilot had an active weather package subscription at the time of the accident. Fueling records provided by a fixed based operator at U96 indicated that the pilot serviced the airplane with the addition of 65.2 gallons of 100 low-lead aviation gasoline at 2217 on the evening of March 29. There was no evidence the airplane had flown between that time and the accident flight. The airplane was equipped with a “No Hazard” de-ice system, which was designed for inadvertent entry into icing conditions and not certified for flight into known icing conditions. The airplane was equipped with a Cirrus Airframe Parachute System (CAPS), which had a demonstrated maximum deployment speed of 133 kts indicated airspeed. An autopsy performed by the New Mexico Office of Medical Investigators revealed that the pilot died as a result of multiple blunt force trauma injuries. Due to the trauma, the autopsy could not determine if significant natural disease was present. The medical examiner reported that the oxygen supply tube and a cannula were comingled with the pilot. Toxicology testing performed by the FAA Forensic Sciences Laboratory did not identify the presence of any screened drug substances or ingested alcohol. Review of FAA medical certificates and supporting documentation indicated that the pilot reported no significant medical concerns, and during his most recent FAA medical examination, the aviation medical examiner identified no significant conditions. The wreckage was located in flat, high desert terrain at an elevation of about 6,185 ft msl, 450 ft southwest of the last recorded radar target, and 30 miles south of FMN. The first identified point of impact was a 4-ft-deep by 10-ft-wide crater, which contained the nose landing gear assembly, two propeller blades, and fragmented engine and airframe components. Two matching linear impact marks, the total length of which corresponded to the airplane's wingspan, extended from the crater on a north-south heading. The right wingtip and green navigation lens fragments were found at the tip of the northern mark, and red navigation lens fragments were located at the tip of the southern mark. The debris field was 450 ft long oriented on a heading of about 210°. The engine came to rest about 30 ft beyond the crater, and the remainder of the debris comprised fragmented pieces of composite main cabin and wing structure, extending out to a width of about 100 ft. The ailerons, elevators, and flaps were crushed and distributed throughout the debris field, and the farthest components were the left forward seat and a fuel tank cap. The rocket-powered airframe parachute was located in the center of the debris field. The harness cables remained attached to their respective airframe fittings, and the top of the parachute canopy remained folded evenly along its pleats and had not unfurled. Although the canopy lines had extended to their full length, the solid-fuel rocket motor remained attached to the parachute assembly and had not been expended, consistent with the parachute system not having been activated in flight. The engine sustained significant impact damage, liberating the oil sump, most of the accessories, and bending the forward cylinders aft. Internal examination did not reveal any evidence of catastrophic failure, and examination of the spark plugs revealed wear signatures and coloration consistent with normal operation. The turbine and compressor wheels for both turbochargers were impinged against their respective housings and exhibited bending damage to their tips opposite the direction of rotation. The airplane was equipped with a crash-hardened recoverable data module, installed in the vertical stabilizer. The unit was designed to record flight, engine, and autopilot parameters, logged once per second, and stored internally on a compact flash (CF) card. Examination revealed that the unit was undamaged; however, review of the data in the CF card revealed that the last recorded flight occurred on October 13, 2018. There were no data pertinent to the accident recorded on the device. The MFD unit was also capable of storing engine and aircraft parameters on a CF card; however, the entire unit sustained significant impact damage, and the card was bent in half. The extent of the damage precluded recovery of any data pertinent to the accident flight. On March 31, 2019, about 1439 mountain daylight time (MDT), a Cirrus SR-22, N173CT, was destroyed when it was involved in an accident near Farmington, New Mexico. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The cross-country flight departed Cal Black Memorial Airport (U96), Halls Crossing, Utah, about 1345 with a planned destination of Big Spring Mc Mahon-Wrinkle Airport (KBPG), Big Spring, Texas. According to the pilot's family, he did not have any meetings or appointments that necessitated his return by a specific time, and he had flown the accident route of flight at least a dozen times before and was familiar with the terrain. Federal Aviation Administration (FAA) automatic dependent surveillance-broadcast (ADS-B) data (See Figure 1) revealed the accident airplane depart at 1351 and climb on an eastbound heading. While the target was climbing out of a transponder-reported altitude of 9,125 ft mean sea level (msl), the accident pilot contacted Cedar City Flight Service Station to activate a visual flight rules (VFR) flight plan. During that exchange, the briefer asked the pilot if he had the AIRMET advisory for icing and mountain obscuration for the planned route of flight, and the pilot reported that he did. About 1400, the target had reached 14,000 ft msl, and about that time, the pilot contacted the Denver Air Route Traffic Control Center (ZDV) requesting VFR flight following services. The controller issued the airplane a discrete transponder code, and a few minutes later, advised the pilot that he had established radar contact with the airplane and provided the nearest altimeter setting. By 1409, the airplane had reached its highest altitude of 17,300 ft msl and was about 50 nautical miles southeast of U96. A few minutes later, the target turned left and began to track east. For the next 7 minutes, the track began to slowly transition back to the southeast, after which the pilot was provided and acknowledged a frequency change by the ZDV controller. At 1428, the airplane was about 24 miles southwest of Four Corners Regional Airport (KFMN), and the controller provided the pilot with the KFMN altimeter setting. About that time, the airplane entered a descent to 9,300 ft. The controller then provided the pilot with a frequency change, which the pilot read back correctly. No other radio transmissions were received from the pilot, and at 1438:10, the airplane had descended to 8,575 ft msl (about 3,000 ft agl) and began a descending right turn. The radius of the turn was about 3,200 ft, during which the air

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