Coconut Creek, FL, USA
N889JB
Cirrus Design Corp. SR22
The pilot took off in instrument meteorological flight conditions and shortly thereafter, misinterpreted a series of air traffic control instructions to be for his airplane when they were for another airplane. Subsequent callouts and responses by the pilot indicated confusion, to the point where he stated, "I gotta get my act together here." Less than 1 minute later, the pilot reported "avionics problems," and about 40 seconds after that, during his last transmission, he stated that he was "losin' it." The airplane subsequently descended nose-down, out of clouds, and impacted a house and terrain. The airplane was equipped with a primary flight display (PFD), as well as separate backup instruments in case the display failed. The airplane had approximately 98 hours of operation since being manufactured, and had a history of PFD failures. The pilot had previously practiced partial panel (no PFD) flight. The airplane was also equipped with a parachute system, which was not deployed in flight.
HISTORY OF FLIGHT On January 15, 2005, at 1223 eastern standard time, a Cirrus Design Corporation SR22, N889JB, was destroyed when it impacted a house, then terrain, in Coconut Creek, Florida. The certificated commercial pilot was fatally injured. Instrument meteorological conditions prevailed, and the airplane was operating on an instrument flight rules flight plan from Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida, to Naples Municipal Airport (APF), Naples, Florida, and back to Fort Lauderdale Executive. The personal flight was conducted under 14 CFR Part 91. According to information received from the Federal Aviation Administration (FAA), the airplane departed Fort Lauderdale Executive at 1217. Radar and transponder data revealed that after the airplane departed Fort Lauderdale Executive, it climbed to the northwest, to 1,600 feet, before beginning a right turn toward the northeast. The airplane then climbed to 1,800 feet, continued the right turn, and once on a southeast heading, descended to 1,000 feet. Subsequently, the airplane turned left, and headed northeast, climbing to 1,900 feet. It then made a right turn to the south, and descended to 400 feet during a 12-second period, followed by a climb to 1,400 feet during the next 12-second period. The airplane subsequently made one more left turn, through north, to the northwest, and its last altitude readout, at 1223:17, was 1,100 feet. The last radar contact was about 500 feet southeast of the accident site. A review of the voice communication tape revealed: At 1219:13, the pilot stated: "cirrus november eight eight nine juliet bravo is through a thousand, ah (unintelligible)." At 1219:59, the controller responded: "eight eight niner juliet bravo you're radar contact, turn left heading two seven zero." The pilot then responded with: "ah, two seven zero, nine zero, ah, nine juliet bravo. At 1220:07, the controller stated (to another pilot): "seven eight five, turn right, heading zero niner zero." At 1220:10, an unidentified voice, similar to the accident pilot's, responded: "ah, did you say a right turn to two seven zero?" At 1220:15, the controller stated: "turn right zero niner zero seven eight five." The pilot from that airplane did not respond. At 1220:21, the controller stated: "three six seven eight five, turn right heading zero niner zero." At 1220:27, there was a sound similar to two pilots blocking each other's transmissions. At 1220:29, the controller stated: "eight juliet, correction, niner juliet bravo, turn left, two seven zero." At 1220:32, the pilot responded: "two seven zero for nine juliet bravo" At 1220:35, the controller stated: "turn now please." At 1220:39, the controller stated: "november six niner xray, turn left, heading one five zero," and that pilot responded with: "one five zero, six niner xray." At 1220:43, the controller stated: "november nine juliet bravo, turn left, heading two seven zero, two seventy the heading niner juliet bravo. you've turned the wrong way." At 1220:49, the pilot responded: "you told me to turn ninety; i'm turning back to two seventy now." At 1220:52, the controller stated: "negative sir, that was for a seven eight five. november niner juliet bravo, continue in the turn heading of zero niner zero. traffic alert. traffic eleven o'clock, one mile, indicates two thousand, he's southbound." At 1221:06, the pilot responded: "zero nine zero on the heading, nine juliet bravo." At 1221:13, the controller stated: "november niner juliet bravo, just continue on a ninety heading. november six niner xray, turn right, heading of zero, correction, turn right, heading two seven zero." That pilot responded: "two seven zero, six niner x." At 1221:25, the controller stated: "november seven eight kilo, turn left, turn left, heading zero niner zero, maintain three thousand," and the pilot responded: "zero nine zero, seven eight kilo." At 1221:30, the controller stated: "cirrus niner juliet bravo, climb and maintain two thousand, over." At 1221:35, the pilot responded: "climbing to two thousand (pause), and you want me (transmission cut off)." At 1221:40, the controller stated: "november niner juliet bravo, just continue on a ninety heading, heading zero niner zero. i'm trying to get you away from a cessna." There was no response from the pilot. At 1221:50, the controller stated: "november niner juliet bravo, fly heading zero niner zero, over." There was no response from the pilot. At 1221:59, the controller asked: "november eight eight niner juliet bravo, how do you hear, over?" At 1222:05, the pilot responded: "i'm hearin' ya. i'm hearin' ya. i'm, i'm, i gotta get, ah, my act together here." At 1222:11, the controller stated: "november niner juliet bravo, fly heading zero niner zero. i have aircraft off your left, will be on the approach at pompano. just fly a ninety heading, climb and maintain two thousand." There was no answer from the pilot. At 1222:30, the controller stated: "seven eight kilo, turn left, three six zero, it's going to be a short vector, i've got a cirrus disorientated out to the of, ah, east of you. i have to get him under control again." That pilot responded: "three six zero, seven eight kilo." At 0222:39, the controller stated: "thank you. november seven eight five, turn right, heading one eight zero. this will be vectors across the localizer for aircraft that's just going to be coming across pompano at two thousand feet." There was no response from that pilot. At 1222:52, the controller asked: "cirrus eight eight niner juliet bravo, miami, how do you hear?" At 1222:55, the pilot responded: "i hear you, but i've got, i've got problems, i've got avionics problems." At 1223:02, the controller stated: "cirrus niner juliet bravo, roger. do you have a gyro?" At 1223:07, the pilot responded: "i'm trying to get the plane, ah, level, nine juliet bravo." At 1223:11, the controller asked: "okay, november niner juliet bravo, do you see the ground?" At 1223:16, the pilot responded: "negative, I do not see the ground, nine juliet bravo." At 1223:21, the controller asked: "all right, you have your wings level?" At 1223:23, the pilot responded: "the wings are level, nine juliet bravo." At 1223:24, the controller asked: "november niner juliet bravo, roger, do you have a directional gyro?" At 1223:28, the pilot stated: "i'm losin', i'm losin' it again here." There were no further transmissions from the pilot. A witness, an airline transport pilot who was at a park near the accident site, reported that he heard the airplane flying southeast at a very low altitude. He looked up, but couldn't see it through the low overcast and mist. The airplane didn't sound like it had any engine problems, but as it flew farther away, it sounded as if it was maneuvering. A second witness, who was outside his home near the accident site, stated that he heard an airplane above the clouds that sounded like it was conducting acrobatics, climbing and descending. Suddenly, it descended out of the clouds, then banked and headed back up into the clouds in a northeasterly direction. As it ascended, the witness heard "an rpm change, like it was climbing." The witness then heard the engine get louder, followed by the sound of an explosion. The witness did not see the airplane exit the clouds a second time due to trees in his line of sight. Another witness, who did see the airplane descend from the clouds the second time, stated that when it did so, the airplane was perpendicular to the ground, "but on a slant." The accident occurred during daylight hours, in the vicinity of 26 degrees, 15.5 minutes north latitude, 080 degrees, 10.4 minutes west longitude. PERSONNEL INFORMATION The pilot held a commercial pilot certificate. According to notations in his logbook, the pilot obtained his private pilot certificate on June 1, 2003, his instrument rating on October 6, 2003, and his commercial certificate on March 25, 2004. The pilot had logged 483 hours of flight time, with 405 hours between two SR22s. He began flying the first SR22, N97CT, on June 5, 2003, and logged 304 hours in it. He began flying the accident SR22 on June 2, 2004. The pilot had also logged a total of 15 hours of actual instrument time, and 61 hours of simulated instrument time. His last flight before the accident flight was 1.6 hours on January 7, 2005, in which he also logged one instrument approach and 0.2 hours of actual instrument time. On December 30, 2004, the pilot logged a flight in which he flew two ILS, one VOR, and one GPS approach. According to the flight instructor on that flight, one of the approaches was flown partial panel, without the PFD. The flight instructor also noted that it wasn't the first time they had practiced partial panel; they had done it a number of times previously. The pilot's latest FAA first class medical certificate was issued on April 16, 2004. AIRCRAFT INFORMATION The airplane was manufactured in 2004, and was equipped with an Avidyne FlightMax Entrega-Series Primary Flight Display (PFD). Information provided by the PFD included airplane attitude, airspeed, heading and altitude, a horizontal situation indicator, and a vertical speed indicator. Below the PFD, on a "bolster panel" in front of the pilot, were backup altimeter, airspeed, and attitude indicators, to be used "in case of total or partial PFD failure." The airplane was also equipped with a Cirrus Airplane Parachute System (CAPS). According to the SR22 Pilot's Operating Handbook: "CAPS [is] designed to bring the aircraft and its occupants to the ground in the event of a life-threatening emergency. The system is intended to save the lives of the occupants but will most likely destroy the aircraft and may, in adverse circumstances, cause serious injury or death to the occupants." "CAPS is initiated by pulling the activation T-handle installed in the cabin ceiling on the airplane centerline just above the pilot's right shoulder. A placarded cover, held in place with hook and loop fasteners, covers the T-handle and prevents tampering with the control. The cover is removed by pulling the black tab at the forward edge of the cover. Pulling the activation T-handle will activate the rocket and initiate the CAPS deployment sequence. To activate the rocket, two separate events must occur: 1. Pull the activation T-handle from its receptacle. Pulling the T-handle removes it from the o-ring seal that holds it in place and takes out the slack in the cable (approximately two inches of cable will be exposed). Once the slack is removed, the T-handle motion will stop and greater force will be required to activate the rocket. 2. Clasp both hands around [the] activation T-handle and pull straight downward with a strong, steady, and continuous force until the rocket activates. A chin-up type pull works best. Up to 45.0 pounds [of] force, or greater, may be required to activate the rocket. the greater force required occurs as the cable arms and then releases the rocket igniter firing pin. When the firing pin releases, two primers discharge and ignite the rocket fuel." There were no flight data or cockpit voice recording devices installed on the airplane. MAINTENANCE INFORMATION The airplane had been primarily maintained at two maintenance facilities, one in Georgia, and one in Florida. According to maintenance records, the PFD was replaced on June 4, 2004, at 12.2 hours, on September 14, 2004, at 55.2 hours, and on December 20, 2004, at 80.6 hours. According to customer invoices: The original PFD was replaced in June 2004 at the Cirrus Design Factory Service Center, due to "failure of altimeter and VSI." The replacement unit was listed as serial number 1153. The second unit was replaced in September 2004 at the Georgia maintenance facility because "PFD VOR knob only changes 2-3 degrees." PFD serial number 21602354 was then installed. In October 2004, the airplane was at the Florida maintenance facility for installation of an air conditioning system. In December 2004, the last PFD change-out occurred, at the Georgia maintenance facility. The invoice stated: "PFD red X on ADI...Removed PFD for repair. Found that PFD serial number D1433 did not match the serial number that was supposed to be in the aircraft. Contacted customer and he stated that the aircraft had been in Florida for A/C installation and that they had broken the pitot and static fittings, and swapped units with no logbook entry. The customer contacted the Florida shop and they found the unit in their parts room. They [the Florida facility] sent the unit to Avidyne for repair, and Avidyne sent the unit to [the Georgia facility] for reinstallation." The reinstalled unit was listed as serial number 21602354. METEOROLOGICAL INFORMATION Fort Lauderdale Executive Airport was located about 4 miles to the south of the accident site. Weather, recoded there at 1153, included winds from 340 degrees true, at 4 knots, surface visibility 10 statute miles, and an overcast cloud layer at 600 feet. Weather, recorded at 1253, included winds from 310 degrees true, at 5 knots, surface visibility 5 statute miles, light rain and mist, and an overcast cloud layer at 600 feet. WRECKAGE AND IMPACT INFORMATION The airplane's wreckage was located in a back yard of one house, next to another house. The right wing tip was broken off in the roof of the second house. The wreckage, which displayed no ground impact marks consistent with forward motion, was consumed in a post-impact fire. All flight control surfaces were accounted for at the scene, and control cable continuity was confirmed from the cockpit, to where all flight surface attach points would have been. The engine sustained impact damage. The three-bladed propeller, and the front of the engine, including the crankshaft to just aft the number six connecting rod, were separated from the rest of the engine and buried in the ground. One of the propeller blades was broken off about 5 inches from the hub, another blade exhibited deep chordwise scratching, and the third was bent aft. There was no evidence of any pre-impact anomaly to either the engine or airframe. All flight instruments were destroyed in either the ground impact or the post-impact fire. The CAPS parachute bag extended, by attached risers, about 40 feet from the wreckage, and came to rest in front of a fence. The parachute was still in the parachute bag. The CAPS cover was located near the airplane, and exhibited a circular impact mark on the inside, consistent with rocket activation. The primers had also been fired. The rocket motor and lanyard were found near the parachute bag. The CAPS T-handle safety pin was found in the wreckage, away from the T-handle, with its red safety flag wrapped around it. The T-handle was found pulled out of its housing by about 2 1/2 inches; however, it could not be determined if the pilot had pulled it, or if it had been displaced by impact forces. Total operating time of the airplane could not be exactly determined due to the condition of the wreckage. However, the estimated total time on the airplane was approximately 98 hours, based on the last maintenance logbook entry, the pilot's subsequent flight logbook entries, and the duration of the accident flight. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was conducted on the pilot at the Broward County Medical Examiner's Office, Fort Lauderdale, Florida, and toxicological testing was subsequently performed at the FAA Bioaeonautical Sciences Research Laboratory, Oklahoma City, Oklahoma. ADDITIONAL INFORMATION On January 16, 2005, the wreckage release was acknowledged by the vice president of the aircraft recovery company.
The pilot's failure to maintain aircraft control, which resulted in an uncontrolled descent to the ground. Factors included an avionics failure, pilot disorientation, and instrument meteorological conditions. A factor in the severity of the impact was the pilot's failure to deploy the airplane's onboard parachute system.
Source: NTSB Aviation Accident Database
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