Tallahassee, FL, USA
N827GM
CIRRUS DESIGN CORP SR22
During an instrument-landing-system approach in night meteorological conditions, the airplane initially joined the localizer course but subsequently veered off to the right. The controller made numerous advisory calls to the pilot to direct him back toward the localizer course; however, though the airplane initially made corrections back toward the localizer course, it subsequently turned again toward the right. Radar data indicate that the airplane continued to descend while flying a serpentine track to the right of the localizer course until it made one final turn back toward the localizer and entered a low altitude stall/spin. Immediately prior to entering the stall/spin, the pilot stated over the radio "gotta go." No mechanical anomalies were noted with the airplane and no physical anomalies were noted with the pilot. While the airplane was equipped with a parachute system that, contrary to the checklists, was not armed by the pilot before flight, the low altitude at which the pilot lost control of the airplane would have made a successful deployment doubtful even with the system armed. The pilot and a passenger were fatally injured, one person on the ground was seriously injured, and two others received minor injuries when the airplane impacted automobiles and terrain.
HISTORY OF FLIGHT On November 13, 2008, at 1914 eastern standard time, a Cirrus SR22, N827GM, was substantially damaged when it impacted automobiles and terrain in Tallahassee, Florida. The certificated private pilot and the passenger were fatally injured. In addition, one person on the ground was seriously injured, while two others incurred minor injuries. Night instrument meteorological conditions prevailed. The airplane was operating on an instrument flight rules flight plan, and departed Port Columbus International Airport (CMH), Columbus, Ohio, at 1429, destined for Tallahassee Regional Airport (TLH), Tallahassee, Florida. The personal flight was being conducted under the provisions of 14 Code of Federal Regulations Part 91. A review of recorded radio transmissions and Federal Aviation Administration (FAA) voice transcripts revealed that as he was approaching Tallahassee, the pilot advised the controller that he had the current weather, and requested the "ILS" (instrument landing system) runway 27 approach. The approach controller provided descent altitudes and vectors for the approach, then subsequently cleared the pilot for the approach and advised him to switch to the Tallahassee Tower radio frequency, which the pilot acknowledged. The inbound course for the ILS runway 27 approach was 272 degrees magnetic. The glide slope angle was 3 degrees, and the decision altitude was 200 feet above the ground, or 253 feet above mean sea level (msl). Runway elevation was 48 feet msl. At 1910:44, the pilot contacted Tallahassee Tower and stated that he was on the ILS runway 27 approach. The controller cleared him to land, and reported the winds being from 170 degrees at 6 knots. At 1912:06, the controller advised the pilot that he was right of course, fly heading 240, and rejoin the localizer. The pilot did not respond initially, but after the controller repeated the instruction, the pilot acknowledged it. At 1912:27, the controller again told the pilot to turn left to a 240-heading, which the pilot acknowledged. At 1912:33, the controller stated, "you're going north ah north-westbound, turn left to two four zero," which the pilot did not acknowledge. At 1913:38, the controller again directed the pilot to turn left to 240, and advised him that he was still right of course, which the pilot acknowledged. At 1913:49, the controller stated "seven golf mike Tallahassee," and the pilot responded, "seven golf mike's gotta go." There were no further transmissions from the pilot. A hand held "GPS" (global positioning system) unit that was recovered from the airplane was downloaded at the Safety Board. When the positions were plotted over the inbound course, they revealed that the airplane initially joined the localizer before veering off to the right about 5 nautical miles (nm) from the airport. The airplane then flew a serpentine pattern for the next 2 miles, finally turning south before the GPS stopped recording. The last recorded position was almost directly above the accident site, and indicated that the airplane was 30 feet above the ground. The previous recorded position, 5 seconds earlier, was about .07 miles to the north, and indicated the airplane was 260 feet above the ground. The lowest recorded radar contact occurred when the airplane was about 300 feet above the ground. According to a witness standing in front of his house, the airplane came from across the street, snapped a transmission wire, then impacted two cars, one of which was parked behind the other, that were in his driveway. Another witness, also standing in front of the house, stated that she first saw a red light in the sky, and as it came closer, she recognized that the airplane was initially flying straight. The airplane then "came down flipping in circles," including two 360-degree turns, then hit the cars, one of which subsequently ran over her. PERSONNEL INFORMATION The pilot, age 64, held a private pilot certificate with airplane single engine land and instrument airplane ratings. According to the pilot's logbook, prior to the accident flight, he had recorded 721 hours of total flight time, 17 hours in airplane make and model, 56 hours of night time, 76 hours of actual instrument time, and 64 hours of simulated instrument time. The pilot's logbook also indicated that he had acquired the airplane on October 8, 2008, and flew four flights, including six instrument approaches, with a certificated flight instructor between October 8, 2008, and October 14, 2008. Between October 19, 2008, and November 6, 2008, the pilot logged four more flights and three instrument approaches. The last logged flight included 1 hour of night proficiency. The pilot's latest FAA third class medical certificate was issued on May 21, 2008. AIRCRAFT INFORMATION The airplane was manufactured in 2002, and was powered by a Teledyne Continental Motors IO-550-series engine. According to maintenance records, the latest annual inspection was completed on October 7, 2008, at 482.9 hours since new and 25.6 hours before the accident. The airplane was equipped with individual flight instruments that included an attitude gyro, a horizontal situation indicator (HSI), an altimeter, a vertical speed indicator, an airspeed indicator, and a turn coordinator. The attitude indicator was vacuum driven, while the HSI was electronic. The airplane was also equipped with a multi-function display (MFD) that had been updated to record information. Navigation was provided via two Garmin GNS 430 units. There was also a bracket on the dash face in front of the pilot where the hand held GPS could have been mounted. The airplane was also equipped with a Cirrus Airplane Parachute System (CAPS), which included a solid-propellant rocket used to deploy a 2,400-square-foot round canopy. According to the SR22 pilot operating manual (POH), "CAPS is normally initiated by pulling the CAPS 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. A maintenance safety pin is provided to ensure that the activation handle is not pulled during maintenance. However, there may be some circumstances where an operator may wish to safety the CAPS system….The pin is inserted through the handle retainer and barrel locking the handle in the “safe” position. A 'Remove Before Flight' streamer is attached to the pin." In the POH "Normal Procedures, Preflight Walk-Around" checklist, item 1 states: "CAPS Handle…Pin Removed." In the "Before Starting Engine" checklist, item 4 states: "Verify CAPS handle safety pin is removed." In the "Before Takeoff" checklist, item 2 states: "CAPS Handle…Verify Pin Removed." The POH also discusses, in Section 10, CAPS deployment altitude, stating, "As a guideline, the demonstrated altitude loss from entry into a one-turn spin until under a stabilized parachute is 920 feet. Altitude loss from level flight deployments has been demonstrated at less than 400 feet. With these numbers in mind, it might be useful to keep 2,000 feet AGL in mind as a cut-off decision altitude." POH Section 4 states that as airspeed is slowly reduced, there will be a slight airframe buffet, and a stall warning horn will sound between 5 and 10 knots before the stall. The airplane was not equipped with airbags. METEOROLOGICAL INFORMATION Weather, recorded the airport at 1853, included winds from 150 degrees true at 6 knots, visibility 10 statute miles, a broken cloud layer at 400 feet, an overcast cloud layer at 1,500 feet, temperature 23 degrees Celsius (C) , dew point 22 degrees C, and an altimeter setting of 29.92 inches Hg. According to U.S. Naval Observatory data, sunset occurred at 1741, and the end of civil twilight occurred at 1806. WRECKAGE AND IMPACT INFORMATION The accident site was mostly contained in the front yard of a house located about 1 ½ nautical miles east of runway 27, and ½ nautical mile north of the localizer centerline, in the vicinity of 30 degrees, 23.92 minutes north latitude, 084 degrees, 18.15 minutes west longitude. Transmission lines in front of the house, along the street, were cut and frayed. Two automobiles that had been parked one behind the other in the driveway, facing the house, were damaged, and displaced to the left of their original positions. The automobile that had been nearest the street exhibited impact marks, with its engine compartment crushed downwards and outwards on the right side. The airplane came to rest further to the left of the automobiles, upside down. The engine was separated from, and located further to the left of the airplane. The airplane's right wing was fragmented and separated from the fuselage, and the empennage was partially separated from fuselage, right-side up, with part of the tail sticking into a window of the house. All flight control surfaces were accounted-for at the scene. Control continuity was established from the cockpit to the left aileron, the rudder and the elevator. The right aileron was separated, with cable ends exhibiting separation consistent with overload. The three-bladed propeller and hub were separated from the engine, with the crankshaft separated aft of the propeller flange. Separation surfaces exhibited 45-degree shear marks and radial cracking consistent with torsional overload. All three propeller blades exhibited s-bending. Two of the blades exhibited significant leading edge damage, and some chordwise scratching. The spinner exhibited spiral crushing. An estimated 5 gallons of fuel flowed from the left wing fuel tank during wreckage recovery. No mechanical anomalies were noted with the engine. Crankshaft continuity was confirmed, cylinders were borescoped, spark plugs were examined and magnetos were sparked. The CAPS was not deployed, and the rocket was disarmed at the accident site. The maintenance safety pin was found still inserted through the handle retainer and barrel, with the "Remove Before Flight" streamer attached. When removed and examined, the pin did not exhibit any deformation or witness marks. MFD engine data was downloaded at the Safety Board; however, the last 57 seconds of the flight were not recorded. MEDICAL AND TOXICOLOGICAL INFORMATION An autopsy of the pilot, conducted at the District Two Office of the Medical Examiner, Tallahassee, Florida, determined the cause of death to be "multiple blunt force trauma." Toxicological testing was subsequently performed by the FAA Forensic Toxicology Research Team, Oklahoma City, Oklahoma, with no anomalies noted.
The pilot's failure to maintain adequate airspeed on final approach, which resulted in a low-altitude aerodynamic stall and spin. Contributing to the accident was the pilot's failure to fly the published instrument approach and his subsequent failure to execute a timely missed approach.
Source: NTSB Aviation Accident Database
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