Green Cove Springs, FL, USA
N389CP
CIRRUS DESIGN CORP SR20
During an instructional flight while in contact with a Federal Aviation Administration air traffic control facility, the student pilot reduced the throttle to descend with no response. The CFI took the controls and attempted several times to move the throttle control but was unable. The certified flight instructor (CFI) maneuvered the airplane toward a nearby airport, but was unable to maintain altitude due to the decreased engine rpm. During controlled flight while descending, the airplane impacted the tops of trees then impacted the ground. The CFI, whose hand was on the airframe parachute system handle at the point of tree contact, unintentionally fired the parachute at the moment of ground contact. The airplane then nosed over and the rear seat occupant broke the rear window using the emergency egress hammer. All 3 occupants exited the airplane. Further inspection of the engine compartment revealed the No. 2 alternator output cable was routed under the throttle cable, which is contrary to the routing when the airplane was manufactured. The throttle cable housing chafed thru the insulation of the Alternator No. 2 output cable causing arching and fusing both together, preventing movement of the throttle control. Review of the maintenance records revealed six discrepancies related to the No. 2 alternator and two discrepancies related to the throttle control in over a six month period. Two of the corrective action entries for the alternator issued involve removal and replacement of the data acquisition unit (DAU) and master control unit (MCU), while the corrective action for the throttle control was that it was lubricated. Between the date of the six discrepancies related to the No. 2 alternator and the two entries related to the throttle, the airplane was inspected a total of four times either in accordance with a 100-Hour or annual inspection. Inspection of the wiring of the alternator for condition and security is contained in the airplane's maintenance manual.
On November 19, 2008, about 0740 eastern standard time, a Cirrus Design Corporation SR20, N389CP, registered to ATG-GA Leasing, LLC, operated by CAPT, LLC, dba Commercial Airline Pilot Training Program, sustained substantial damage during a forced landing near Reynolds Airpark (FL60), Green Cove Springs, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 instructional, local flight, from Flagler County Airport (XFL), Palm Coast, Florida. The certified flight instructor (CFI) and an observer were not injured. The student pilot sustained a minor injury. The flight originated from XFL about 0711. The CFI stated that after takeoff, they intended on flying to Cecil Field Airport (VQQ) for the purpose of performing landings. While en route to VQQ and in contact with Jacksonville Approach Control, the controller advised them to descend at their discretion. The operator reported that the “flightcrew” had reduced throttle to begin their initial descent and was unable to advance the throttle as the flight reached their target altitude. The CFI further stated that the student informed him that the throttle was sticking and he (CFI) attempted to move it but was unable. The CFI took the controls and maintained best glide airspeed while maneuvering towards FL60. He again tried to advance the throttle but was unable, and advised the controller that the throttle control was jammed and he intended on performing an emergency landing on runway 05 at FL60. The CFI again attempted to advance the throttle but was unable and while flying towards runway 05 at FL60 over a remote wooded area, the airplane contacted the tops of trees while his hand was on the ballistic recovery system (BRS) parachute handle. He estimated the airplane impacted the ground at 70 knots and nosed over. After coming to rest inverted they were unable to open either cabin entry door, and the rear seat occupant used the emergency egress hammer and knocked out the rear window. They evacuated the airplane and he called the airplane operator using a cell phone, telling what had occurred. A search was initiated by law enforcement. Personnel from a fixed base operator at FL60 walked to the airplane and led them out of the area. The student pilot who was seated in the left front seat was taken to a hospital and released the same day. Examination of the accident site revealed the airplane came to rest inverted at a point located approximately 222 degrees and 1/4 statute mile from the approach end of runway 05 at FL60. The airplane was recovered for further examination. The airplane was manufactured in 2007, and at the time of the accident had accumulated 530.6 hours. It was equipped with a Cirrus airframe parachute system (CAPS) and AmSafe Airbag Seatbelt (inflatable restraint system) installed at the pilot and co-pilot seat positions. The airplane was also equipped with an Avidyne primary flight display (PFD) that displays and stores flight data, and also an Avidyne multi-function display (MFD) that displays and stores in part GPS information in addition to engine and electrical system parameters. The PFD and MFD were retained for further examination by NTSB. Examination of the airplane following recovery was performed by representatives of the airplane manufacturer and the inflatable restraint system manufacturer ,with NTSB oversight. Examination of the airframe parachute system revealed the airframe parachute system rocket motor propellant was expended and the “D-Bag” was extracted from the enclosure compartment; however, the parachute remained packed and the rear harness remained snubbed. The reefing line cutters remained attached to the rear harness and were not activated; they were removed and the ordinance was disposed of. Inspection of the left forward seat revealed the honeycomb absorbing material was compressed a maximum of ½ inch, and inspection of the right forward seat revealed the honeycomb absorbing material was compressed a maximum of 1/4 inch. Inspection of the rear seat revealed the forward edge of the seat pan had separated from the forward cross tube at the rivets. Inspection of each seat restraint system revealed all operated correctly when tested postaccident. Inspection of the pilot and co-pilot’s inflatable restraint system revealed the vent holes of both exhibited squaring of the top vent hole. Examination of the engine compartment revealed an electrical cable (alternator output P/N RF 24-30-03 DET) from the No. 2 (standby) alternator was fused against the housing of the throttle cable (P/N 14392-103). The electrical cable P/N RF 24-30-03 DET was routed under the throttle cable P/N 14392-103, and exhibited a close radius loop of nearly 180 degrees. Further inspection of the engine compartment revealed a mark on a wire bundle protective sleeve of an adel clamp associated with light contact with the electrical cable P/N RF 24-30-03 DET. Two impressions associated with clamping were noted on the exterior surface of the electrical cable P/N RF 24-30-03 DET. Additionally, a plastic tie wrap adjacent to the adel clamp with the light contact mark was noted to be loose. Personnel from the airplane manufacturer reported that during manufacturing, the electrical cable P/N RF 24-30-03 DET is not secured by the plastic tie wrap. Personnel from the airframe manufacturer also reported that the clock position of the electrical cable at the alternator was not in the same position as the clock position at the alternator when the airplane was manufactured. The representative of the airframe manufacturer also reported that during manufacture of the airplane, the electrical cable from the No. 2 (standby) alternator is routed over the throttle cable. At the time of manufacturing, electrical cable P/N RF 24-30-03 DET has a wide radius loop of nearly 180 degrees. Discrepancy sheets provided by the operator which record discrepancies associated with the airplane in service revealed that between April 23, 2008, and November 10, 2008, or 9 days before the accident, there were six entries pertaining to the No. 2 alternator, and two entries pertaining to the throttle. The dates of the discrepancies associated with the No. 2 alternator were April 23 (two entries), April 26, an undated entry between April 29 and June 2, June 2, and October 7. The dates of the discrepancies associated with the throttle were October 13, and November 3; both entries indicate the throttle control was either tight or difficult to move. The corrective action for two of the discrepancies pertaining to the No. 2 alternator indicated that on April 25, 2008, the data acquisition unit (DAU) was replaced and on June 3, 2008, the master control unit (MCU) was removed and replaced, requiring in part only removal and reinstallation of electrical wires associated with both alternators at the MCU. The remainder of the corrective action entries pertaining to the No. 2 alternator indicates it operationally tested satisfactory on the ground. The corrective action entry for both throttle control discrepancies indicates the throttle control cable was lubricated. Readout of the PFD and MFD by the Safety Board Vehicle Recorders Division located in Washington, DC, revealed that at approximately 0735, or approximately 24 minutes after takeoff, the MFD recorded the engine rpm decreasing to 1,500, and approximately 20 seconds later, at 0735:20, the MFD recorded a sudden increase in amperage of the Bus No. 2 load amps. The PFD recorded that the engine rpm continued decreasing to approximately 1,240 about the time of the ground contact. Review of the airplane maintenance manual revealed that during inspection of the No. 2 alternator, the wiring is required to be checked for condition and security. The maintenance records reflect that the last 100-Hour inspection occurred on November 14, 2008, or 5 days before the accident. The maintenance records also reflect that between the dates of the discrepancies associated with the No. 2 alternator and the throttle control, or between April 23, 2008, and November 10, 2008, the airplane was inspected a total of four times either in accordance with a 100-Hour or annual inspection.
The fusing of an electrical cable from the No. 2 (standby) alternator with the throttle cable resulting in the flight crew’s inability to move the throttle control. Contributing to the accident was the failure of maintenance personnel to detect inadequate clearance and chafing of the Alternator No. 2 output cable against the throttle cable housing during the 100-Hour inspections.
Source: NTSB Aviation Accident Database
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