Aviation Accident Summaries

Aviation Accident Summary ERA19FA234

Americus, GA, USA

Aircraft #1

N921CD

Cirrus SR22

Analysis

The pilot (who was the owner of the airplane) and pilot-rated passenger departed the airport for a cross-country flight in dark night instrument meteorological conditions (IMC), destined for an airshow for the final weekend of the event. Radar data showed the airplane's radar track after takeoff in a 180° left arc. The airplane climbed to about 1,300 ft mean sea level (msl), or about 850 ft above ground level, and then descended to 1,100 ft msl before radar contact was lost about 1 minute after takeoff. The pilot-rated passenger had access to the flight controls and held pilot certificates, ratings, and flight experience that would have allowed him to act as a pilot for the flight It could not be determined what his role was for the flight, be that solely a passenger, assisting the pilot/owner, or manipulating the airplane’s controls during all or a portion of the accident flight. Examination of the wreckage revealed no evidence of preimpact mechanical malfunctions or failures of the airplane. Weather information and a witness statement were consistent with weather conditions likely to have produced restricted visibility in addition to the darkness that prevailed at the time of the accident. The wreckage distribution, which was consistent with a relatively high-speed impact, the airplane's turning ground track and descent about 1 minute after takeoff, and the low visibility at the time of the accident, were indicative of a loss of airplane control after the onset of spatial disorientation. Further, the pilot/owner did not obtain an official weather briefing, did not file an instrument flight rules flight plan for a flight that departed into IMC, and was flying the airplane after the annual inspection was due; thus, it is likely that he had developed an anti-authority attitude, as evidenced by the disregard for several rules and regulations. While it could not be determined what role the pilot-rated passenger played in the decision making that took place before and during the flight, the pilot-rated passenger should have had the training and experience necessary to recognize these hazards. In addition, they may have experienced "get-there-itis" because they were flying to the airshow for its final few days and, thus, wanted to arrive as quickly as possible, which resulted in the decision to depart the airport in dark IMC under visual flight rules. Although toxicology testing detected ethanol in tissue samples from the pilot and passenger, medical evidence was insufficient to determine if the pilot or passenger were impaired.

Factual Information

HISTORY OF FLIGHTOn July 24, 2019, about 0550 eastern daylight time, a Cirrus SR22 airplane, N921CD, was destroyed when it was involved in an accident near Americus, Georgia. The pilot and the pilot-rated passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot’s son, the pilot was heading to Experimental Aircraft Association AirVenture Oshkosh, in Oshkosh, Wisconsin, which began on July 22 and ended on July 28. The airplane departed Jimmy Carter Regional Airport (ACJ), Americus, Georgia, about 0547 in night instrument meteorological conditions (IMC); no flight plan was filed. Radar data provided by the Federal Aviation Administration (FAA) showed the airplane's radar track as six radar targets over a span of 1 minute, with the targets 12 seconds apart. A line connecting each target, as well as the accident site, depicted a 180° left arc. The first target was located about 1,700 ft beyond the departure end of runway 5 (468 ft elevation) at 900 ft mean sea level (msl), 432 ft above ground level. The airplane's second target was at 1,200 ft msl, the next three targets were about 1,300 ft msl, and the final target was about 1,100 ft msl. The pilot and passenger did not communicate with air traffic control during the accident flight. According to a witness who lived across the road from the farm where the airplane crashed, he heard the sound of an airplane engine about 0550. He indicated that it was cloudy and still dark outside. In addition, he stated that he used to work around agricultural airplanes and that the accident airplane sounded similar to when an agricultural airplane is turning and the engine whines. He said the engine was "whining really loud," and then he heard an explosion. PERSONNEL INFORMATIONAccording to FAA airmen records, the pilot held a commercial pilot certificate with ratings for airplane single-engine land, airplane single-engine sea, and instrument airplane. In addition, he also held a mechanic certificate with ratings for airframe and powerplant. At the time of the pilot’s last aviation medical examination in April 2018, he reported 300 hours flight time within the 6 months before the examination. According to FAA airmen records, the pilot-rated passenger held a commercial pilot certificate with ratings for airplane single engine land and instrument airplane. In addition, he held a mechanic certificate for airframe, powerplant, and inspection authorization ratings. At the time of the pilot-rated passenger’s last aviation medical examination in April 2018, he reported 1,850 hours total hours of flight experience, of which 48 hours of flight time within the 6 months before the examination. AIRCRAFT INFORMATIONAccording to the airplane’s maintenance logbooks, the most recent annual inspection was completed on April 3, 2018, at 1,767.2 total aircraft hours. The last three annual inspections were completed about every other year. METEOROLOGICAL INFORMATIONThe 0550 recorded weather observation at ACJ, which was located about 2 miles south of the accident site, included an overcast ceiling at 500 ft, and wind from 050° at 5 knots. The visibility was 10 miles, the temperature was 22° C, the dew point was 21° C, and the altimeter setting was 29.95 inches of mercury. According to the Astronomical Applications Department at the United States Naval Observatory, the beginning of civil twilight was at 0619, and sunrise was at 0646 and the beginning of civil twilight was at 0619. At 0445, the National Weather Service Aviation Weather Center issued an updated AIRMET Sierra, which advised of IMC with ceilings below 1,000 ft, visibility below 3 statute miles, precipitation, and mist. Data from the Geostationary Operational Environmental Satellite number 16 indicated that the approximate cloud-top height over the accident site was 6,500 ft msl about the time of the accident. The pilot did not request or receive a weather briefing through Leidos or ForeFlight. It is unknown if he checked or received any additional weather information before or during the accident flight. AIRPORT INFORMATIONAccording to the airplane’s maintenance logbooks, the most recent annual inspection was completed on April 3, 2018, at 1,767.2 total aircraft hours. The last three annual inspections were completed about every other year. WRECKAGE AND IMPACT INFORMATIONThe airplane came to rest on a farm at an elevation of 477 ft, and all major components were accounted for at the scene. The wreckage path was about 400 ft long, oriented about a 180° heading. An initial tree strike was observed about 34 ft above the ground. The initial ground scar was observed about 50 ft beyond the tree strike, and the airplane came to rest about 75 ft beyond the initial ground scar. Several trees along the debris path were damaged by fire and wilted consistent with fuel blight. The airframe and flight control surfaces were highly fragmented. The rudder pedals and control yokes were impact separated from their mounts in the cockpit, but control cable continuity was confirmed from the cockpit to attachments and bellcranks associated with flight control surfaces through overload breaks and cuts by first responders. The horizontal situation indicator and attitude indicator were impact separated and found along the wreckage path. They were disassembled and displayed rotational scoring on their respective gyros and housings. The Cirrus Aircraft Parachute System was examined, and the safety pin, with its "Remove Before Flight" banner attached, remained installed in the deployment handle. The parachute remained in its deployment bag, and the suspension lines and risers were draped over a tree in the direction of the main wreckage. The engine was separated from the airframe, and the crankcase was split down its spine. Crankshaft continuity was confirmed from the forward section of the engine to the accessory section. All connecting rods were still attached to their respective journals. The No. 6 connecting rod was separated from the piston, but the piston pin was not damaged. The torsion dampers were still attached to the crankshaft with all pins. The Nos. 1, 3, 5, 2, and 4 cylinders remained attached to the crankcase, and the fins exhibited impact damage. The No. 6 cylinder remained attached to the crankcase, but the cylinder head was impact separated from the barrel. Examination of the valves and piston domes revealed normal wear and combustion deposits with no anomalies noted. Both magnetos were separated from the engine but could not be tested due to impact damage. The impulse couplings operated when rotated by hand. The oil filter was impact separated from the engine. The oil filter was dated "7/7/17" and had a Hobbs time of "1,760.8." It was disassembled, and no metallic debris was noted in the oil filter. The constant speed propeller was separated from the airplane, but all three propeller blades remained attached to the hub. The propeller blades each displayed similar twisting, bending, and chordwise scratching. There were no anomalies noted with the airplane that would have precluded normal operation. ADDITIONAL INFORMATIONRisk Management Handbook (FAA-H-8083-2) According to Chapter 5, Aeronautical Decision-Making: A Basic Staple, "In get-there-itis, personal or external pressure clouds the vision and impairs judgment by causing a fixation on the original goal or destination combined with a total disregard for alternative course of action." Pilot's Handbook of Aeronautical Knowledge (FAA-H-8083-25B) According to Chapter 2, Aeronautical Decision Making, the anti-authority attitude "is found in people who do not like anyone telling them what to do. In a sense, they are saying 'No one can tell me what to do.' They may be resentful of having someone tell them what to do or may regard the rules, regulations, and procedures as silly or unnecessary." According to Chapter 17, Aeromedical Factors, "spatial disorientation specifically refers to the lack of orientation with regard to the position, attitude, or movement of the airplane in space." In addition, it stated that "a rapid acceleration, such as experienced during takeoff, stimulates the otolith organs in the same way as tilting the head backwards. This action may create what is known as the 'somatogravic illusion' of being in a nose-up attitude, especially in conditions with poor visual references. The disoriented pilot may push the aircraft into a nose-low or dive attitude." MEDICAL AND PATHOLOGICAL INFORMATIONThe Division of Forensic Sciences, Georgia Bureau of Investigation performed the autopsies on the pilot and passenger. The autopsy reports indicated the cause of death for the pilot and the passenger as multiple blunt force trauma. The FAA Forensic Sciences Laboratory performed toxicology testing of the pilot’s tissue specimens and detected N-propanol and 94 mg/dL of ethanol in the muscle. The FAA Forensic Sciences Laboratory performed toxicology testing of the passenger’s tissue specimens and detected N-butanol, N-propanol, and 64 mg/dL of ethanol in the muscle and 24 mg/dL of ethanol in the lung.

Probable Cause and Findings

The pilot’s decision to depart in dark instrument meteorological conditions, which resulted in spatial disorientation and subsequent loss of airplane control. Contributing to the accident was the pilot’s and pilot-rated passenger’s self-induced pressure to complete the flight and the pilot’s anti-authority attitude.

 

Source: NTSB Aviation Accident Database

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