Tomball, TX, USA
N420SS
Cirrus Aircraft SR22
The pilot was in the process of receiving transition flight training after he accepted delivery of his factory-new airplane earlier in the week. On the morning of the accident, the pilot told his factory flight instructor that he did not feel well, and the decision was made to fly cross-country to the pilot’s homebase instead of continuing his transition training at the delivery center. The flight approached the intended destination when about 1 minute before the accident, about 988 ft above ground level (agl) and 2.26 nautical miles (nm) from the runway displaced threshold, there was a total loss of fuel flow and subsequent loss of engine power. About 15 seconds later, 860 ft agl and 1.8 nm from the displaced threshold, the automatic flight control system (AFCS) was turned off and remained off for the remainder of the flight. With the AFCS disengaged, the flight crew continued the descent toward the runway under manual flight control and in visual meteorological conditions. The position of the power (throttle) lever and mixture control were not recorded parameters. However, based on recorded manifold pressure indications, the throttle was decreased once and then increased twice after the total loss of engine power. The first, partial, increase of throttle occurred about 31 seconds after the loss of engine power as the airplane descended through 602 ft agl about 1.49 nm from the runway displaced threshold. This first throttle increase was likely when the pilot attempted to increase engine power to increase the airplane’s airspeed at his flight instructor’s request. The second throttle increase, likely to the full throttle position, occurred about 42 seconds after the loss of engine power as the airplane descended through 407 ft agl about 1.23 nm from the runway displaced threshold. The airplane impacted trees and terrain about 20 seconds after the second throttle increase and came to rest in a wooded mobile home neighborhood. The second throttle increase likely was when the flight instructor became aware of the loss of engine power and assumed control of the airplane from the pilot. However, when the flight instructor advanced the throttle to full forward, the airplane was at least 200 ft below the minimum altitude threshold (600 ft agl) for a normal Cirrus Airframe Parachute System (CAPS) deployment. CAPS training documentation and pilot operating handbook (POH) guidance recommend the immediate deployment of CAPS if no other survivable alternative exists. At no point after the total loss of engine power did the airplane have sufficient altitude to glide to the runway. Based on recorded data, there was ample fuel in both fuel tanks at the time of the accident. A postaccident examination revealed no evidence of obstructions or debris in the fuel system. The 90° elbow inlet fitting to the electric fuel pump was found separated at the accident site. Based on a laboratory analysis, the 90° elbow inlet fitting separated during ground impact and, as such, did not contribute to the sudden loss of fuel flow to the engine. Examination of the engine and related systems did not reveal any mechanical malfunctions or failures that would have precluded its normal operation. Although residual fuel dye was observed on the external surface of the elbow fitting adjacent to its socket-side opening and suggested the possibility of a preexisting fuel leak, the laboratory examinations determined that this likely was not due to a fuel leak, but rather fuel dye that soaked into and was retained by a residual silicone film on the socket-side of the fitting postaccident. Although the silicone film covered both the tube and socket sides of the joint, the blue fuel dye was only observed on the socket-side. The lack of fuel staining on both sides of the joint further supports that the 90° elbow inlet fitting separated during ground impact. Review of the recorded engine data did not reveal erratic engine operation typically associated with a loss of engine power due to fuel starvation or exhaustion. Postaccident flight testing revealed that when the mixture control was moved full aft to the idle cutoff position with the electric fuel pump off, the decrease in fuel flow closely matched the recorded data from the accident flight. The flight testing also revealed that if the mixture control was moved full aft to the idle cutoff position with the fuel pump on, the engine would have continued to operate but with noticeable roughness. In the absence of any mechanical failure or obstruction of the fuel system, and with ample fuel onboard, it is likely the mixture control was inadvertently moved to idle cutoff during the descent with the electric fuel pump off, which resulted in the sudden and total loss of fuel flow to the engine. The investigation focused on how two appropriately certificated pilots, one of which was a factory flight instructor, did not adequately identify the total loss of engine power for the nearly one minute it took from the loss of fuel flow to impact, despite being visible on the airplane cockpit instrumentation, and detectable as a decrease in airplane performance. The investigation determined it is likely that both pilots were distracted and unaware of the loss of engine power for different reasons including inexperience in the airplane make/model, illness and physiological distress, and a lack of effective communication between the pilot and the flight instructor. The flight instructor was a new employee who had recently completed the transition training and obtained his Cirrus Standardized Instructor Pilot (CSIP) qualification. The flight instructor had no previous experience in Cirrus airplanes before he was hired as a factory flight instructor about 4 months before the accident. The consensus from all the factory instructors interviewed was that while the accident flight instructor did require additional time and performed slightly below average in comparison to other new hires in training, he did ultimately perform to a satisfactory level and was proficient enough to work with customers. The flight instructor was likely in physiological distress during the flight, which distracted him from maintaining situational awareness as the flight approached the destination. According to the pilot and the passenger, shortly after departing on the accident flight, the flight instructor stated that he had to urinate. It was the pilot’s perception that the flight instructor was in discomfort during the latter stages of their flight for this reason. Being under any sort of physiological stress would have diminished the flight instructor’s ability to perceive the environment around him and would have diverted his attention away from the task at hand. Divided or diverted attention makes it difficult to detect and correctly interpret stimuli, which in turn affects the decision-making process. Additionally, distraction can prevent a person from either identifying or properly attending to important information. The pilot was inexperienced in the airplane and was operating under the assumption that the flight instructor was the one who was ultimately responsible for the flight, thereby shedding some of the heightened level of awareness typically required to safely fly the airplane. The pilot was also not feeling well (he was diagnosed with COVID-19 after the accident), which was the primary reason that they were returning to his homebase and not continuing his training at the delivery center. Numerous studies have been conducted on how being sick might affect cognitive performance, and how fatigue (a common side effect of being sick) affects performance. Researchers liken both to a level of impairment similar to what one might expect from being intoxicated. Common results are loss of memory, inattention, lack of alertness, and poor judgment and decision-making. When interviewed, the pilot was not aware that there was a loss of engine power. The pilot stated that the flight instructor did not ask him to verify control positions or troubleshoot anything in the moments before the accident, nor did they discuss any anomalies with the airplane or if they should deploy the CAPS. As such, it is likely that the flight instructor was not immediately aware of a loss of engine power. The pilot stated that he believed the engine was operating at the time of the accident, but thought it was odd that he did not hear the engine “roar” with power after the flight instructor further increased the throttle. It is likely that the aural cues associated with engine operation were already diminished due to the already low engine power setting used during the approach and because they were wearing noise-canceling headsets. For both pilots, it is highly likely that they were susceptible to the cognitive bias of plan continuation error. Once they were within proximity of their destination, their desire to achieve their goal would have directly affected their decision making and ability to maintain positive situational awareness. In addition, they would have also been susceptible to change blindness, meaning cues that were there for the senses to detect could have gone unnoticed. As a result, neither pilot noticed the loss of engine power until the airplane’s altitude and airspeed decreased noticeably and the reaction time they required to rectify the loss of engine power or deploy CAPS decreased to a critical level. The investigation determined that the purpose for the accident flight was not effectively communicated between the flight instructor and the pilot. The pilot believed the flight instructor was the pilot-in-command (PIC) for the cross-country flight although he admitted they never had a conversation to confirm that presumption. Further, to satisfy the airplane’s insurance coverage PIC requirements, the pilot was required to complete an instrument proficiency checkride or “flight school” in the same make/model as the accident airplane, but neither of those tasks were completed before the accident flight. The pilot stated that before they departed on the flight, he and the instructor did not communicate what roles each would have should an emergency arise. The absence of a predetermined plan likely led to confusion as to who was responsible for taking that next critical step once placed in the emergency. When interviewed, most of the factory flight instructors or supervisors stated that if the customer had not completed standardization training, the factory flight instructor would act as PIC and would have ultimate responsibility for the safety of the flight (including emergency situations requiring CAPS deployment). Based on their decision to return to the pilot’s homebase due to the pilot feeling unwell (instead of remaining at the delivery center to complete his transition training), the investigation concluded that the flight instructor was acting as PIC during the accident flight and ultimately responsible for the safety of the flight. The impact resulted in a loss of occupiable volume when the structure above the occupants was peeled away and the structure between the front crew seats and aft passenger seats was disrupted. Both the pilot and rear seat passenger remained restrained and only suffered non-life-threatening injuries. During the accident sequence, the front right crew seat separated from the airplane and the flight instructor was ejected from the seat. His fatal multiple blunt force injuries were consistent with impacts with trees and/or the ground. Neither of the surviving occupants could confirm whether the flight instructor was wearing his restraint properly at the time of the accident. The airbag deployed and the four-point restraint system was found intact, undamaged, and functional but unlatched. It was noted that the lap portion of his restraint had anti-rattle plugs installed in the incorrect position on the buckle side, and that the webbing routed through the buckle’s load bar was twisted. However, there were no witness marks such as rubbing, discoloration or fraying of the webbing that would indicate that the belt was pulled through the buckle rapidly. Additionally, there were no loading indicators on the webbing stitching. The buckle functioned normally when tested after the accident. Based on the buckle examination, is unlikely that the incorrect position of the anti-rattle plugs contributed to the right front seat occupant’s injuries or death. Additionally, the investigation was unable to determine if the flight instructor’s seat restraint buckle being unlatched occurred before or during the accident sequence.
HISTORY OF FLIGHTOn September 1, 2022, about 1707 central daylight time, a Cirrus Aircraft SR22 airplane, N420SS, was substantially damaged when it was involved in an accident near Tomball, Texas. The flight instructor was fatally injured; the pilot and passenger sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. Earlier in the week, on August 29, 2022, the pilot accepted delivery of his factory-new Cirrus SR22 airplane at the Cirrus Aircraft Vision Center located at the McGhee Tyson Airport (TYS), near Knoxville, Tennessee. He had no previous flying experience in a Cirrus airplane besides a 30-minute demonstration flight that was flown about 1.5 years before the accident. As part of his purchase agreement, the pilot was scheduled to receive transition training in his new airplane for the remainder of the week. The pilot’s first interaction with his assigned Cirrus Aircraft Factory Flight Instructor was the night before he accepted delivery of his airplane. During the phone call, the flight instructor asked what the pilot wanted to accomplish during his flight training, and the pilot replied that he needed to learn how to fly instrument approaches and to make takeoff and landings in the airplane. According to the pilot, his first flight in the airplane consisted of a takeoff, traffic pattern, and landing. No flight instruction was provided during this initial 10 to15 minute delivery flight that was completed with another Cirrus Aircraft pilot. After the pilot accepted delivery of his airplane, the assigned flight instructor began the pilot’s transition training. The first task completed was to review operating parameters for and demonstrate how to use the Cirrus Airframe Parachute System (CAPS) using a simulator. Afterwards, they reviewed the airplane’s fuel and electrical systems on a whiteboard and introduced the Cirrus Perspective+ integrated avionics system using a tabletop simulator. On August 30, 2022, the pilot and his flight instructor began flight training in his airplane. Before their flight they discussed how to preflight the airplane. Due to engine power restrictions (maintain at least 75% power) for a new airplane, they were unable to conduct traffic pattern work and the pilot felt they “couldn’t really learn anything” that he hoped to achieve on the flight. Instead, they focused on using the Cirrus Perspective+ system. The pilot stated that the flight instructor did not provide more feedback on how to fly the airplane, such as providing the different airspeeds to be flown during the different phases of flight. When interviewed, the pilot expressed his concern that Cirrus Aircraft “didn’t have some syllabus for me” dictating what he was to learn each day. On August 31, 2022, the weather at TYS was windy, so the pilot asked his flight instructor if they could fly to an uncontrolled airport where they could work on flying the airplane in the traffic pattern and practice takeoff and landings. According to the pilot, it was during this flight that the flight instructor first provided the reference airspeeds for downwind, base, and final approach. The pilot stated that he placed a note with the reference airspeeds on the cockpit dashboard. The pilot stated that before the fourth day of transition training, he woke up overnight shivering and sweating. On the morning of September 1, 2022, the pilot told his flight instructor that he did not feel well, and the decision was made to fly to the pilot’s homebase located at David Wayne Hooks Memorial Airport (DWH), Spring, Texas. Based on interviews, it was not clear with whom the pilot would have continued his transition training after returning to his homebase. Cirrus Aircraft’s Chief Pilot stated the pilot would have likely resumed training with a local Cirrus Standardized Instructor Pilot (CSIP), while the pilot was under the impression that he would have continued with the factory flight instructor if he was feeling better the next day. The flight instructor had not planned on flying to DWH and, as such, he had to reschedule some other work obligations and kennel his dog for at least one night. The pilot stated that before they departed on the cross-country flight, he and the instructor did not communicate what roles each would have should an emergency arise during the flight. The first flight leg was supposed to be from TYS to Alexandria International Airport (AEX), Alexandria, Louisiana. However, due to adverse weather that impacted their intended route, the flight diverted to Monroe Regional Airport (MLU), Monroe, Louisiana. The pilot stated that the flight instructor appeared to briefly fall asleep during the flight from TYS to MLU. The pilot stated that he flew most of the flight with the airplane’s automatic flight control system (AFCS) engaged, making necessary heading changes using the heading bug on the primary flight display (PFD). The pilot stated the airplane was topped-off with fuel after landing at MLU and that they were on the ground for about 30-45 minutes, during which the pilot and the passenger each drank a cup of coffee, and the flight instructor drank a soda. The pilot stated that shortly after they departed MLU, about 10 minutes into the flight, the flight instructor told him that he needed to urinate. The pilot offered the flight instructor one of his “Little John” pilot urinals, but the flight instructor declined to use the urinal. The pilot stated that the flight instructor appeared to be in discomfort (shifting around in his seat and grimacing) for the remainder of the flight and did not speak much or provide any feedback until they got closer to DWH. The pilot stated that the airplane’s AFCS was engaged for most of the flight from MLU to DWH, and that he used the heading bug on the PFD to make any heading changes that were issued by air traffic control. The flight was on an instrument flight rules flight plan, and the controller issued several vectors to keep the airplane clear from areas of adverse weather. As the flight approached DWH, the pilot listened to the Automatic Terminal Information Service broadcast and selected the RNAV runway 17R instrument approach at DWH using the Cirrus Perspective+ system, but he was unsure if he activated the approach. While the flight tracked north toward Conroe, Texas, the controller asked if they wanted the full RNAV runway 17R approach or the visual approach to runway 17R. The flight instructor replied to the controller that he wanted the visual approach to runway 17R. The pilot told his flight instructor that he had never flown a visual approach before and asked how to use the Cirrus Perspective+ system during this type of approach. The flight instructor then showed the pilot how to “scroll-down” on the display to see data associated with a visual approach. When interviewed, the pilot stated that he did not know how the visual approach was supposed to work in the Cirrus Perspective+ system and that he was confused that there was no altitude step downs or waypoints visible after the visual approach was selected. The controller issued a heading to intercept the final approach course to runway 17R at DWH, cleared the flight for the visual approach, and told the pilots to contact the DWH tower controller. The pilot stated that he saw the runway and its associated precision approach path indicators (PAPI) lights after the airplane turned onto the final approach course and that the airplane appeared to be on a proper descent path to the runway. The airplane’s airspeed began to decrease as the flight continued toward the runway, and the flight instructor told him to “give it some throttle” to increase airspeed. The pilot increased the throttle slightly but noted that he did not hear the engine “roar” with power. The flight instructor stated “My airplane” or “I’ve got the controls” shortly after the pilot increased the throttle. The pilot estimated “a few seconds” transpired between his increase of throttle and when the flight instructor took control of the airplane. The pilot stated that after the flight instructor took control of the airplane, the airplane descended below the proper glidepath where he could no longer see the PAPI system or the runway. The pilot stated that in the moments before the accident the flight instructor rolled the airplane into a left-wing-down attitude, likely trying to maneuver the airplane into a clearing left of the airplane’s position. The airplane impacted several trees before it came to rest in a wooded mobile home neighborhood. When asked, the pilot did not recall completing the pre-landing checklist but stated that he believed it was something that would have been completed before the accident. Additionally, he could not specifically recall individual positions of the throttle, mixture control, and fuel selector at the time of the accident; however, he recalled the ignition/magneto switch was positioned to both. The pilot stated that he believed the airplane’s automatic flight control system (AFCS) was still engaged when the flight instructor took control of the airplane. The pilot stated that the flight instructor did not ask him to verify control positions or troubleshoot anything in the moments before the accident, nor did they discuss any anomalies with the airplane or if they should deploy the CAPS. The pilot stated that he believed the engine was operating at the time of the accident, but thought it was odd that he did not hear the engine “roar” with power after the flight instructor took control of the airplane and increased the throttle. The pilot, flight instructor, and passenger were wearing noise-canceling headsets during the flight. The pilot did not recall completing any emergency action procedures before impact. Further, the pilot reported that he did not interfere with, nor did he remember the instructor interfering with the fuel mixture control throughout the latter duration of the flight. He stated that a tablet was strapped to his knee and a cell phone was in the seat pocket. Likewise, according to the pilot, the flight instructor did not have any items that could interfere with the operation of the airplane. A review of recorded data downloaded from both the airplane’s Cirrus Perspective+ system and Recoverable Data Module, along with recorded ATC communications, revealed that the flight received radar vectors to join the visual approach to runway 17R at DWH, as shown in Figure 1. At 1701:36, the flight was cleared for the visual approach and told to contact the DWH tower controller. At 1703:51, the tower controller cleared the flight to land on runway 17R. The airplane’s AFCS was engaged during the earlier portions of the approach, and the flight crew used vertical speed mode to descend to and level off at specified intermediate altitudes based on a lateral navigation only (LNAV) instrument procedure, as shown in Figure 2 and Figure 3. Additionally, according to the recorded data, there were several engine power changes (increases/decreases) made during the approach. Figure 1 – Plot of the airplane ground track. Figure 2 – Plot of airplane altitude, ground speed, true airspeed, indicated airspeed, and vertical speed. Figure 3 – Plot the airplane’s descent profile during the visual approach. Based on recorded data from the airplane, beginning at 1705:58, there was a loss of fuel flow to the engine, as shown in Figure 4, as the airplane continued in a descent toward runway 17R in visual meteorological conditions, as shown in Figure 5. At that time, the airplane was about 1,126 ft msl (988 ft agl) and 2.26 nm from the runway 17R displaced threshold. About 16 seconds after the loss of engine power, the AFCS was turned off and remained off for the remainder of the flight. With the AFCS disengaged, the flight crew continued the descent toward the runway under manual flight control. Figure 4 – Plot of engine speed, EGT, engine power, fuel flow, and manifold pressure. Figure 5 – Plot of the airplane’s descent path at the end of the flight. Based on recorded engine manifold pressure values after the total loss of fuel flow to the engine, the power (throttle) lever was decreased once and then increased twice. The first, partial, increase of throttle began at 1706:29 as the airplane descended through 738 ft msl (602 ft agl) about 1.49 nm from the runway 17R displaced threshold. About 11 seconds later, there was a second throttle increase, likely to the full throttle position, as the airplane descended through 544 ft msl (407 ft agl) about 1.23 nm from the displaced threshold. According to the recorded data, at 1706:50, about 394 ft msl (258 ft agl) and 1.01 nm from the displaced threshold, the wing flaps were retracted from 50% to 0%, as shown in Figure 2. About 6 seconds later, the stall warning tone activated as the airplane decelerated below 82 knots indicated airspeed (KIAS). At 1707:00, the final recorded data, indicated that the airplane had descended to 214 ft msl (76 ft agl) and decelerated to 74 KIAS. According to the Cirrus SR22 Pilot Operating Handbook (POH), the airplane’s wings-level aerodynamic stall at maximum gross weight is 74 KIAS. The airplane subsequently impacted trees and terrain about 0.76 nm from the runway 17R displaced threshold. PERSONNEL INFORMATIONFlight Instructor A comprehensive flight record for the flight instructor was not located during the investigation. On March 17, 2022, the flight instructor reported 697 total flight hours when he submitted his application for employment with Cirrus Aircraft. Based on Cirrus Aircraft’s flight records, on April 20, 2022, the flight instructor flew 1.2 hours in a Cirrus SR22 airplane in conjunction with his interview for a Cirrus Factory Flight Instructor position. Besides the interview flight, the flight instructor did not have any flight time in a Cirrus airplane nor was he qualified as a Cirrus Standardized Instructor Pilot (CSIP) before he was hired by Cirrus Aircraft in May 2022. While employed by Cirrus Aircraft, the flight instructor flew 109.4 hours, of which 44.9 hours were dual-instruction-received in conjunction with his Cirrus SR22 transition training and CSIP qualification. On July 1, 2022, the flight instructor received his CSIP qualification following a successful 1.7-hour checkride administered by another Cirrus Factory Flight Instructor. While employed by Cirrus Aircraft, the flight instructor flew 14.2 hours as pilot-in-command in support of internal company flight operations and provided 48.6 hours of dual-flight-instruction to four customers, including the accident pilot. The investigative team interviewed several factory flight instructors who were responsible for training the accident flight instructor to perform his duties with Cirrus Aircraft’s customers. The training included three phases; transition training in the Cirrus SR22, an intermediate phase to gain additional flight experience in the SR20/22 airplane while supporting internal company flight operations, and finally the completion of CSIP training. The primary instructor pilot responsible for the training noted that the accident flight instructor had difficulties in progressing through the Cirrus SR22 transition training program. Documented in training records were concerns about the accident flight instructor maintaining situation awareness while operating in areas of high traffic (Class B airspace), maintaining positive control (i.e. “staying ahead”) of the airplane in dynamic situations, and decision-making regarding CAPS deployment. The primary instructor pilot stated that after 23.9 hours of dual instruction completed over a 9-day period, he felt the accident flight instructor was not ready to fly solo and required additional training once a relocation to the Cirrus Aircraft Vision Center in Knoxville, Tennessee, could occur and before the trainee would be ready to transition to the company’s CSIP training. The accident flight instructor’s training records also listed difficulties with managing airplane automation and airplane handing. The consensus from the instructors interviewed was that while the
The flight instructor’s inadequate supervision of the flight, which allowed for an unintentional movement of the mixture control to the cutoff position that remained unnoticed until the airplane lost engine power due to fuel starvation and descended below the minimum altitude required for a normal deployment of the airframe parachute system. Contributing to the accident was the impairment of the pilot due to his illness, the flight instructor being distracted by his physiological distress, and the apparent lack of communication between the pilot and flight instructor about who was responsible for the safety of the flight, all of which created a situation where neither individual was adequately monitoring the engine operation during a critical phase of flight.
Source: NTSB Aviation Accident Database
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