Monday, August 01, 2011

Cirrus SR20, Anansi Aeronautics LLC, N365DP: Accident occurred July 29, 2011 in Fredonia, Arizona

http://registry.faa.gov/N365DP

http://www.shashek.com

NTSB Identification: WPR11FA354 
14 CFR Part 91: General Aviation
Accident occurred Friday, July 29, 2011 in Fredonia, AZ
Probable Cause Approval Date: 06/28/2012
Aircraft: CIRRUS SR20, registration: N365DP
Injuries: 2 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

The airplane collided with terrain while maneuvering in dark night visual meteorological conditions while on the third leg of a 1,665 nautical mile (nm) cross-country flight. The airplane, with the pilot/owner and a pilot-rated passenger aboard, had departed the east coast in the morning and had been en route for about 16 hours. It could not be determined which of the two pilots was manipulating the flight controls at the time of the accident. The planned length of the last leg of the flight was 660 nm, which was about equal to the airplane’s calculated maximum range for a no wind condition with a 45 minute reserve. Radar data revealed that during the last few minutes of the flight, the airplane changed course several times toward different nearby airports. These heading excursions were most likely due to a decision by the pilots to divert to an alternate airport after realizing that the destination airport could possibly be beyond the current range of the airplane. The last radar return was about 0.1 nm south of the accident site, which was located in a remote, sparsely populated area. Examination of the accident site revealed signatures, including tree strikes and wreckage distribution, consistent with controlled flight into terrain. Postaccident examination of the engine and airframe revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. It is likely that the pilots lost situational awareness and failed to maintain terrain clearance. Conditions conducive to controlled flight into terrain included fatigue due to the pilots’ long duty day, the dark night light condition, the lack of ground lighting in the region, and the fact that neither pilot was instrument rated.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The non-instrument-rated pilots’ loss of situational awareness during a dark night flight over a remote area, which resulted in their failure to maintain an altitude sufficient to ensure adequate terrain clearance. Contributing to the accident was the pilots’ fatigue due to their long duty day.


HISTORY OF FLIGHT

On July 29, 2011, about 2100 mountain standard time, a Cirrus Design Corp SR20, N365DP, was substantially damaged after impacting terrain while maneuvering about 30 nautical miles (nm) southwest of Fredonia, Arizona, in the Kaibab National Forest. Both the private pilot and registered owner of the airplane, and commercial pilot/passenger, sustained fatal injuries. The flight was conducted under the provisions of 14 Code of Federal Regulations Part 91 as a personal cross-country flight. Visual meteorological conditions (VMC) prevailed at the time of the accident, and no flight plan had been filed. The flight departed from the Rock Hill Airport-Bryant Field (UZA), Rock Hill, South Carolina, about 0800 eastern daylight time (EDT), with its destination being the Henderson Executive Airport (HND), Henderson, Nevada.

A family member of the private pilot reported to the National Transportation Safety Board investigator-in-charge (IIC), that the purpose of the flight was to reposition the airplane from UZA to HND. The family member further reported that she thought the flight departed UZA about 0800 EDT on the morning of the accident, but wasn’t entirely sure of the precise time. The family member stated that she spoke with the pilot that afternoon, who reported that he was refueling in Stillwater, Oklahoma, and would be arriving HND about 2130 or 2200 Pacific daylight time (PDT) that evening. The family member revealed that after falling asleep and awakening about 0300 PDT the next morning and realizing that the flight had not returned, she became very concerned and began making phone calls in an effort to locate the pilots.

A family member of the commercial pilot reported to the IIC that the majority of her conversation with the pilot was basically of a personal nature, with very little of the conversation regarding the trip itself. However, she did provide a communication timeline relative to the personal texting she and the pilot conducted while he was en route (all times are Pacific daylight times):

7:00 am received text stating he was on the move
9:41 am received two texts stating he was in Tennessee and Arkansas
10:41 am about eating in Arkansas in a 737 [restaurant]
11:48 am: stating “off we go”
4:50 pm: voicemail saying they were leaving from Guymon after getting food and gas
5:57 pm: text stating he was about to pass Taos, New Mexico
8:23 pm: text mentioning it was slow going, still 90 min[utes] out
8:45 pm: texting personal information, about 10 texts until she did not receive any more
(7 min or so worth of texting if she were to estimate)

Law enforcement personnel reported to the IIC that in a conversation with a family member of the private pilot, the family member stated that the flight had departed from UZA at 0800 EDT. The family member further stated that the airplane had landed somewhere in the Oklahoma panhandle to refuel. The family member revealed that the commercial pilot called a family member at 2023 and said that they were going to refuel somewhere in Arizona before proceeding to HND. She added she thought that the commercial pilot had sent a text message to the family member at 2045.

Law enforcement personnel reported to the IIC that in a conversation with a family member of the commercial pilot, she had received a text message from him stating that they planned to land at HND by 2130. The family member added that it was her belief that the airplane had not landed anywhere else to refuel after leaving Oklahoma.

An alert notification (ALNOT) was issued by the Prescott Flight Service Station, Prescott, Arizona, about 0800 MST on the morning of July 30. The airplane wreckage was subsequently located that morning about 1000, 31 nm southeast of Fredonia, Arizona.

It was determined by fuel receipts and witness statements that after departing UZA, the airplane landed at the Walnut Ridge Airport (ARG), Walnut Ridge, Arkansas, at about 1330 central daylight time (CDT); the distance between UZA and ARG was about 486 nm. After landing, the airplane was refueled by the pilot using the self-service fuel island with 50.1 gallons of aviation fuel; according to Cirrus Aircraft, the total usable fuel for the SR20 is 56.0 gallons. Witnesses reported that the airplane departed ARG about 1400 CDT.

After departing ARG, the airplane proceeded westbound to the Guymon Municipal Airport (GUY), Guymon, Oklahoma; the arrival time could not be determined during the investigation. The distance between Walnut Ridge, Arkansas and Guymon, Oklahoma is about 512 nm. Guymon airport personnel stated that they didn’t think the pilots had eaten at the airport during their stopover, but they were not certain. A fuel receipt did indicate that the airplane was refueled with 44.2 gallons of aviation fuel, time stamped at 1851 CDT. Airport personnel did say that they thought the airplane departed about 1900 CDT.

Radar data provided by the 84 RADES, Hill Air Force Base, Ogden, Utah, revealed the last 26 minutes of the accident flight covered a distance of 58 nm. During this period of time, the airplane was transmitting a 1200 transponder code, but was not transmitting MODE C (altitude) reporting information.

From 20:28:55 to 20:54:10 (25 minutes, 15 seconds), data indicated that the airplane was flying a magnetic heading of 244 degrees with an average ground speed of 132 knots.

At 20:54:10, radar data indicated the airplane turned right approximately 16 degrees, followed by an approximately 50-degree turn to the left 36 seconds later.

From 20:54:47 to 20:55:24 (37 seconds), radar data indicated that the airplane’s magnetic heading was 210 degrees with an average ground speed of 116 knots. This heading was determined to be in line with the Kingman Airport (IGN), Kingman, Arizona, which was located about 115 nm from the airplane’s position at the time of the turn.

From 20:55:24 until the last radar return at 20:55:36 (12 seconds), radar data revealed that the airplane had turned right about 90 degrees to a northwest heading. This heading was in line with the Kanab Airport (KNB), Kanab, Utah, which was located 34 nm northwest of the last radar return.

The accident site was located about 0.1 miles north of the last radar return in the Saddle Mountain Wilderness of the Kaibab Plateau, a sparsely populated area about 20 nm north of the Grand Canyon National Park’s north rim. The airplane had impacted high standing trees at an elevation of about 8,900 feet msl, on a measured magnetic heading of 355 degrees. The energy path extended along the impact heading for about 385 feet, and extended over a lateral distance of about 110 feet.

Subsequent to an on site survey of the wreckage and the surrounding area, the airplane was recovered to a secured storage facility in Phoenix, Arizona, for further examination.

PERSONNEL INFORMATION

The private pilot, age 39, was the owner of the airplane and possessed a private pilot certificate with a rating for airplane single-engine land. A review of Federal Aviation Administration (FAA) records revealed that the pilot received his private pilot certificate on April 13, 2008, in a Cessna 172 airplane. According to the Airman Certificate and/or Rating Application submitted to the FAA examiner prior to his private pilot check ride, the pilot listed a total flying time of 73.4 hours. During the investigation, the pilot’s personal logbook was not recovered, and as a result his time in make and model, as well as a breakdown of other pilot times was not determined.

A search of FAA records revealed that the pilot’s most recent application for his airman medical certificate was dated July 24, 2007, which was his initial medical examination for a student pilot certificate. A third-class FAA medical was approved on July 31, 2007, with 0 flight time noted.

The commercial pilot, age 32, possessed a commercial pilot certificate with airplane single-engine land, airplane multiengine land, and airplane single-engine sea ratings. The pilot’s commercial pilot certificate was issued on July 16, 2009, and his FAA third-class medical certificate on May 15, 2008. At the time of his application for the medical certificate, the pilot listed a total flying time of 400 hours. A family member related to the NTSB IIC that at the time of the accident the pilot’s total time was about 600 hours. No breakdown of the pilot’s flight time was determined, as his personal logbook was not available during the investigation.

AIRCRAFT INFORMATION

The Cirrus SR20, serial number 1062, was a four-place, low wing, fixed tricycle landing gear airplane, manufactured in 2000. A Continental Motors, IO-360-ES series, 210-horsepower, horizontally-opposed six-cylinder engine powered the airplane.

A review of the airplane’s maintenance records revealed that the airframe and engine’s most recent annual inspection was conducted on March 2, 2011, at a recorded HOBBS time of 2,468.0 hours. It was revealed during the inspection that the engine had accumulated 1,046.9 hours since its last overhaul. Additionally, maintenance records indicated that on March 22, 2011, the expired parachute and rocket motor were replaced with parachute CDC#14242-101, S/N 003130R1, and rocket motor CDC#26602-001, S/N 0197.

COMMUNICATIONS

A review of air traffic facilities revealed that there were no communications between the pilot and air traffic control on the day of the accident.

METEOROLOGICAL INFORMATION

At 2054 MST, the weather reporting facility at the Grand Canyon National Park Airport (GCN), Grand Canyon, Arizona, located about 34 nm south of the accident site, reported wind 210 degrees at 6 knots, visibility 10 miles, scattered clouds at 11,000 feet, temperature 22 degrees Celsius (C), dew point 11 degrees C, and an altimeter setting of 30.28 inches of mercury.

At 2054 mountain daylight time, the weather reporting facility at the Kanab Airport, Kanab, Utah, located about 36 nm northwest of the accident site, reported wind 340 degrees at 8 knots, visibility 10 miles, sky clear, temperature 27 degrees C, dew point 8 degrees C, and an altimeter setting of 30.15 inches of mercury.

At 2053 mst, the weather reporting facility at the Page Municipal Airport (PGA), Page, Arizona, which is located about 42 nm east-northeast of the accident site, reported wind 320 degrees at 3 knots, visibility 10 miles, sky clear, temperature 33 degrees C, dew point 3 degrees C, and an altimeter setting of 30.03 inches of mercury.

A review of the weather by an NTSB meteorologist indicated that there was no evidence of “cloud” below 16,000 to 17,000 feet in the area of the accident site. These bases were obtained from the GCN METAR, which indicated clouds from 10,000 to about 11,000 feet above ground level, and that the tops of the clouds were roughly 22,000 feet mean sea level. The meteorologist added that there were no pilot reports (PIREPS) in the area that he could account for, and that there was some rain in southwestern Utah. The meteorologist further added that the meteorological data he reviewed was consistent with an environment that would not have been conducive to meteorological clouds; it was too dry.

According to the U.S. Naval Observatory, Astronomical Applications Department, the phase of the moon on the evening of the accident was waning crescent with 1% of the Moon's visible disk illuminated. Moonset was at 1851 MST.

WRECKAGE AND IMPACT INFORMATION

An on site examination of the wreckage was conducted under the supervision of the NTSB IIC, who was accompanied by a representative from Cirrus Aircraft Design. A detailed survey of the wreckage revealed that all components necessary for flight were accounted for at the accident site.

The airplane was located at an elevation of 8,869 feet msl, at coordinates 36 degrees 30.870 minutes north latitude and 112 degrees 09.768 minutes west longitude. The first identified point of contact (FIPC) was a pine tree, with broken branches estimated to be about 55 feet up the approximately 65-foot tall tree. Paint chips were observed on the ground along the energy path in line with the second point of impact. The energy path was measured to be on a magnetic heading of 355 degrees.

A large pine tree with a piece of bark missing from its trunk was located 69 feet from the FIPC; there was also a piece of fiberglass imbedded in the tree trunk. Additionally, larger pieces of fiberglass, the right aileron, and green glass consistent with the right navigation light lens were located in the immediate vicinity of the tree. The tree scar was measured to be about 32 feet above ground level.

Approximately 140 feet from the FIPC, a shallow crater was observed with various airplane components in the immediate vicinity. Further north, about 190 feet from the FIPC, several trees and the ground were observed to have been blackened with soot and ashes from a post impact fire. The flaps, left aileron and half of an elevator were located in the next 100 feet leading up to the main wreckage. Remnants of spot fires were also observed.

The propeller was located approximately 280 feet from the FIPC, and was separated from the engine.

The main components of the front crew seats were located approximately 342 feet from the FIPC.

Pages from the Pilot Operating Handbook (POH) were the last items in the debris field, located about 385 feet from the FIPC.

The debris field was approximately 110 feet at its widest point near the main wreckage.

The cockpit and cabin areas were identified, and observed to have been consumed by fire and destroyed. No cockpit instrumentation was located for examination. The only component that was distinguishable at the wreckage site was the face of the altimeter, which read 30.47 inches of mercury and 1033 millibars of pressure.

The main wreckage was located approximately 255 feet from the FIPC. It consisted of a large section of the aft left fuselage, the FS222 bulkhead, and the empennage, to include the vertical and horizontal stabilizers with their associated flight control surfaces. The carry-through wing spar, flight control cables, engine, and the inboard section of the right side of the wing were also observed in this area.

The right wing was consumed by fire and impact damaged. A section of the right aileron, which was located about 120 feet southwest of the main wreckage, was bent and twisted, and exhibited no thermal damage. Its associated trim tab was not located. The right flap had separated from the wing, and was against a tree about 75 feet in line with the energy path and prior to the main wreckage. The flap was observed bent at a downward angle at about mid-span. The right wing fuel tank was consumed by fire.

The left wing was consumed by fire and impact damage. The left aileron was observed separated, and found against a tree about 45 feet along the energy path and prior to the main wreckage. The aileron was bent and twisted, and exhibited no signs of thermal damage. The wing’s flap was located just west of the energy path, and about 45 feet from the main wreckage. The flap was bent and twisted, with no signs of thermal damage noted. The left wing fuel tank was consumed by fire.

The empennage, which came to rest on the north edge of the main wreckage site, exhibited no signs of thermal damage. The rudder, elevators, and both horizontal stabilizers remained attached at various attach points. The rudder was observed split at mid-span. Both elevators sustained impact damage and deformation. Both stabilizers also sustained significant deformation. Elevator and rudder control cable continuity was confirmed.

The front cockpit seats and seat tracks were found separated from the airplane, and exhibited impact damage and fragmentation. The rear seats were also fragmented.

The nose landing gear attach point with the engine mount was located about 40 feet prior to the main wreckage site and in line with the energy path. The nose gear tire, which had separated from the landing gear structure, was found about 125 feet prior to the main wreckage site along the energy path.

Both main landing gear were identified at the accident site. The left gear had separated from the left wing, while the right main landing gear remained attached to its wing. Thermal damage was observed to the right main landing gear.

MEDICAL AND PATHOLOGICAL INFORMATION

On August 1, 2011, an autopsy was performed on the private pilot at the Coconino Health Department, Office of The Medical Examiner, Flagstaff, Arizona. The findings of the autopsy revealed that the cause of death was as a result of blunt force injuries.

The Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aeronautical Institute for the private pilot. The report indicated that tests for Carbon Monoxide and Cyanide were not performed, and that no Ethanol was detected in Muscle or Kidney. Loratadine was detected in the Lung and Kidney. Loratadine is an over the counter non-sedating antihistamine that is used to treat allergies, and not considered to pose a significant hazard to flight safety.

On August 1, 2011, an autopsy was performed on the commercial pilot at the Coconino Health Department, Office of The Medical Examiner, Flagstaff, Arizona. The findings of the autopsy revealed that the cause of death was as a result of blunt force injuries.

The Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aeronautical Institute for the commercial pilot. The report revealed that specimens were unsuitable for analysis of Carbon Monoxide; no Cyanide was detected in the blood, and no drugs were detected in the blood. The following values of Ethanol were noted in the report:

24 (mg/dL, mg/hg) Ethanol detected in Muscle
13 (mg/dL, mg/hg) Ethanol detected in Blood
No Ethanol detected in Kidney

TESTS AND RESEARCH

Under the supervision of the IIC, an examination of the airframe and engine was performed by representatives from Cirrus Aircraft and Continental Motors, Inc. (CMI), at the facilities of Air Transport, Phoenix, Arizona, on August 11, 2011.

Airframe examination

The examination of the airframe revealed that all components necessary for flight were identified and accounted for. It was also determined that no pre-impact anomalies existed with the airframe that would have precluded normal operation of the airplane.

Engine examination

The examination revealed that the engine had separated from the airframe and propeller assembly. The crankshaft propeller flange had separated from the engine, and remained attached to the propeller assembly. The magnetos, fuel pump, alternator, and vacuum pump were all observed to have separated from the engine.

The cylinders were boroscoped. The piston heads and combustion chambers were observed to have light grey deposits. The valve heads were undamaged and had no signs of abnormal thermal discoloration. The number 1 and 3 valve head areas had an oil residue. The crankshaft was moved with the use of a pipe wrench and had approximately 5 degrees of rotation. The camshaft was rotated from the forward accessory drive with valve continuity confirmed. The cylinder overhead components were lubricated; numbers 1, 2, 4, and 6 cylinder were undamaged. The overhead components for numbers 3 and 5 had impact damage.

Examination of both magnetos revealed that each had separated from the engine; their positions could not be determined. One magneto had impact damage to its housing and mounting flange. Small sections of the ignition leads remained attached to the magneto distributer cap. The magneto drive was rotated by hand, and the impulse coupling engaged. Spark was visible at the damaged ignition lead ends. Examination of the second magneto revealed that its distributor cap and attached housing had separated and were not available during the inspection. The magneto’s drive shaft rotated by hand.

The vacuum pumps were found in the main wreckage and disassembled. The electrically driven vacuum pump had impact damage and was found partially opened. Small sections of the rotor were found in the cavity. The cavity was free of damage and chatter marks. The engine driven vacuum pump was observed separated from the engine and had impact damage to its mount. The drive coupler was intact, with minor impact damage noted. The pump was disassembled. The rotor was cracked in several sections. The cavity was free of damage and chatter marks.

The propeller had separated from the engine, and the crankshaft propeller flange remained attached to the hub. The separated surfaces of the crankshaft propeller flange had 45-degree shear-lips and impact damage. The spinner had impact damage and was crushed aft revealing the piston dome. Blade A was bent aft near the shank and had S-type bending at the tip. Blade B was loose in the hub, and the blade surfaces had multidirectional gouging. The leading and trailing edges from the mid-section to the tip had gouging. Blade B was bent aft at the shank and aft again at the tip.

The technician concluded that the inspection of the engine did not reveal any abnormalities that would have prevented normal operation and production of rated horsepower.

Cirrus Airframe Parachute System (CAPS)

An examination of the Cirrus Airframe Parachute System (CAPS) revealed that the activation handle was in the handle holder. The safety pin was not observed. The activation cable housing had been destroyed by fire. The activation cable was continuous from the activation handle to the igniter assembly. The igniter assembly and launch tube exhibited thermal damage. The parachute enclosure was separated from the bulkhead, and was located in the debris field beyond the main wreckage. The parachute remained in the D-Bag, and was located approximately 35 feet beyond the main wreckage in the direction of the energy path. The rocket motor and pickup collar separated from the lanyards, and were not observed.

Performance Data

During the investigation and at the request of the IIC, Cirrus Aircraft provided performance data for the SR20 airplane. Calculations revealed that on the accident leg of the flight, from GUY to HND, including the 45 minute reserve requirement under Federal Aviation Regulation 91.151, the estimated range of the airplane would have been 658 nm; the distance from GUY to HND is 659.8 nm. (Refer to the Cirrus Aircraft Final Mishap Report, which is appended to this report, for detailed performance calculations.)

ADDITIONAL INFORMATION

Controlled Flight Into Terrain (CFIT)

On March 1, 2003, the Federal Aviation Administration issued Advisory Circular number 61-134, "General Aviation Controlled Flight Into Terrain Awareness." The circular was issued to the general aviation community to "...emphasize the inherent risk that controlled flight into terrain (CFIT) poses for general aviation (GA) pilots."

The circular defines CFIT as a situation which "...occurs when an airworthy aircraft is flown under the control of a qualified pilot, into terrain (water or obstacles) with inadequate awareness on the part of the pilot of the impending collision."

According to the CFIT circular, "situational awareness" is defined as "...when the pilot is aware of what is happening around the pilot's aircraft at all times in both the vertical and horizontal plane. This includes the ability to project the near term status and position of the aircraft in relation to other aircraft, terrain, and other potential hazards."

Maximum Elevation Figures

According to the Las Vegas Sectional Aeronautical Chart that was current at the time of the accident, the depicted Maximum Elevation Figure in the area of the accident site was 9,400 feet msl; the accident site was located at 8,869 feet msl. As defined in the legend of the sectional chart, the Maximum Elevation Figures (MEF) shown in the quadrangles bounded by ticked lines of latitude and longitude are represented in THOUSANDS and HUNDREDS of feet above mean sea level. The MEF is based on information available concerning the highest known feature in each quadrangle, including terrain and obstructions (trees, towers, antennas, etc.). Example: 12,300 feet would be displayed as 12³ in the middle of the quadrangle.

Alternate airports

The following alternate airports were located within 40 nm of the accident site. Each had a runway that was 5,950 feet in length or longer:

Page Municipal Airport (PGA), Page, Arizona, had a lighted runway that was 5,950 feet in length; it was 38 nm from the accident site on a magnetic heading of 040 degrees.

Grand Canyon Airport (GCN), Grand Canyon National Park, Arizona, had a lighted runway that was 8,999 feet in length; it was 34 nm from the accident site on a magnetic heading of 167 degrees.

Kanab Municipal Airport (KNB), Kanab, Utah, has a lighted runway that was 6,193 feet in length; it was 35 nm from the accident site on a magnetic heading of 315 degrees.

Federal Aviation Regulation (FAR) 91.151 (a)

Federal Aviation Regulation 91.151(a), “Fuel requirements for flight in VFR conditions” states: “No person may begin a flight in an airplane under VFR conditions unless (considering wind and forecast weather conditions) there is enough fuel to fly to the first point of intended landing and, assuming normal cruising speed –

(1) During the day, to fly after that for at least 30 minutes; or

(2) At night, to fly after that for at least 45 minutes.

==================== 

SONOMA -- A Sonoma man was identified Monday as one of two victims of a plane crash near the north rim of the Grand Canyon.

Jacobe Daniel Foster, 32, is believed to have died when a single-engine Cirrus SR20 flying from Rock Hill, S.C., to Henderson, Nev., crashed Friday night in the Kaibab National Forest.

Foster and Andrew Jay Weiner, 39, of Henderson were both believed to be on board the plane, authorities said. It is unknown who was at the controls, but records show that Foster was a licensed pilot.

The plane was built in 2000 and has no previous record of incidents, according to federal aviation databases. The National Transportation Safety Board is investigating the crash.

Foster's family declined to comment Monday.

Foster ran track and served as team captain at the University of North Carolina, where he majored in computer science.

A Facebook page dedicated to Foster describes him as "the superhero who officially has his wings in heaven now."

No comments:

Post a Comment