Saturday, August 11, 2012

Cirrus SR22, Photopherisis Inc., N110EB: Accident occurred April 21, 2012 in Newcomerstown, Ohio

NTSB Identification: CEN12FA251 
14 CFR Part 91: General Aviation
Accident occurred Saturday, April 21, 2012 in Newcomerstown, OH
Probable Cause Approval Date: 02/04/2015
Aircraft: CIRRUS DESIGN CORP SR22, registration: N110EB
Injuries: 1 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.

About 5 minutes before the accident, when the airplane was in cruise flight in instrument meteorological conditions (IMC), at 8,000 ft mean sea level (msl), and at 156 knots ground speed, an air traffic controller updated the altimeter setting via the radio. The pilot acknowledged the call, and his voice sounded normal. No other radio transmissions were received from the pilot, and he made no distress calls. Radar data showed that the airplane then began a descending right turn, that the airspeed increased slightly through the turn, and that the airspeed then suddenly decreased to 61 knots as the turn radius decreased. The airplane had turned about 270 degrees and descended to an altitude of 4,900 ft msl before radar contact was lost. A witness reported seeing the airplane coming out of the low clouds (the cloud ceiling was about 700 to 800 ft above ground level) in a nose-down descent with the wings about level before it disappeared behind a tree line. Examination of the airframe and engine did not reveal any preimpact anomalies.

Data from the on-board recoverable data module (RDM) showed an anomaly in the electrical bus voltages, autopilot mode changes, and a momentary dropout of the pilot transmission frequency. Specifically, the RDM data showed that the airplane was flying at 8,000 ft pressure altitude at an airspeed of 148 knots with the autopilot on when alternator 1 dropped offline followed by alternator 2 dropping offline; the airplane is equipped with a two-alternator, two-battery, 28-volt direct current electrical system. About 3 seconds later, the autopilot disengaged. The RDM data confirmed that the airplane then entered a descending right turn with the airspeed increasing slightly and then suddenly decreasing. The data further showed that the airplane then rolled right and that the pitch attitude sharply decreased. The airspeed then increased, and both the roll and pitch reversed back toward wings level before the data ended.

The bolster switches for alternator 1, alternator 2, battery 1, battery 2, and the avionics were cycled “on” and “off” on an exemplar airplane to determine what may occur in the cockpit when the bolster switches are manually moved. Seven sets of various electrical bolster switch activations and deactivations were documented. During the tests, bolster switch operation on the exemplar airplane yielded recorded data similar to the accident flight data; however, the reason for the recorded electrical anomalies could not be determined because the RDM does not record the physical position of either the bolster switches or circuit breakers. The data did reveal that the airplane began its deviation off course and its subsequent descending right turn in IMC conditions a few seconds after the alternators went offline and that the pilot was likely attempting to troubleshoot the electrical anomaly with bolster switch activations and deactivations as the airplane descended and turned through the clouds. The electrical anomalies likely distracted the pilot and led to his subsequent loss of airplane control. The witness’s statement that the airplane came out of the low clouds with the wings about level and the RDM data indicate that the pilot may have been able to recover from the turn and rapid descent to some degree but that there was insufficient altitude for a full recovery.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot’s loss of airplane control in instrument meteorological conditions due to his distraction by electrical system anomalies, which resulted in an uncontrolled descent. The reason for the electrical system anomalies could not be determined. 

HISTORY OF FLIGHT

On April 21, 2012, approximately 1220 eastern daylight time, a Cirrus Design Corp SR22, N110EB, registered to Photopheresis INC., of Morristown, New Jersey, was substantially damaged when it impacted heavily wooded terrain in the vicinity of Newcomerstown, Ohio. The private pilot, who was the sole occupant, sustained fatal injuries. Instrument meteorological conditions prevailed in the vicinity and an instrument flight rules (IFR) flight plan was filed. The flight was being operated under the provisions of 14 Code of Federal Regulations Part 91 as a personal cross country flight. The flight originated at 1013 from the Somerset Airport (SMQ), and its intended destination was Ohio State University Airport (OSU), Columbus, Ohio.

According to radar data and recorded radio communications provided to the NTSB by the FAA, approximately 5 minutes prior to the accident, the airplane was in cruise flight at 8,000 feet msl at 156 knots ground speed, when Indianapolis Air Route Traffic Control Center (ARTCC) updated the altimeter setting via radio. The pilot acknowledged the call and his voice sounded normal. No other radio transmissions or distress calls were from received from the pilot after the altimeter setting acknowledgment.

Radar data showed the airplane begin a descending right turn with airspeed increasing slightly through the turn and then suddenly decreasing to 61 knots as the radius of the turn decreased. The airplane had turned approximately 270 degrees of heading and descended to an altitude of 4,900 feet msl before radar contact was lost.

There were no eye-witnesses to the accident, however, a boy who was a passenger of a car reported that he thought that he saw the airplane coming out of the low clouds in a descent, about wings level before it disappeared out of sight behind a tree line. The boy stated that he then saw black smoke.

Recovered data from the on-board data module (RDM) showed an anomaly in the electrical bus voltages, autopilot mode changes, a momentary drop out of the pilot transmit frequency, and a descending right turn with a decreasing radius until impact. Detailed information is provided in the TESTS AND RESEARCH section of this report.

PERSONNEL INFORMATION

According to FAA records, the pilot held a valid private pilot certificate with Airplane Single Engine Land (ASEL) and Instrument Airplane ratings. He held a valid third class medical certificate, issued April 28, 2010. At the time of his most recent medical exam, the pilot reported about 1,200 hours total flight time, of which 100 hours were within the preceding 6 months. The pilot attended and completed the Cirrus Standard Perspective Differences and Cirrus Turbo Differences Course on April 14, 2009. Additionally, he completed the Cirrus Icing Awareness Course on October 5, 2009.

According to information provided by a flight instructor who had flown about once a month with the pilot in recent years, the pilot completed a successful bi-annual flight review in the SR22 on February 17, 2012.

Remnants of the pilot's logbook were found at the accident site, but the contents were damaged from impact and could not be documented.

AIRCRAFT INFORMATION

Cirrus SR22-3423, registration number, N110EB, received its standard airworthiness certificate on April 13, 2009. Cirrus records indicate that the pilot purchased the airplane new and took delivery on April 13, 2009. According to the records on file at Cirrus Aircraft, the airplane was equipped with: Garmin Perspective avionics with dual AHRRS and a single air data computer, Chartview, a GFC 700 autopilot with yaw dampener, Enhanced Vision System (EVS), Synthetic Vision, air conditioning, a Tornado Alley turbo-charging system, supplemental oxygen, engine monitoring, traffic alerting system, terrain awareness system (TAWS-B), XM weather/radio, FIKI, a Tanis heater, and a recoverable data module (RDM). 

The cover for the airframe, engine, and propeller logbooks were found at the accident site, but the pages were not located. 

The airplane was equipped with a two-alternator, two battery, 28-volt direct current (VDC) electrical system designed to reduce the risk of electrical system faults. The system provides uninterrupted power for avionics, flight instrumentation, lighting and other electrically operated and controlled systems during normal operation. The electrical system also provides automatic switching from either battery or alternator to the Essential Bus in the event of an electrical system failure by the opposing alternator or battery. 

The bolster panel contains the pilot switches for operating ALT 1, ALT 2, BAT 1, and BAT 2. The switches are mounted adjoining so that a pilot can control all four switches with a single hand. Power generated from the alternators is fed into the Master Control Unit (MCU). The MCU regulates and distributes the power to the batteries and the system loads. Each alternator provides constant charging current for the corresponding battery and primary power to the aircraft electrical system during normal system operation.

The flight instructor who had given the pilot his most recent bi-annual flight review reported that there had been one instance whereby the autopilot had disengaged during a flight sometime in the fall of 2011. He recalled that the problem may have been associated with a battery issue, but could not recall all of the details.

METEOROLOGICAL INFORMATION

The closest weather reporting location to the accident site was from Zanesville Municipal Airport (ZZV), Zanesville, Ohio, located approximately 24 miles southwest of the accident site at an elevation of 900 feet. The airport had an un-augmented ASOS and reported the following conditions at the approximate time of the accident: Zanesville (ZZV) special weather observation at 1222 EDT, automated, wind from 340º at 5 knots, visibility 7 miles in light rain, ceiling broken at 800 feet agl, overcast at 1,200 feet, temperature 6º C, dew point 4º C, altimeter 29.89 inches of Hg. Remarks - automated observation system, ceiling 600 variable 1,000 feet, hourly precipitation 0.01 inch.

The pilot of N110EB contacted the Washington, DC, Federal Aviation Administration (FAA) contract Automated Flight Service Station (AFSS) at 0745 EDT (1145Z) on April 21, 2012 and obtained a weather briefing and filed an IFR flight plan. A copy of the event reconstruction for that briefing was obtained and is included as Attachment 1 in the NTSB Meteorology Group Chairman's Factual Report. An audio file was also reviewed and documented to evaluate the accuracy and content of that briefing, which follows: The pilot initially contacted the AFSS for an outlook briefing for the flight departing at 0800 EDT on April 22, 2012. 

A complete meteorological factual report prepared by a NTSB meteorology specialist is available in the supporting docket for this report.

FLIGHT RECORDERS

The Recoverable Data Module (RDM) was located in the debris field and sent to the NTSB Vehicle Recorder Laboratory in Washington DC for evaluation and download. 

WRECKAGE AND IMPACT INFORMATION

General

The airplane's main wreckage was located on a heavily wooded hillside at 40°14'58.32" North latitude, 81°32'44.95" West longitude at an approximate elevation of 1,060 feet msl. The direction of energy was about 093 degrees magnetic. The hillside had a 10-degree up slope. The initial point of impact consisted of two trees about 31 feet apart. One tree had missing bark and tree scars on one of its large branches approximately 44 feet above the ground. The second tree's trunk was broke off approximately 34 feet above the ground. Three more tree trunks in the direction of energy ranging in size from 4-8 inches were freshly broken off. 

About 80 feet from the initial point of impact there was a 3-4 foot deep crater that measured approximately 11 feet long. Within the crater, the propeller hub remained attached to a portion of the crankshaft, which still had the #6 cylinder attached to it by the piston and connecting rod. There were two trees at the far end of the crater. The main wreckage including the firewall, engine, instrument panel, and center console, was found leaning uphill against the trees. 

The remainder of the airplane was severely fragmented and dispersed over a debris field that measured roughly 370 feet long by about 250 feet wide at its widest point. Evidence of spot fires were present throughout the debris field. Brown wilted vegetation was present that was consistent with fuel damage. Evidence at the site was consistent with the airplane impacting the trees about 25-30 degrees nose down and level wings.

Engine

The main portion of the engine was located approximately four feet from the impact crater and exhibited impact damage. The forward portion of the crankshaft and propeller hub, and the number six cylinder were located in the impact crater and was embedded the ground. Fractured pieces of the engine crankcase and oil sump were located in the impact crater along with a turbocharger, forward section of the cam shaft, parts of the propeller governor,and magneto drive gears. The engine and all components and accessories exhibited impact damage. The right magneto was separated from the engine, exhibited impact damage and the housing was fractured. The magneto was disassembled with no pre-impact anomalies noted. The left magneto was separated from the engine, exhibited impact damage and the housing was fractured exposing the internal parts of the magneto. The magneto was disassembled with no pre-impact anomalies noted. The ignition harness exhibited impact damage. The spark plugs exhibited impact damage and had light colored combustion deposits. The electrodes were normal when compared to the Champion Check A Plug chart. The fuel pump was fractured free of the engine and located in the debris field. The fuel pump exhibited impact damage. The drive coupling was fractured and only half of it was located. The fuel pump turned freely by hand using a screw driver. The fuel pump was disassembled and exhibited normal operating signatures. The oil pump remained attached to the engine. The cover was not removed due to damage to the oil pump housing studs. The oil sump exhibited impact damage and was fractured into several small pieces in the impact crater.

Cylinder number six and a portion of the crankshaft were separated from the engine and located in the impact crater. Cylinder five was separated from the crankcase and remained attached to the crankshaft by the piston and connecting rod. All six cylinders exhibited impact damage. All cylinders were inspected using a lighted bore scope. The internal combustion chambers exhibited a material consistent with that of light combustion deposits. The cylinder bores were clear of scoring and no evidence of hard particle passage was observed in the cylinder bore ring travel area. Dirt was observed in the combustion chambers and all induction risers were fractured from the cylinders. Impact damage to the valve train, rocker arms and rocker arm covers was observed. The rocker arm covers were removed and those that were not breached contained a residue of oil. All damage noted was consistent with impact damage. The crankcase exhibited impact damage and the forward section was fragmented. The accessory portion of the crankcase was fractured. The crankshaft was fractured between the number 5 and number 6 rod journals. The forward portion of the crankshaft was separated from the crankcase and the propeller hub remained attached to the propeller flange. The camshaft gear and magneto drive gears were found in the wreckage and exhibited impact damage.The starter was fractured at its base and exhibited impact damage. The base remained attached to the starter adaptor and the other half of the starter remained attached to the firewall by a cable.

The propeller hub remained attached to the engine crankshaft propeller flange. All three of the composite propeller blades were fractured near the hub and located in the debris path. All three blades exhibited nicks, gouges, and portions of the blades were missing.

Fuselage and Cabin Section

The fuselage was severely fragmented along the debris path. Both crew doors were fragmented. Larger portions of the upper and lower sections of both doors were located within the debris field. The latching mechanisms for the upper and lower latches for both doors were located and exhibited impact damage. The baggage door was found separated from the fuselage and exhibited impact damage.

All the seats were fragmented. The left front crew seat airbag was deployed. A large portion of the right front crew seat was hanging in a tree and was not accessible for examination. The right front airbag could be seen and was deployed.

Cockpit

Switch positions and settings could not be documented due to severe impact damage. A flight bag, Jeppesen chart notebooks, airplane manuals, and miscellaneous items (baggage tie down straps, fuel sampler cup, etc.) were present in the debris field. A rolled up set of sun reflector mats were present in the debris field. The pilot's logbook was present in debris field. It had sustained fire damage and no usable information was obtained. A propeller logbook binder cover was present in the debris field. Pages from the propeller logbook were not recovered. The cover for the airframe logbook was located in the debris field. Pages from the logbook were not recovered.

Seats and Restraints

All the seats were fragmented. The left front crew seat airbag was deployed. A large portion of the right front crew seat was hanging in a tree and was not accessible for examination. The right front airbag could be seen and was deployed.

Wing Section and Control Surfaces 

The wing was found severely fragmented. Three main pieces of aileron were identified in the debris field that made up the majority of the left aileron. Two main pieces of the left flap were located in the debris field that made up the majority of the left flap. The right flap was found separated from the wing and exhibited fire and impact damage. Three pieces of aileron were identified in the debris field that made up the majority of the right aileron. About 4 feet of the center aileron control cable was found from the left hand turnbuckle to the console aileron actuation pulley. The cable was fractured at the console aileron actuation pulley. When visually examined, the fracture had a broom straw appearance consistent with tension overload. The other end of the cable was fractured at the turnbuckle. Two sections of aileron control cable were located in the debris field with the flap hinge assemblies present on the cable. When visually examined, both sections of control cable had fractures with a broom straw appearance consistent with tension overload. 

The roll trim motor position could not be determined due to impact damage. 

The flap actuator shaft was found separated from the flap motor. When the flap motor components were laid out together the shaft extension was approximately 4 inches which was consistent with the flaps being in and 'UP' position.

Empennage and Stabilizers

The empennage was mostly fragmented. The horizontal stabilizer was found separated from the empennage and exhibited impact damage, with both the upper and lower skins mostly intact. Both elevators were separated from the horizontal stabilizer and exhibited impact damage. The pitch trim motor was in a neutral position. Elevator control cable continuity was confirmed.

The vertical stabilizer was found fragmented. The rudder was separated from the vertical stabilizer and exhibited impact damage. Rudder control cable continuity was confirmed.

Landing Gear

The nose landing gear assembly separated from the airplane and exhibited impact damage. The left main landing gear and its surrounding mounting structure separated from the wing and exhibited impact damage. The right main landing gear was fragmented.

Cirrus Airframe Parachute System (CAPS)

The CAPS safety pin was located in the debris field and evidence at the site was consistent with the system not being deployed prior to impact. The activation handle was found separated from the activation cable and was located in the debris field. About 10.5 feet of the activation cable remained attached to the igniter assembly. Most of the activation cable housing was not present. When visually examined the fractured end of the cable had a broom straw appearance consistent with tension overload.

The FS222 bulkhead was fragmented. The rocket motor launch tube assembly was found attached to the FS222 bulkhead and exhibited impact damage. The igniter base, when viewed looking down the launch tube, had a brownish appearance consistent with residue from a rocket motor ignition. The parachute enclosure was found separated from the FS222 bulkhead. The CB7 access panel was found separated from the FS222 bulkhead. There was forward bowing of the lower portion of the panel. Four cuts were present in the bowed portion of the panel that were consistent in size and shape of the 3-point shackles. Vertical scratching was present on the aft side of the panel.

The CAPS harnesses, risers and a portion of the parachute suspension lines extended from the main wreckage on an 80 degree magnetic azimuth and were tangled through several trees. The incremental bridle and lanyards remained attached to the D-bag. The incremental bridle was partially unstitched. There were 75 bar tack stitches present. When measured, the stitched portion of the incremental bridle was 36 inches in length. The parachute was found in the D-bag. The suspension lines of the parachute were found partially extracted from the D-bag. Part of the nylon D-bag appeared melted. The rear harness was partially undone with 20 inches remaining stitched together. One reefing line cutter was attached to a Y-strap. The ignition loop was bent but present in the reefing line cutter. The other reefing line cutter was not observed. The white cord that secures the triple D-ring assembly had been cut. A small portion of the white cord remained tucked behind the Velcro enclosure for the reefing line cutters.

The CAPS enclosure cover was located about 75-100 feet uphill of the main wreckage and exhibited impact damage.

The rocket motor was located approximately 165 feet uphill from the main wreckage. The placard atop of the motor canister was scratched and torn. The pick-up collar and support were present on the rocket motor and exhibited impact damage. The rocket motor and pick-up collar assembly had separated from the incremental bridle lanyards.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot and no medical issues were discovered that could have contributed to the accident. Toxicology tests performed were negative.

TESTS AND RESEARCH

RDM Description

The Heads Up Technologies RDM is a crash hardened unit installed in the tail of the aircraft in order to record flight, engine, and autopilot parameters. Data is logged once per second and stored internally on 4 thin small outline package (TSOP) memory devices inside the crash hardened enclosure. When the storage limit is reached the oldest record is deleted.

Autopilot Description

The Garmin GFC 700 digital Automatic Flight Control System (AFCS) Autopilot system is a fully digital, dual channel, fail-passive digital flight control system composed of multiple Line-Replaceable Units (LRUs) and servos. The GFC 700 is fully integrated within the Cirrus Perspective Integrated Avionics System architecture and is used to stabilize the aircraft pitch, roll and yaw (optional) axes. Pitch auto trim provides trim commands to the pitch trim servo to relieve any long-term effort required by the pitch servo. 

Summary of RDM Data for the Accident Flight

The recorded data indicate that prior to the upset the airplane had been travelling at about 8000 feet pressure altitude, at an airspeed of 148 knots, heading 273 degrees magnetic while on autopilot (in the GPS lateral mode and ALT vertical mode) navigating to APE (the GPS way point for the Appleton, Ohio VOR antenna). 

About 16:18:30 UTC, the data for Alternator 2 became invalid after having been at a previous value of 25 Amps. At the same time, the data for Battery 1 also became invalid for one second, and then changed to -27 Amps. Subsequently, the voltages for the Main Bus 1 and 2, and the Essential Bus decreased from about 28-29 volts, to about 23-25 volts. 

About 3 seconds later at 16:18:33, the autopilot disengaged (the Autopilot/Flight Director parameter changed from AP/FD to FD only). About 2 seconds after that, the airplane began rolling to the right (right wing down) and the heading began to increase (right turn). About 10 sends later, the pitch attitude began to decrease (airplane nose down) and the altitude began to decrease. 

About 16:18:53, the autopilot was re-engaged, and the AP mode had changed from GPS and ALT to ROLL and PITCH. At this time, the roll attitude was about 32 degrees right wing down and the pitch attitude was about 5 degrees nose down. These values increased to a peak of about 63 degrees right wing down and 24 degrees nose down, before they began to reduce. When the values had reduced to 48 degrees of right roll and 16 degrees of nose down pitch and at an airspeed of 203 knots, the autopilot mode changed to LEVEL for both the lateral and vertical coupled modes at about 16:19:09. The engine power was reduced about 5 seconds later. 

The nose down pitch attitude then reduced gradually and continually was toward level and reached 0 at about 16:19:27. Over this time the roll attitude oscillated down (toward wings level) to about 30 degrees right wing down and then increased back to about 41 degrees right wing down at 16:19:27. 

The airplane then rolled sharply to the right, reaching 155 degrees of right roll, while the pitch attitude sharply decreased to about 71 degrees nose down. Shortly thereafter, the airspeed increased to about 277 knots. Both roll and pitch then reversed their trends back toward level, and had reached about 18 degrees right wing down and 46 degrees nose down, before the data ended at 16:19:47. During this trend reversal, the normal acceleration reached the recorded limit of 5 positive G's. 

Note: The entire Vehicle Recorder Laboratory Factual Report prepared by a NTSB vehicle recorder specialist is available in the supporting docket for this report.

Electrical System, Autopilot and RDM Data Observations in an Exemplar Airplane

During the week of September 29, 2014, under the oversight of the NTSB IIC, Cirrus SR22, serial number 3771, was ground run with the same Garmin Integrated Avionics (GIA) software version as the accident airplane (Version 6.07 also referred to as Phase C+). Bolster switches for ALT1, ALT2, BAT1, BAT2, and Avionics were cycled OFF then ON in various combinations to observe the cockpit displays and compare them with the RDM data recorded for the same time frame.

Seven sets of various bolster switch activations/deactivations were documented to demonstrate what occurs in the cockpit and what data the RDM records respective to manual movements of the switches (i.e., ON/OFF). The areas in the RDM data that were examined were: Essential Bus volts, Main Bus 1 volts, Main Bus 2 volts, Alternator 1 amps, Alternator 2 amps, Pilot Transmit Frequency, and Automatic Flight Control System (AFCS) Modes. 

#1 Avionics Switch OFF, Then Turned Back ON 

The Avionics Switch was turned OFF for approximately 10 seconds. In the RDM data, the Essential and Main Bus voltages remained the same; the ALT 1&2 and BAT1 amp readings remained the same. The pilot transmit frequency changed from the selected communications frequency to a null value represented by 5 dashes. No change in the AFCS Modes occurred. 

The PFD displayed an "Avionics OFF" crew alerting system (CAS) message. A Red X was displayed over the location of the transponder information. 

During the time the Avionics switch was turned off the COM1 frequency number displayed on the PFD turned white. According to the Garmin Pilot's Guide when both active COM frequencies appear white it is an indication that no COM radio is selected for transmitting (on the audio panel).

Once the Avionics Switch was turned back on, the audio panel lights all lit up momentarily consistent with the unit conducting a self-test during normal start-up. Immediately following this, the selections that had been on prior to the Avionics Switch being shut off were re-illuminated. At about this time the COM1 frequency turned green again on the PFD. Additionally, the Red X over the Transponder Status Box was replaced with the transponder information. 

#2 BAT1 Switch OFF

The BAT1 switch was turned off for approximately 12 seconds. In the RDM data, the Essential and Main Bus voltages remained the same; the ALT 1&2 and BAT1 amp readings remained the same. No change in the Pilot Transmit Frequency or AFCS Modes occurred. The PFD did not display any messages during the time the BAT1 switch was in the OFF position.

#3 ALT 1&2 OFF

The ALT 1&2 switches were turned off for approximately one minute. In the RDM data, the Essential and Main Bus voltages decreased. ALT 1&2 amps decreased to zero or dashes. BAT1 amps increased. No change in the Pilot Transmit Frequency or AFCS Modes occurred. The PFD displayed multiple CAS caution messages.

#4 ALT 1&2 and Avionics Switch OFF, Then Avionics Switch Turned Back ON

The ALT 1&2 and Avionics Switch were turned OFF. Then the Avionics Switch was immediately turned back ON. In the RDM data, the Essential and Main Bus voltages decreased. ALT 1&2 amps decreased to zero or dashes. BAT1 amps increased. The Pilot Transmit Frequency went from the selected communications frequency to dashes for two seconds. No change in AFCS modes occurred.

The PFD behavior was consistent with the behavior described in #1 above.

#5 ALT 1&2 and BAT1 Switches OFF, Then BAT1 Switch Turned Back ON

The ALT 1&2 and BAT1 switches were turned OFF. Then the BAT1 switch was immediately turned back ON. 

In the RDM data, the Essential Bus and Main Bus 1&2 volts decreased. ALT 1&2 amps decreased to zero or dashes. BAT1 amps increased. The Pilot Transmit Frequency went from the selected communications frequency to dashes for two seconds. The autopilot data changed from "AGA--Y----" to "FGA-------". 

"AGA--Y---"

"A" = Autopilot and Flight Director engaged

"G" = GPS coupled lateral mode 

"A" = Altitude coupled vertical mode

"Y" = Yaw dampener ON

"FGA"-------"

"F" = Flight Director engaged

"G" = GPS coupled lateral mode

"A" = Altitude coupled vertical mode

"-" = Yaw Dampener OFF

The PFD displayed the AFCS Status Annunciation Warning: "PITCH." 

The AFCS Status Box displayed an Automatic Autopilot Disengagement indicated by a flashing red and white "AP" annunciation and by the autopilot disconnect aural alert, which continued until the AP Key was depressed on the AFCS control panel. 

Additionally, the AFCS Status Box displayed an Automatic Yaw Dampener disengagement indicated by a five-second flashing yellow "YD" annunciation. After five seconds the "YD" extinguished (went blank).

The COM2 frequency momentarily was Red X'ed. Multiple messages were listed in the Comparator Window. CAS caution messages were displayed over time with regard to electrical busses and BAT1. 

Approximately 18 seconds after the BAT1 switch was turned back on, the AP Key on the AFCS control panel was depressed. The aural alert tone "warbled" and the flashing red & white "AP" extinguished. The AP Key was pushed a second time and the aural alert was silenced. Normal operation usually requires the AP Key be depressed one time to silence the aural alert. 

Following this, additional attempts to depress the AP Key did not result in the engagement of the autopilot until the AFCS Status Annunciation Warning: "PITCH" extinguished. Once the warning did extinguish, depressing the AP Key immediately engaged the autopilot.

#6 ALT1&2, BAT1, Avionics Switch OFF, Then BAT1 and Avionics Switches ON

The ALT 1&2 and BAT1 switches were turned OFF. Then the BAT1 and the Avionics switch were immediately turned back ON. 

In the RDM data, the Essential Bus and Main Bus 1&2 volts decreased. ALT 1&2 amps decreased to zero or dashes. BAT1 amps increased. The Pilot Transmit Frequency went from the selected communications frequency to dashes for three seconds. The autopilot data changed from "AGA--Y----" to "FGA-------".

Ten seconds later the autopilot data changed from "FGA-------" to "FRP-------".

"FGA-------" 

"F" = Flight Director engaged

"G" = GPS coupled lateral mode

"A" = Altitude coupled vertical mode

"FRP-------" 

"F" = Flight Director engaged

"R" = Roll coupled lateral mode

"P" = Pitch coupled vertical mode

The PFD displayed the AFCS Status Annunciation Warning: "PITCH." 

The AFCS Status Box displayed an Automatic Autopilot Disengagement indicated by a flashing red and white "AP" annunciation and by the autopilot disconnect aural alert, which continued until the Autopilot Disconnect Button was depressed on the pilot's yoke.

The AFCS Status Box also displayed an Automatic Yaw Dampener disengagement, indicated by a five-second flashing yellow "YD" annunciation. After five seconds the "YD" extinguished (went blank).

The AFCS Status Box also indicated that the flight director was reverting to the default mode in both the lateral and vertical axis. This was displayed as a flashing yellow mode annunciation for both GPS and ALT for 10 seconds. After 10 seconds the flashing yellow annunciation stopped and was replaced with a green Roll Hold Mode annunciation (ROL) and a green Pitch Hold Mode annunciation (PIT).

Following this, additional attempts to depress the AP Key did not result in the engagement of the autopilot until the AFCS Status Annunciation Warning: "PITCH" extinguished. Once the warning extinguished, depressing the AP Key immediately engaged the autopilot.

#7 ALT1&2, BAT1&2, Avionics Switch OFF, Then All Switches Immediately Back ON

The ALT 1&2, BAT 1&2, and Avionics Switch were all turned OFF. Then all the switches were immediately turned back ON. 

In the RDM data, the Essential Bus and Main Bus 1&2 voltages remained constant. ALT1&2 and BAT1 amps remained constant. The Pilot Transmit Frequency changed from the selected communications frequency to 121.500 for one second then returned to the previously selected communications frequency. The autopilot data changed from "AGA--Y----" to all dashes. Engine monitoring data parameters continued to record whereas multiple other parameters reverted to dashes. 

The PFD momentarily displayed all possible flags except for the comparator and CAS message boxes. Shortly after this the "AHRS ALIGN: Keep Wings Level" message appeared while the screen background was all black. The AFCS Control Unit lights all extinguished.

Summary of Bolster Switch Operations

Bolster switch operation on the exemplar airplane yielded recorded data similar to the accident flight data. It also provided insights regarding power interruptions to key components like the autopilot and audio panel and data recorded in association with their operation. However, the source of the power interruption during the accident flight could not be definitively reproduced or identified – i.e., electrical anomalies, bolster switch operation, or circuit breaker operation because the RDM does not record the physical position of either the bolster switches or circuit breakers.

ADDITIONAL INFORMATION

After the on-scene phase of the investigation, the airplane wreckage was recovered to Atlanta Air Salvage, Atlanta, Georgia, and later released to the owner's representative.


  http://registry.faa.gov/N110EB

NTSB Identification: CEN12FA251 
14 CFR Part 91: General Aviation
Accident occurred Saturday, April 21, 2012 in Newcomerstown, OH
Aircraft: CIRRUS DESIGN CORP SR22, registration: N110EB
Injuries: 1 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. 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.


 On April 21, 2012, approximately 1220 eastern daylight time, a Cirrus Design Corp SR22, N110EB, registered to Photopheresis INC., of Morristown, New Jersey, was substantially damaged when it impacted heavily wooded terrain in the vicinity of Newcomerstown, Ohio. The private pilot, who was the sole occupant, sustained fatal injuries. Instrument meteorological conditions prevailed in the vicinity and an instrument flight rules (IFR) flight plan was filed. The flight was being operated under the provisions of 14 Code of Federal Regulations Part 91 as a personal cross country flight. The flight originated at 1013 from the Somerset Airport (SMQ), and its intended destination was Ohio State University Airport (OSU), Columbus, Ohio.

According to preliminary radar data and recorded radio communications, approximately 5 minutes prior to the accident, the airplane was in cruise flight at 8,000 feet msl at 156 knots ground speed, when Indianapolis Air Route Traffic Control Center (ARTCC) updated the altimeter setting via radio. The pilot acknowledged the call and sounded normal. No other transmissions were from received from the pilot.

Preliminary radar data showed the airplane begin a descending right turn with airspeed increasing slightly through the turn and then suddenly decreasing to 61 knots as the radius of the turn decreased. The airplane had turned approximately 270 degrees of heading and descended to an altitude of 4,900 feet msl before radar contact was lost.

The airplane's main wreckage (cabin and engine) was located on a heavily wooded hillside at 40°14'58.32" North latitude, 81°32'44.95" West longitude at an approximate elevation of 1,060 feet msl. The direction of energy was about 093 degrees magnetic. The hillside had a 10-degree upslope. The initial point of impact consisted of two trees 31 feet apart from one another. One tree had missing bark and tree scars on one of its large branches approximately 44 feet above the ground. The second tree’s trunk was broke off approximately 34 feet above the ground. Three more tree trunks in the direction of energy ranging in size from 4-8 inches were freshly broken off. The remainder of the airplane was severely fragmented and dispersed over a debris field that measured roughly 370 feet long by about 250 feet wide at its widest point. Evidence of spot fires were present throughout the debris field. Brown wilted vegetation was present that was consistent with fuel damage. Evidence at the site was consistent with the airplane impacting the trees approximately 25-30 degrees nose down and about level wings.

The airplane's Cirrus Airframe Parachute System (CAPS) system was examined at the accident site and evidence showed that it had not deployed prior to impact.

The airplane's Remote Data Module (RDM) was located in the debris field and taken into custody by the NSTB IIC for examination at the NTSB Vehicle Recorder Laboratory, Washington DC.

There were no eye-witnesses to the accident, however, a boy who was a passenger of a car reported that he thought that he saw the airplane coming out of the clouds in a descent before it disappeared out of sight behind a tree line. He stated that he then saw black smoke.

The closest weather reporting location to the accident site was from Zanesville Municipal Airport (KZZV), Zanesville, Ohio, located approximately 24 miles southwest of the accident site at an elevation of 900 feet. The airport had an un-augmented ASOS and reported the following conditions at the approximate time of the accident: Zanesville (KZZV) special weather observation at 1222 EDT (1622Z), automated, wind from 340º at 5 knots, visibility 7 miles in light rain, ceiling broken at 800 feet agl, overcast at 1,200 feet, temperature 6º C, dew point 4º C, altimeter 29.89 inches of Hg. Remarks - automated observation system, ceiling 600 variable 1,000 feet, hourly precipitation 0.01 inch.

After the on-scene phase of the investigation, the airplane wreckage was recovered to Atlanta Air Salvage, Atlanta, Georgia.


 

Dr. Emil Bisaccia
~

The Basking Ridge, New Jersey, physician was 59 when he was killed April 21, 2012 flying his Cirrus SR22 en route to Ohio, where one of his offices of Affiliated Dermatology Cosmetic Surgery Center is located. Other offices are in the Liberty Corner section of Bernards Township, Morristown, Roxbury and Somerville.
 Credit Courtesy of Affiliated Dermatology 



  Cirrus SR22, N110EB


NEWCOMERSTOWN -- The National Transportation Safety Board has not yet released information on what may have caused a New Jersey doctor to crash land into a heavily wooded area near Newcomerstown on April 21.

Dr. Emil Bisaccia, 59, of Basking Ridge, New Jersey, was killed when his 2009 Cirrus SR22 crashed while he was en route to Ohio State University Airport from Somerset Hills Airport in New Jersey.

The impact of the crash reportedly buried the engine several feet into the ground and left debris spanning the size of a football field. Bisaccia died at the scene.

The airplane's Cirrus Airframe Parachute System was examined at the accident site and evidence showed it did not deploy prior to impact, according to the preliminary report by the NTSB.