Thursday, September 27, 2012

Cirrus SR22 GTS X G3, N221DV: Accident occurred September 01, 2012 in Falmouth, Massachusetts

NTSB Identification: ERA12FA540
14 CFR Part 91: General Aviation
Accident occurred Saturday, September 01, 2012 in Falmouth, MA
Probable Cause Approval Date: 11/17/2014
Aircraft: CIRRUS DESIGN CORP SR22, registration: N221DV
Injuries: 1 Fatal, 2 Serious.

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.

During the cross-country instructional flight in the side-stick airplane, with the student pilot on the controls in the left seat and the flight instructor in the right seat, the airplane entered the landing pattern. During the final approach, witnesses saw the airplane drifting to the left while descending at a relatively high sink rate. Witnesses heard the power being adjusted, and, close to the ground, the engine went to high power. The airplane’s nose rose, and the airplane veered to the left. The airplane touched down left wing down off the runway in grass, heading about 40 degrees left of the runway centerline. It then entered woods, where it hit numerous trees and came to rest upside down and on fire. The student pilot stated that he thought the instructor was on the flight controls with him as had happened during previous flights. He also recalled the instructor pointing to the airspeed indicator on final approach and took it to mean that the airplane was slow. Although the instructor had previously used positive passing of controls on other flights, neither the student pilot nor the passenger recalled hearing him say anything during the final approach. The student pilot indicated that at some point he was not sure who was flying, although, after the accident, witnesses heard him saying multiple times that he was sorry he “did that.” Examination of the wreckage revealed no preexisting mechanical anomalies that would have precluded normal operation. Wind, as recorded at a nearby airport, was from slightly left of runway heading at 15 knots, gusting to 18 knots. Five of the instructor’s seven private pilot candidates failed their initial practical test, which went unnoticed by his flight school. However, none of the failures were due to poor landings, all the candidates passed on their second try, and all interviewed had positive words about the instructor. One of the instructor’s previous students indicated that he had ridden the controls with her as well. The instructor had been known to work extra hours, but there was no evidence that he was fatigued during the flight. The instructor likely also had a discussion with a principal of the flight school that resulted in him arriving late for the flight, but there was no indication that it distracted him during the approach. The instructor was responsible for the safety of the flight and, as such, should have effected positive remedial action before the student pilot was able to put the airplane in an unrecoverable position. 

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The flight instructor’s inadequate remedial action. Contributing to the accident was the student pilot’s poor control of the airplane during the approach. 

HISTORY OF FLIGHT

On September 1, 2012, about 1105 eastern daylight time, a Cirrus SR22, N221DV, was substantially damaged when it impacted trees during a landing attempt at Falmouth Airpark (5B6), Falmouth, Massachusetts. The certificated flight instructor (CFI) was fatally injured, and the student pilot and the passenger were seriously injured. Visual meteorological conditions prevailed, and no flight plan had been filed for the flight from Tweed-New Haven Airport (HVN), New Haven, Connecticut. The instructional flight was conducted under the provisions of 14 Code of Federal Regulations Part 91.

Due to the extent and severity of his injuries, the student pilot first provided a statement through his attorney on March 31, 2013. At that time, he stated that on the day of the accident, "the flight was conducted in the same manner as previous occasions." The student pilot had earlier advised the flight school that he and his wife wanted to fly to 5B6 to spend Labor Day weekend. When they arrived at the flight school, they met the CFI, who did the flight planning while the student pilot performed the airplane preflight inspection. 

When the CFI was ready, they boarded the airplane with the student pilot in the left seat, the CFI in the right seat, and the student pilot's wife in one of the rear seats. The student pilot was manipulating the controls and performing radio communications at the direction of the CFI. 

The flight to 5B6 was uneventful. The student pilot remembers obtaining weather information approaching Falmouth from, he believes, Hyannis, south of Falmouth. The CFI directed that he enter the landing pattern at 5B6 by flying over the airport at 3,000 feet and then descending to enter the downwind for a right traffic pattern to runway 7. They conducted the landing checklist before turning onto the base leg. 

As in the past, the student pilot was flying the airplane with the CFI's hands and feet on the controls. The student pilot remembered making a right turn to enter the base leg of the approach and turning onto final. The airplane cleared the trees at the approach end of runway 7 when the CFI said that the airplane was "low and slow." The student pilot did not remember much thereafter other than then being "jounced around a bit" in the airplane. He did not remember "seeking" the runway or touching down on or near the runway. He did not know if the CFI took control of the airplane, or if he continued to fly it, nor did he recall the CFI saying anything else to him other than they were "low and slow." The next thing the student pilot remembered was the airplane hitting trees, breaking up and coming to rest. He did not realize that there was a fire until he saw the skin on his hands was coming off. He could not unfasten his seat belt but his wife had been able to do so and had left the airplane. He called for help and she returned and unbuckled him and pulled him from the burning wreckage.

In response to additional questions posed through his attorney, and after his release from the hospital, the student pilot recalled that the CFI had not said that they were low and slow. Instead, the CFI had pointed to the airspeed indicator, "to indicate a slower than desired landing approach speed. He did not verbalize any words; he just pointed at the electronic display which I understood to mean that he wanted me to note our speed which was 69 knots, a slightly low speed. I corrected that condition…I was still in the hospital and heavily medicated when I initially spoke to [my attorney], and do not recall our exact conversation." 

The student pilot further noted that his wife was also wearing headphones, and did not recall any conversation between himself and the CFI. 
According to the student pilot's wife, her first awareness of something unusual was the crash itself. She realized that she was standing in fire in the airplane on the ground. She recalled unbuckling her husband and pulling him out of the plane with her right hand. The fire was so intense that they had to exit the airplane, and she shouted that the CFI was still in the airplane to the people who began arriving at the site.

The wife also believed that her husband was flying the airplane, with the CFI providing instruction. She did not know if the CFI had his hands on any of the airplane's controls at any point that day, but in the past had seen him do so. 

According to several witnesses, the airplane completed a right downwind for runway 7. The final approach over trees was described as "unstable, with rocking wings," and one witness asked another if he thought the airplane was going to go around. 

Exact recollections differed, but in general, witnesses recalled that as the airplane neared the runway, the airplane's rate of descent increased, and there were some additions and reductions in power. The airplane started veering to the left, there was an addition of power, and the left wing almost hit the ground. The airplane then touched down in the grass to the left of the runway, went through the last section of a wooden fence, entered some woods and burst into flames. 

In an email, one witness stated, "Subject aircraft was on a short final when he came in over the trees…he was low and slow…he got in to a high sink rate and he went to full power and pulled the nose up abruptly about 30 to 40 degrees nose up and the plane veered to the left and went in to the trees and exploded on impact." 

In an interview, one witness stated that at the crash site, the student pilot repeatedly said that he was "sorry I did that." 

PERSONNEL INFORMATION

The CFI, age 24, held a commercial pilot certificate with single engine land, multi-engine land, and instrument-airplane ratings. He also held a flight instructor certificate with single engine land, multi-engine land and instrument-airplane ratings. The CFI's latest FAA first class medical certificate was dated May 1, 2012.

The CFI completed "Cirrus Standardized Instructor Pilot" training on September 29, 2011.

A copy of the CFI's logbook entries through August 13, 2012, listed 1,519 total flight hours, with 1,407 hours of single engine flight time, and 1,002 hours of instructor time. 

The CFI's fiancée, who had moved to the local area in preparation for their wedding, was asked about the CFI's recent history leading up to the accident. According to the fiancée, she worked as a nurse during the night shift, and because of their differing schedules, and not wanting to disturb each other's sleep, she was sleeping on the couch while he slept in the bedroom. She saw the CFI on the morning of the day before the accident, but because of their work schedules, she didn't see him that night. The day of the accident, he had left for work prior to her waking up.

CFI Employer

According to the employer's attorney, "Robinson Flight, LLC ('Robinson Flight'), and Robinson Aviation, Inc. ('Robinson Aviation'), are two separate and distinct entities with their own legal status. Robinson Flight is a subsidiary company of Robinson Aviation – it is a single-member limited liability company with its single member being Robinson Aviation [Flight?]. Robinson Aviation is a C-corporation with [one person] serving as the President and Treasurer. Those who actually manage Robinson Aviation are not necessarily the same as those who manage Robinson Flight. Robinson Flight maintains its own separate payroll, has its own checks, and pays rent to Robinson Aviation. [The CFI] was employed by and paid by Robinson Flight."

"All of the time that was billed for the [student pilot's] flights was for instructional purposes." In addition, "Robinson Aviation was unaware of the passenger onboard. Officers of Robinson Flight also were unaware that there was to be a passenger on board."

CFI Student Pass Rate

According to FAA records, seven of the CFI's student pilots attempted the private pilot practical (flight) test. Of the seven, five failed the test on their initial try, but all of those passed their test on their second try.

Four of the five former students who initially failed were able to be contacted. None of the four indicated any instructional lapses for their initial failures, and none of the failures involved landing pattern work or normal landings. Two of the pilots attributed their initial performance to nerves, one due to fatigue because a family member had returned home the night before, and one included weather as a factor and was off required altitude. Most involved navigation. The designated examiner for the fifth student pilot confirmed that his failure also did not involve landing pattern work or normal landings.

When asked about the CFI's low initial pass rate, or if any corrective actions were taken, the attorney for the flight school responded, "Robinson Flight disagrees with the above characterizations. Robinson Flight is interested in seeing the basis for these conclusions. Robinson Flight saw no reason to take corrective action." 

CFI – Students' Perceptions

From the four student pilots previously noted and one additional student who switched to another airplane make and model in the midst of training (she didn't continue with the CFI because he wasn't qualified in that airplane at the time):

"Very mellow and relaxed in the cockpit. He was a good pilot, a good instructor, good instincts, who always had a plan, while other instructors would just show up to fly. He always had something he wanted to accomplish during the flight." He was also always alert; and the student pilot felt safe with him.

"The best of all of them." He was the best rounded, patient, and made the student pilot feel comfortable; "very thorough and meticulous." 

Always professional in the airplane; "encouraging," and loved to fly; always at the airport.

A "very good instructor" who knew what he wanted to do, how to do it, and then did it. The student pilot enjoyed flying with him, felt no fear with him and was comfortable with him as an instructor. 

He was a "pretty good instructor," especially compared to another instructor, and he had a lot more confidence in the student pilot. She felt very comfortable with him; he explained everything very well. 

CFI and the Destination Airport

According to the attorney for the flight school, when asked if the CFI expressed any concerns about flying to 5B6, particularly in regards to the winds/crosswinds, the response was "Not to the knowledge of Robinson Flight."

The accident student pilot was asked the same thing through his attorney and responded, "He did not express any concerns whatsoever." 

CFI Workload

According to the attorney for the flight school, "[The CFI] did not have a set schedule or general hours for Robinson Flight; he was responsible for setting and managing his own schedule including flights, ground school, and office hours. [The CFI] very rarely worked more than 40 hours per week." 

When asked if there was a contract to confirm the working arrangement, the attorney replied, "There was no written contract or written instruction explicitly stating that [the CFI] was responsible for setting and managing his own schedule. That was the practice that was acceptable to both Robinson Flight and [the CFI]."

In addition, "[the CFI] was permitted to, and from time to time did, voluntarily stay in the office on his own accord to answer phones in an attempt to garner more business. Such voluntary office hours, however, were not reflected in [his] hours or pay." 

When asked about the CFI's work schedule, his fiancée stated that he worked as many hours as he could during the week to maximize his opportunities to fly. His normal work schedule was 7 a.m. to 7 p.m. and sometimes he would fly and sometimes he would not. When asked if there were any fatigue issues, the fiancée stated that there were none that she knew of. She also stated that she would say to him that he was getting worked too hard, but he never complained. 

When asked if there were any other issues at work, the fiancée stated that there were no issues that she knew of.

CFI – Accident Student Pilot Relations 

According to the fiancée, the CFI had a good rapport with all his students. 

When asked about the relationship between the CFI and the student pilot/owner of the airplane, she stated that it was a very good one. She did not hear anything negative about student pilot and even if there was something, the CFI was professional in that he never said anything about any of his students. 

The fiancée also stated that the CFI had a "great" relationship with the student pilot. In fact, the student pilot let the CFI use his airplane when he wanted, as long as he put fuel in it. About 2 weeks prior to the accident, the CFI and fiancée flew together in the airplane to Ohio to get their wedding license. 

Accident Student Pilot

The student pilot, age 55, stated that he had 117 hours of flight time at the time of the accident, and that his logbook was destroyed in the postcrash fire. His FAA third class medical certificate was issued on February 7, 2012.

He also stated that he stated that he started taking flight training at "Robinson Aviation," and was introduced to a Cirrus SR20 as well as other types of airplanes. Since he was interested in buying an airplane, he researched what was available and decided on a Cirrus SR22 based on its performance, load carrying ability and utility. When he purchased the accident airplane, he had accumulated about 17 hours of dual instruction and continued to take flight instruction at Robinson, where he was assigned the accident CFI as his primary instructor.

The student pilot further noted that most of his flight instruction began with a ground briefing where the CFI would explain what they would be doing, including the maneuvers to be performed. The student pilot would perform the preflight inspection of the airplane. 

The student pilot would sit in the left seat, and the CFI in the right seat. Throughout each lesson, whether they were maneuvering or flying in the traffic pattern, the CFI would keep his hands on the controls while the student pilot flew the airplane, "meaning he would keep the right-hand side stick in his right hand, his feet on the rudder pedals and his left hand on the throttle below my hand." During the lessons there were many occasions where the CFI would take control of the airplane if he felt he should do so, then would typically explain the reason for doing so and, if appropriate, have the student pilot perform the maneuver again.

On occasion, the student pilot and his wife would want to go somewhere overnight or for a weekend, and the only way they could use the airplane was to hire "Robinson Aviation" to transport them. The accident CFI would fly those trips. They would meet at HVN at Robinson facilities where the CFI would take care of all flight planning duties, and the student pilot would typically perform the preflight inspection. During the flight, the student pilot would sit in the left seat with the CFI in the right seat and the student pilot's wife in one of the rear seats. Upon arrival at the destination airport, the student pilot would fly the traffic pattern and make the landing, again with the CFI providing direction and keeping his hands and feet on the controls.

After deplaning at the intermediate destination, the CFI would then fly the airplane back to HVN, and when the student pilot and his wife were ready to return home, the CFI would return to pick them up. The flight back would then be conducted in the same manner as the outbound flight. The student pilot paid Robinson for each of the flights.

The student pilot's wife confirmed that there had been a number of occasions where the CFI had flown with them to a destination, then fly the airplane back to HVN and return to pick them up again for the return trip home. It was her understanding that the CFI was providing instruction to her husband and that his credit card was billed by Robinson Aviation.

When asked why, with 117 hours of flight time, the student pilot had not taken his private pilot test yet, he replied through his attorney, "He was not in a rush to obtain his private pilot certificate and believed that the additional time and instruction would only make him a better, safer, pilot. He also advises that a substantial amount of his flight hours, perhaps 30 hours, were conducted in a manner similar to the day of the accident where he was being taken to a location by [the CFI] and was not devoted to instruction. He also advises that he had not completed several areas of required instruction that was needed before he could obtain his license, including night flying and cross country solo work."

When asked if there were any problem areas that the CFI suggested needed more work, the student pilot responded through his attorney, "[The CFI] suggested no areas to focus on during the flight that day." The student pilot also stated that the CFI had not advised him of any areas that needed special attention in the recent past leading up to the accident flight. Before an instructional flight, the CFI would usually tell the student pilot what area they would focus on that day, such as landings or stalls, "although on occasion, he would just suggest that they go out and fly, or something to that effect." 

CFI on the Controls

Because the student pilot indicated that the CFI would be on (ride) the controls with him at times, the question of riding the controls was asked of the other five student pilots who were interviewed. Three said he did not ride the controls, one said that he would be on the rudders and one, who was only with the CFI before her solo, said he did. All but one of the student pilots flew with the CFI in a conventional, yoke-configured airplane. The one who flew with him in a side-stick Cirrus was also one of the student pilots who said the CFI did not ride the controls, but further noted that he had about 60 hours' experience in a Cirrus while taking previous training in California. 

CFI Distractions

On the morning of the accident, another flight instructor spoke with the CFI as he was walking out to the accident airplane. The CFI seemed upset and for the first time ever, made disparaging remarks about the president of Robinson Aviation. The other CFI did not ask about what brought about the remarks. 

The student pilot also stated that they were delayed about an hour in waiting for the CFI, and that he appeared "normal but slightly distracted," but said something like, "ready to have some fun." During the flight, the CFI "seemed to be his normal self but somewhat casual." 

AIRPLANE INFORMATION

The airplane, which was manufactured in 2008, was purchased by the student pilot in 2012 from a Fort Lauderdale, Florida, company. A pre-buy inspection was completed on March 28, 2012, at 768.2 flight hours, 842.0 Hobbs hours; an annual inspection was completed April 10, 2012, with the same number of flight hours noted; and the student pilot accepted the airplane on April 15, 2012.

Additional maintenance logged by Robinson Aviation included a change of the batteries on August 28, 2012, and an alternator change on August 31, 2012, at 875.9 flight hours, 965.3 Hobbs hours. 

AIRPORT INFORMATION

Falmouth Airpark had a single runway, 7/25, that was 2,298 feet long and 40 feet wide. Runway 7 elevation threshold was 38 feet. There was no control tower or recorded communications. 

METEROROLOGICAL INFORMATION

Weather, recorded at an air national guard base 4 miles to the north, at 1055, included a few clouds at 1,600 feet, visibility 10 statute miles, wind from 050 degrees true (066 degrees magnetic), at 15, gusting to 18 knots, temperature 24 degrees C, dew point 19 degrees C, altimeter setting 30.02 inches Hg. 

WRECKAGE INFORMATION

An examination of the accident site revealed skid marks in the grass to the left of the runway, with the mark attributed to the position of the left main landing gear appearing first. The marks commenced about 80 feet left of the runway, 300 feet from the approach end, and headed about 030 degrees magnetic, toward the woods. The airplane's left wing was found separated from the rest of the airplane at the first large tree in the woods, and the airplane came to rest about 80 feet beyond that tree, upside down.

The airplane was mostly consumed by fire. Evidence of all flight control surfaces was found at the scene, and continuity was confirmed from the cockpit along the lengths of all flight control cables. The flap actuator indicated that the flaps were at 50 percent. 

The engine exhibited severe fire damage, and the crankshaft could not be rotated. Two of the three metal propeller blades exhibited torsional bending, and one blade could be rotated in the hub. The third propeller blade was straight, but had cut into the propeller spinner toward the direction of rotation. The spinner also had a large concave indentation in it, similar in shape to a tree trunk. 

Data chips were not recovered from the primary flight display and multifunction display, which were charred and jelled together. The tail-mounted remote data module was recovered and forwarded to the NTSB Recorders Laboratory; however, the unit was thermally damaged internally, and no data extraction was possible. 

MEDICAL AND TOXICOLOGICAL INFORMATION 

An autopsy was conducted on the CFI by the Commonwealth of Massachusetts, office of the Chief Medical Examiner, Boston, Massachusetts. Cause of death was listed as, "inhalation of heated gases and thermal injuries."

Toxicological testing, which was performed by the FAA Forensic Toxicology Research Team, Oklahoma City, Oklahoma, included 10 percent carbon monoxide saturation in heart blood, and no drugs detected. 

ADDITIONAL INFORMATION

FAA Advisory Circular 61-115, "Positive Exchange of Flight Controls Program," states that, "Numerous accidents have occurred due to a lack of communication or misunderstanding as to who actually had control of the aircraft, particularly between students and flight instructors." In addition, "During flight training, there must always be a clear understanding between students and flight instructors of who has control of the aircraft."

FAA-H-8083-25, "Pilot's Handbook of Aeronautical Knowledge," notes that, "To the pilot, 'torque' (the left turning tendency of the airplane) is made up of four elements:"

1. Torque reaction from the engine and propeller, which, for most U.S. engines that rotate the propeller clockwise as viewed from the pilot's seat, tend to make the airplane roll left.
2. Corkscrewing effect of the slipstream, which at high propeller speeds and low forward airplane speed, produces a compact spiraling rotation of the slipstream that exerts a strong sideward force on the airplane's left side of the vertical tail surface.
3. Gyroscopic action (precession) of the propeller, that produces yawing and pitching.
4. Asymmetric loading of the propeller (P Factor), that, during high angles of attack, results in the downward propeller blades moving faster than the upward blades, creating more lift from the downward blades which tends to pull (yaw) the airplane's nose to the left.

http://registry.faa.gov/N221DV

http://www.flickr.com/photo

NTSB Identification: ERA12FA540 
14 CFR Part 91: General Aviation
Accident occurred Saturday, September 01, 2012 in Falmouth, MA
Aircraft: CIRRUS DESIGN CORP SR22, registration: N221DV
Injuries: 1 Fatal,2 Serious.

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 September 1, 2012, about 1100 eastern daylight time, a Cirrus SR22, N221DV, was substantially damaged when it impacted trees during a landing attempt at Falmouth Airpark (5B6), Falmouth, Massachusetts. The flight instructor was fatally injured, and the student pilot and passenger were seriously injured. Visual meteorological conditions prevailed, and no flight plan had been filed for the flight from Tweed-New Haven Airport (NVN), New Haven, Connecticut. The instructional flight was conducted under the provisions of 14 Code of Federal Regulations Part 91.

While the student pilot and a passenger survived the accident, due to the extent of their injuries, they could not be interviewed. According to several witnesses, the airplane completed a right downwind for runway 7. The final approach over trees was described as "unstable, with rocking wings," and one witness asked another if he thought the airplane was going to go around.

Exact recollections differed, but in general, witnesses recalled that as the airplane neared the runway, there were some additions and reductions in power. The airplane started veering to the left, there was an addition of power, and the left wing almost hit the ground. The airplane then touched down in the grass to the left of the runway, went through the last section of a wooden fence, entered some woods and burst into flames.

An examination of the accident site revealed skid marks in the grass to the left of the runway, with the mark attributed to the position of the left main landing gear appearing first. The marks commenced about 80 feet left of the runway, 300 feet from the approach end, and headed about 030 degrees magnetic, toward the woods. The airplane's left wing was found separated from the rest of the airplane at the first large tree in the woods, and the airplane came to rest about 80 feet beyond that tree, upside down.

The airplane was mostly consumed by fire. Evidence of all flight control surfaces was found at the scene, and continuity was confirmed from the cockpit along the lengths of all flight control cables. The flap actuator indicated that the flaps were at 50 percent.

The engine exhibited severe fire damage, and the crankshaft could not be rotated. Two of the three metal propeller blades exhibited torsional bending, and one blade could be rotated in the hub. The third propeller blade was straight, but had cut into the propeller spinner toward the direction of rotation. The spinner also had a large concave indentation in it, similar in shape to a tree trunk.

Data chips were not recovered from the primary flight display and multifunction display, which were charred and jelled together. The tail-mounted remote data module was recovered and forwarded to the NTSB Recorders Laboratory; however, the unit was thermally damaged internally and no data extraction was possible. The unit's memory chip was then extracted and attempts to restore it are ongoing.


 



.  


 

No comments:

Post a Comment