Abrupt Maneuver: Cirrus SR22T, N707DF; fatal accident occurred February 21, 2018 near Montgomery-Gibbs Executive Airport (KMYF), San Diego, California

Aviation Investigation Report: Loss of Engine Power due to Excessive Fuel Flow in Cirrus SR22T Aircraft 

The NTSB has released an Aviation Investigation Report (AIR-22-04) urging Cirrus Aircraft and the Federal Aviation Administration (FAA) to address safety issues identified in investigations involving Cirrus SR22T airplanes in which an excessive fuel condition led to a loss of engine power during the takeoff climb. We investigated six accidents involving Cirrus SR22T airplanes; in five of them, we were able to retrieve fuel flow data from the recoverable data modules (RDM) installed in the accident airplanes. In each case, the fuel flow data indicated an excessively high fuel flow (ranging from 42.2 to 50.1 gallons per hour [gph]) to the engine just before the loss of power.

What You Should Know

Our examination of these investigations suggests a lack of system safety assessments to identify the cause and reduce the potential of the hazard from occurring. We concluded:

the Cirrus SR22T can experience a loss of engine power due to excessive fuel flow and some causes of excessive fuel flow during takeoff and climb may not have been identified and mitigated. We have recommended that Cirrus Aircraft conduct a functional hazard assessment (FHA) to identify the causes, effects, and severity levels for the SR22T excessive fuel flow hazard condition during takeoff and climb phases of flight and, based on the FHA, update the system safety assessment. 

until the FAA requires implementation of appropriate mitigating actions to prevent the loss of engine power due to excessive fuel flow in the SR22T, additional accidents may occur due to this hazard. We have recommended the FAA review the functional hazard assessment (FHA) recommended in Safety Recommendation A-22-7 and ensure it meets the objectives of Advisory Circular 23.1309-1 E. Upon approval of the FHA, work with Cirrus to identify necessary mitigating actions and require their implementation through the appropriate means, such as an airworthiness directive. 

What You Can Do

We encourage all pilots and operators with Cirrus Aircraft to read this AIR and review the circumstances of the six accidents investigated by the NTSB.

Aviation Accident Final Report - National Transportation Safety Board

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; San Diego, California
Cirrus Aircraft; Duluth, Minnesota
Continental Motors; Mobile, Alabama
Hartzell Propeller; Piqua, Ohio

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

http://registry.faa.gov/N707DF

Location: San Diego, CA

Accident Number: WPR18FA093

Date & Time: 02/21/2018, 0631 PST

Registration: N707DF

Aircraft: CIRRUS DESIGN CORP SR22T

Aircraft Damage: Substantial

Defining Event: Abrupt maneuver

Injuries: 1 Fatal

Flight Conducted Under: Part 91: General Aviation - Personal

Analysis 

The private pilot was taking off in the airplane when witnesses heard the airplane lose engine power at low altitude and described a sequence of events consistent with an aerodynamic stall/spin. Data retrieved from onboard the airplane recorded 47 power cycles, including the accident takeoff. The data revealed an abnormally high fuel flow, about 46 gallons per hour (gph), when takeoff power was applied, reaching 50.1 gph as the airplane entered the initial climb. About 300 ft above ground level (agl), the airplane experienced a total loss of engine power and began to decelerate and roll to the right. The airplane then entered a steep left bank and nearly vertical nose-down attitude as it descended to ground contact. The final data point at 50 ft agl indicated that the airplane was in an 81° nose-down pitch attitude and a 157° (inverted) left roll. The data is consistent with the pilot attempting to return to the runway following a loss of engine power at low altitude and an aerodynamic stall/spin when the pilot exceeded the airplane's critical angle of attack during the turn.

Examination of the engine revealed signatures consistent with an excessively rich fuel/air mixture. The fuel manifold and engine-driven fuel pump were removed from the engine and installed onto a slave engine for a test run, during which the slave engine began to surge when the power was increased to 2,300 rpm; the fuel pressure indicated 234 psi (about 39 gph); a nominal value was 210-220 psi. The engine-driven fuel pump adjustment screw was adjusted in the lean direction, and the engine operated within normal parameters; however, when the test cell fuel boost pump was turned on, the engine lost total power.

The airplane was equipped with an electric fuel boost pump that could be manually activated by the pilot via a cockpit switch. The pump had two modes; the BOOST position supplied an additional 4-6 psig at 19 gph to the engine and was used for vapor suppression when required and during takeoff, climb, landing, and when switching fuel tanks. The HIGH BOOST/PRIME position provided a capacity of 42 gph at 16 psig with a maximum full relief (no flow) pressure of 23 psig to the engine, and was used for priming the engine before start and suppressing vapor formation at flight altitudes above 18,000 ft with hot fuel.

It is likely that the excess fuel being delivered to the engine during the initial climb resulted in the total loss of power; however, the reason for the excessive fuel flow values could not be determined. According to the manufacturer, the initial fuel flow adjustments occurred at the factory about 4 months before the accident and before the pilot took delivery of the airplane. There were no maintenance logbook entries to indicate that the fuel flow had been adjusted since that time. The data did not indicate a gradual increase in fuel flow values over time; therefore, it is unlikely that the engine-driven fuel pump adjustment screw was becoming loose. It is possible that the pilot placed the fuel boost pump in the HIGH BOOST/PRIME position before takeoff, which would have increased fuel flow to about 42 gph, but this scenario does not account for the 50-gph fuel flow value reflected in the data. (The fuel boost pump position was not a recorded parameter and the position of the switch at the time of takeoff could not be determined.) Thus, based on the available information, the reason for the fuel flow rates being so high during the takeoff could not be determined.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

The pilot's exceedance of the airplane's critical angle of attack during an attempted return to the runway following a total loss of engine power after takeoff, which resulted in an aerodynamic stall. Contributing to the accident was the excessive amount of fuel being delivered to the engine for reasons that could not be determined based on the available information.

Findings

Aircraft

Angle of attack - Capability exceeded (Cause)

Fuel - Fluid management (Factor)

Fuel pumps - Not specified

Personnel issues

Aircraft control - Pilot (Cause)

Not determined

Not determined - Unknown/Not determined (Factor)

Factual Information

History of Flight

Initial climb

Fuel related

Loss of engine power (total)

Approach

Abrupt maneuver (Defining event)

Aerodynamic stall/spin

Uncontrolled descent

Collision with terr/obj (non-CFIT) 

On February 21, 2018, about 0631 Pacific standard time, a Cirrus SR22T airplane, N707DF, impacted terrain shortly after takeoff from Montgomery-Gibbs Executive Airport (MYF), San Diego, California. The private pilot was fatally injured and the airplane sustained substantial damage. The airplane was registered to the pilot who was operating it as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed and no flight plan was filed for the flight, which was originating at the time of the accident.

Three witnesses provided statements regarding the accident. One stated that the airplane was "not very high" when the engine "went silent" and produced a small trail of black smoke that dissipated quickly. The airplane then entered a nose-down descent to ground contact. Another witness also described a sound consistent with a loss of engine power. The third witness recalled hearing the airplane's engine but stated that it was quiet. When the airplane was "just above the treeline," it turned right and shortly thereafter, "went straight down."

The airplane came to rest in a dirt construction site about 1/2 mile northwest of the departure end of MYF runway 5.

The airplane's recoverable data module (RDM) was removed for download at the National Transportation Safety Board Recorders Laboratory. The data revealed 47 power cycles. During the taxi, when the airplane turned to runway heading, the engine stabilized at a power setting of about 2,490 rpm and manifold pressure of about 35.3 inches of mercury (inHg). The fuel flow rate indicated over 46 gallons per hour (gph). As the airplane began its initial climb at 100 knots, the manifold pressure began to rise, reaching 36.6 inHg. The fuel flow also began to increase, reaching a peak value of 50.1 gph. Several seconds later, the manifold pressure decreased to its previous level of 35.3 inHg, and the fuel flow remained at 50.1 gph. Shortly thereafter, about 300 ft above ground level, the engine rpm, manifold pressure, exhaust gas temperature, and fuel flow began to decrease sharply. The airplane began to decelerate and rolled to the right. The airplane's left wing then dropped, and the airplane entered a nose-down pitch attitude. The final data point, at 50 ft agl, indicated that the airplane was in an 81°-nose-down pitch attitude with a 157° angle of bank.

The RDM captured two flights the day before the accident; review of the data revealed no anomalies. During those takeoffs, the engine stabilized at a power setting of about 2,490 rpm and 35.8 inHg manifold pressure; the fuel flow stabilized between 38 and 40 gph.

Pilot Information

Certificate: Private
Age: 61, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 08/26/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 03/28/2017
Flight Time:  2700 hours (Total, all aircraft), 1000 hours (Total, this make and model), 2600 hours (Pilot In Command, all aircraft), 15 hours (Last 90 days, all aircraft), 2 hours (Last 24 hours, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: CIRRUS DESIGN CORP
Registration: N707DF
Model/Series: SR22T
Aircraft Category: Airplane
Year of Manufacture: 2017
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 1621
Landing Gear Type: Tricycle
Seats: 5
Date/Type of Last Inspection: 02/16/2017, Condition
Certified Max Gross Wt.:
Time Since Last Inspection: 2 Hours
Engines: 1 Reciprocating
Airframe Total Time: 66 Hours at time of accident
Engine Manufacturer: Continental Motors
ELT: C126 installed, not activated
Engine Model/Series: TSIO-550-K
Registered Owner: On file
Rated Power: 315 hp
Operator: On file
Operating Certificate(s) Held: None

The airplane was manufactured in October 2017 and the pilot took delivery on November 1, 2017. The pilot had previously owned at least two Cirrus aircraft before the accident airplane; one was a SR22T and the other was a SR22. On November 4, 2017, the Cirrus Design Factory Service Center made a minor adjustment to the manifold pressure setting and subsequent ground engine run before the pilot's departure. According to a Cirrus Aircraft representative, the initial fuel flow adjustments occurred on October 11, 2017 at the Cirrus Aircraft factory.

At the accident site, the Hobbs meter read 66.1 hours and the flight meter indicated 52.7 hours. Review of the maintenance logs revealed a 50-hour inspection and oil change on February 16, 2018, which included an exhaust check and turbo check valve inspection.

The airplane's fuel system was equipped with an electric fuel boost pump, which could be manually activated by the pilot via a cockpit switch. The BOOST position supplied an additional 4-6 psig at 19 gph to the engine, which was used for vapor suppression when required, and during takeoff, climb, landing, and when switching fuel tanks. The HIGH BOOST/PRIME position provided a capacity of 42 gph at 16 psig with a maximum full relief (no flow) pressure of 23 psig to the engine; this position was used for priming the engine before start and for suppressing vapor formation at flight altitudes above 18,000 ft with hot fuel. Electric fuel boost pump operation was not recorded by the RDM.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Dawn
Observation Facility, Elevation: MYF, 427 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 0653 PST
Direction from Accident Site: 240°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: Broken / 10000 ft agl
Visibility (RVR):
Wind Speed/Gusts: 6 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 120°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.13 inches Hg
Temperature/Dew Point: 7°C / -4°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: San Diego, CA (MYF)
Type of Flight Plan Filed: None
Destination: Yuma, AZ (YUM)
Type of Clearance: None
Departure Time: 0630 PST
Type of Airspace:

Airport Information

Airport: Montgomery-Gibbs Executive Air (MYF)
Runway Surface Type: Asphalt
Airport Elevation:427 ft 
Runway Surface Condition: Dry
Runway Used: 5
IFR Approach: None
Runway Length/Width: 3400 ft / 75 ft
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 32.818889, -117.123056 (est) 

Along the northern side of the accident site was a line of undamaged trees and a light pole with right wing pieces embedded in its base. The first identified point of impact was a small crater from which two narrow indentations extended outward; one propeller blade came to rest next to the crater. Northwest of the small crater was a damaged fence and the outboard portion of the right wing. Southwest of the small crater was a damaged roadway curb with embedded white airframe fragments; other airframe fragments were noted in the immediate area. The main wreckage was located about 7 ft northeast of the initial impact point. The forward fuselage was heavily fragmented and the airframe around the cabin was destroyed. The left wing trailing edge was embedded in the dirt and the wing skin was fracture separated. The inboard right wing was still mostly secured to the airframe; however, the outboard portion was fracture separated. The aft fuselage and empennage were mostly intact and undamaged. The Cirrus Airframe Parachute System (CAPS) parachute was found extended from the aft fuselage; however, it was unopened.

Postaccident examination of the airframe revealed that the CAPS activation handle was stowed and the safety pin remained installed. Flight control continuity was established throughout the airframe. The flaps were in the retracted position. All three propeller blades sustained damage to the trailing edges; two blades were still attached to the propeller hub.

Postaccident examination of the engine revealed operating signatures consistent with an overly rich fuel/air mixture. The spark plugs were sooty and black in color. The cylinders were removed from the engine; the combustion chambers and valve heads were very sooty. In addition, the piston heads exhibited combustion deposits and were sooty. Examination of the turbocharger system revealed spiral streaking on the turbine housing outlet. The fuel manifold and engine-driven fuel pump were removed from the engine and installed onto a slave engine for an engine run.

The slave engine was installed onto a test bench and started normally. After idling for a short time, the power was increased to 2,300 rpm and the engine started to surge; the fuel pressure indicated 234 psi (about 39 gph) and the engine was unable to produce full power. The fuel pressure specification for the engine is 210-220 psi. The engine-driven fuel pump adjustment screw was measured and adjusted in the lean direction. The engine was restarted, and the engine operated up to 2,566 rpm (full power) with a fuel pressure reading between 200 and 213 psi. The test cell fuel boost pump was turned on and the engine lost all power. The engine-driven fuel pump was adjusted back to its original position and the engine was restarted. The throttle was increased to 2,404 rpm and the engine began to surge again. The fuel pressure gauge varied from 220 psi to 261 psi (about 44 gph). Toward the top of the surge, the fuel pressure gauge stayed between 250-260 psi when it would spike at about 260 psi, then return to about 220 psi.

Further examination of the fuel pump revealed that a green paint stripe was present on the adjustment screw and nut; the paint stripe had been previously broken and the paint on the nut did not match the paint on the screw (before adjusting it in the test cell). The green paint is consistent with being applied when the pump was assembled and tested. According to Cirrus Aircraft, once the engine is assembled, it is then shipped and installed onto the airplane, where Cirrus Aircraft employees make changes to the adjustment screw during the engine set up and precertification flight test. Cirrus does not apply torque stripe or paint after making these adjustments, nor are they required to. 

Medical And Pathological Information

An autopsy of the pilot was performed by the San Diego County Coroner, San Diego, California. The cause of death was listed as multiple blunt force injuries.

Toxicology testing was performed by the Federal Aviation Administration Forensic Sciences Laboratory with negative results for carbon monoxide, ethanol, and tested-for drugs.

Dr. John Harvey Serocki

Dr. Serocki graduated from the University of California, San Diego with a degree in applied mechanics and engineering sciences and went on to earn a master's degree in mechanical engineering from the Massachusetts Institute of Technology. He subsequently earned a medical degree from Northwestern University, Feinberg School of Medicine. He practiced as an orthopedic surgeon for more than 25 years with a specialization in Sports Medicine and Hand Surgery. 

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; San Diego, California
Cirrus Aircraft; Duluth, Minnesota
Continental Motors; Mobile, Alabama
Hartzell Propeller; Piqua, Ohio

Location: San Diego, CA
Accident Number: WPR18FA093
Date & Time: 02/21/2018, 0631 PST
Registration: N707DF
Aircraft: CIRRUS DESIGN CORP SR22T
Aircraft Damage: Substantial
Defining Event: Fuel related
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On February 21, 2018, about 0631 Pacific standard time, a Cirrus SR22T airplane, N707DF, impacted terrain shortly after takeoff from Montgomery-Gibbs Executive Airport (MYF), San Diego, California. The private pilot was fatally injured and the airplane sustained substantial damage. The airplane was registered to the pilot who was operating it as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed and no flight plan was filed for the flight, which was originating at the time of the accident.

Three witnesses provided statements regarding the accident. One stated that the airplane was "not very high" when the engine "went silent" and produced a small trail of black smoke that dissipated quickly. The airplane then entered a nose-down descent to ground contact. Another witness also described a sound consistent with a loss of engine power. The third witness recalled hearing the airplane's engine but stated that it was quiet. When the airplane was "just above the treeline," it turned right and shortly thereafter, "went straight down."

The airplane came to rest in a dirt construction site about 1/2 mile northwest of the departure end of MYF runway 5.

The airplane's recoverable data module (RDM) was removed for download at the National Transportation Safety Board Recorders Laboratory. The data revealed 47 power cycles. During the taxi, when the airplane turned to runway heading, the engine stabilized at a power setting of about 2,490 rpm and manifold pressure of about 35.3 inches of mercury (inHg). The fuel flow rate indicated over 46 gallons per hour (gph). As the airplane began its initial climb at 100 knots, the manifold pressure began to rise, reaching 36.6 inHg. The fuel flow also began to increase, reaching a peak value of 50.1 gph. Several seconds later, the manifold pressure decreased to its previous level of 35.3 inHg, and the fuel flow remained at 50.1 gph. Shortly thereafter, about 300 ft above ground level, the engine rpm, manifold pressure, exhaust gas temperature, and fuel flow began to decrease sharply. The airplane began to decelerate and rolled to the right. The airplane's left wing then dropped, and the airplane entered a nose-down pitch attitude. The final data point, at 50 ft agl, indicated that the airplane was in an 81°-nose-down pitch attitude with a 157° angle of bank.

The RDM captured two flights the day before the accident; review of the data revealed no anomalies. During those takeoffs, the engine stabilized at a power setting of about 2,490 rpm and 35.8 inHg manifold pressure; the fuel flow stabilized between 38 and 40 gph.

Pilot Information

Certificate: Private
Age: 61, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 08/26/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 03/28/2017
Flight Time:  2700 hours (Total, all aircraft), 1000 hours (Total, this make and model), 2600 hours (Pilot In Command, all aircraft), 15 hours (Last 90 days, all aircraft), 2 hours (Last 24 hours, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: CIRRUS DESIGN CORP
Registration: N707DF
Model/Series: SR22T
Aircraft Category: Airplane
Year of Manufacture: 2017
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 1621
Landing Gear Type: Tricycle
Seats: 5
Date/Type of Last Inspection: 02/16/2017, Condition
Certified Max Gross Wt.:
Time Since Last Inspection: 2 Hours
Engines: 1 Reciprocating
Airframe Total Time: 66 Hours at time of accident
Engine Manufacturer: Continental Motors
ELT: C126 installed, not activated
Engine Model/Series: TSIO-550-K
Registered Owner: On file
Rated Power: 315 hp
Operator: On file
Operating Certificate(s) Held: None

The airplane was manufactured in October 2017 and the pilot took delivery on November 1, 2017. The pilot had previously owned at least two Cirrus aircraft before the accident airplane; one was a SR22T and the other was a SR22. On November 4, 2017, the Cirrus Design Factory Service Center made a minor adjustment to the manifold pressure setting and subsequent ground engine run before the pilot's departure. According to a Cirrus Aircraft representative, the initial fuel flow adjustments occurred on October 11, 2017 at the Cirrus Aircraft factory.

At the accident site, the Hobbs meter read 66.1 hours and the flight meter indicated 52.7 hours. Review of the maintenance logs revealed a 50-hour inspection and oil change on February 16, 2018, which included an exhaust check and turbo check valve inspection.

The airplane's fuel system was equipped with an electric fuel boost pump, which could be manually activated by the pilot via a cockpit switch. The BOOST position supplied an additional 4-6 psig at 19 gph to the engine, which was used for vapor suppression when required, and during takeoff, climb, landing, and when switching fuel tanks. The HIGH BOOST/PRIME position provided a capacity of 42 gph at 16 psig with a maximum full relief (no flow) pressure of 23 psig to the engine; this position was used for priming the engine before start and for suppressing vapor formation at flight altitudes above 18,000 ft with hot fuel. Electric fuel boost pump operation was not recorded by the RDM.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Dawn
Observation Facility, Elevation: MYF, 427 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 0653 PST
Direction from Accident Site: 240°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: Broken / 10000 ft agl
Visibility (RVR):
Wind Speed/Gusts: 6 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 120°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.13 inches Hg
Temperature/Dew Point: 7°C / -4°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: San Diego, CA (MYF)
Type of Flight Plan Filed: None
Destination: Yuma, AZ (YUM)
Type of Clearance: None
Departure Time: 0630 PST
Type of Airspace:

Airport Information

Airport: Montgomery-Gibbs Executive Air (MYF)
Runway Surface Type: Asphalt
Airport Elevation:427 ft 
Runway Surface Condition: Dry
Runway Used: 5
IFR Approach: None
Runway Length/Width: 3400 ft / 75 ft
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 32.818889, -117.123056 (est) 

Along the northern side of the accident site was a line of undamaged trees and a light pole with right wing pieces embedded in its base. The first identified point of impact was a small crater from which two narrow indentations extended outward; one propeller blade came to rest next to the crater. Northwest of the small crater was a damaged fence and the outboard portion of the right wing. Southwest of the small crater was a damaged roadway curb with embedded white airframe fragments; other airframe fragments were noted in the immediate area. The main wreckage was located about 7 ft northeast of the initial impact point. The forward fuselage was heavily fragmented and the airframe around the cabin was destroyed. The left wing trailing edge was embedded in the dirt and the wing skin was fracture separated. The inboard right wing was still mostly secured to the airframe; however, the outboard portion was fracture separated. The aft fuselage and empennage were mostly intact and undamaged. The Cirrus Airframe Parachute System (CAPS) parachute was found extended from the aft fuselage; however, it was unopened.

Postaccident examination of the airframe revealed that the CAPS activation handle was stowed and the safety pin remained installed. Flight control continuity was established throughout the airframe. The flaps were in the retracted position. All three propeller blades sustained damage to the trailing edges; two blades were still attached to the propeller hub.

Postaccident examination of the engine revealed operating signatures consistent with an overly rich fuel/air mixture. The spark plugs were sooty and black in color. The cylinders were removed from the engine; the combustion chambers and valve heads were very sooty. In addition, the piston heads exhibited combustion deposits and were sooty. Examination of the turbocharger system revealed spiral streaking on the turbine housing outlet. The fuel manifold and engine-driven fuel pump were removed from the engine and installed onto a slave engine for an engine run.

The slave engine was installed onto a test bench and started normally. After idling for a short time, the power was increased to 2,300 rpm and the engine started to surge; the fuel pressure indicated 234 psi (about 39 gph) and the engine was unable to produce full power. The fuel pressure specification for the engine is 210-220 psi. The engine-driven fuel pump adjustment screw was measured and adjusted in the lean direction. The engine was restarted, and the engine operated up to 2,566 rpm (full power) with a fuel pressure reading between 200 and 213 psi. The test cell fuel boost pump was turned on and the engine lost all power. The engine-driven fuel pump was adjusted back to its original position and the engine was restarted. The throttle was increased to 2,404 rpm and the engine began to surge again. The fuel pressure gauge varied from 220 psi to 261 psi (about 44 gph). Toward the top of the surge, the fuel pressure gauge stayed between 250-260 psi when it would spike at about 260 psi, then return to about 220 psi.

Further examination of the fuel pump revealed that a green paint stripe was present on the adjustment screw and nut; the paint stripe had been previously broken and the paint on the nut did not match the paint on the screw (before adjusting it in the test cell). The green paint is consistent with being applied when the pump was assembled and tested. According to Cirrus Aircraft, once the engine is assembled, it is then shipped and installed onto the airplane, where Cirrus Aircraft employees make changes to the adjustment screw during the engine set up and precertification flight test. Cirrus does not apply torque stripe or paint after making these adjustments, nor are they required to. 

Medical And Pathological Information

An autopsy of the pilot was performed by the San Diego County Coroner, San Diego, California. The cause of death was listed as multiple blunt force injuries.

Toxicology testing was performed by the Federal Aviation Administration Forensic Sciences Laboratory with negative results for carbon monoxide, ethanol, and tested-for drugs. 

Location: San Diego, CA
Accident Number: WPR18FA093
Date & Time: 02/21/2018, 0631 PST
Registration: N707DF
Aircraft: CIRRUS DESIGN CORP SR22T
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal

On February 21, 2018, about 0631 Pacific standard time, a Cirrus SR22T airplane, N707DF, impacted terrain shortly after taking off from Montgomery-Gibbs Executive Airport (MYF), San Diego, California. The pilot was fatally injured and the airplane sustained substantial damage throughout. The airplane was registered to and operated by the pilot as a 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed, and no flight plan was filed. The flight originated from MYF and was destined for Yuma, Arizona.

Witnesses reported that when the airplane was about level with the treetops, the engine sputtered and lost power. The airplane subsequently banked to the right and descended rapidly to the ground.

The airplane has been recovered to a secure location for further examination. 

Aircraft and Owner/Operator Information

Aircraft Manufacturer: CIRRUS DESIGN CORP
Registration: N707DF
Model/Series: SR22T
Aircraft Category: Airplane
Amateur Built: No
Operator: On file
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Dawn
Observation Facility, Elevation: MYF, 427 ft msl
Observation Time: 0653 PST
Distance from Accident Site: 1 Nautical Miles
Temperature/Dew Point: 7°C / -4°C
Lowest Cloud Condition: Clear
Wind Speed/Gusts, Direction: 6 knots, 120°
Lowest Ceiling: Broken / 10000 ft agl
Visibility:  10 Miles
Altimeter Setting: 30.13 inches Hg
Type of Flight Plan Filed: None
Departure Point: San Diego, CA (MYF)
Destination: Yuma, AZ (YUM) 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 32.818889, -117.123056 (est)

Dr. John Harvey Serocki

June 8, 1956 - February 21, 2018 

Dr. Serocki graduated from the University of California, San Diego with a degree in applied mechanics and engineering sciences and went on to earn a master's degree in mechanical engineering from the Massachusetts Institute of Technology. He subsequently earned a medical degree from Northwestern University, Feinberg School of Medicine. He practiced as an orthopedic surgeon for more than 25 years with a specialization in Sports Medicine and Hand Surgery. 

Dr. John Harvey Serocki

San Diego --  Dr. John Harvey Serocki tragically lost his life on February 21, 2018 at the age of 61. John is survived by wife Yvonne Serocki; sister Michele J. Serocki Bluhm and husband Wolfgang; brother Steven Serocki and wife Anne Holler; brother Robert Serocki; daughter Sarah Clark; son Scott Clark and wife Nicole; and grandchildren Elizabeth Hope, Caitlin Joy, and Joshua Michael. He was preceded in death by mother Janette Esther Miller Serocki and father Stanley Thomas Steven Serocki. 

Dr. Serocki was born on June 8, 1956 in Houston, Texas, to Janette and Stanley. He graduated from the University of California, San Diego with a degree in applied mechanics and engineering sciences and went on to earn a master's degree in mechanical engineering from the Massachusetts Institute of Technology. He subsequently earned a medical degree from Northwestern University, Feinberg School of Medicine. He practiced as an orthopedic surgeon for more than 25 years with a specialization in Sports Medicine and Hand Surgery. 

Throughout his medical career, Dr. Serocki touched many lives. He worked with underprivileged children in Nepal and volunteered his surgical talents where they were needed most, from Croatia to Haiti. He practiced at Scripps Memorial Hospital, XiMed Surgery Center, Outpatient Surgery Center of La Jolla, UTC Surgicenter, Otay Lakes Surgery Center, and at the Yuma Regional Medical Center. Outside of the hospital, John was a triathlete and enjoyed climbing, cycling, running, skiing and surfing. He was a kind, compassionate, and caring individual who was an inspiration to those around him. He will be endlessly missed by all who knew and loved him. 

A celebration of Dr. Serocki's life will be held on March 10 at 2:00 pm at the Schaetzel Center on the campus of Scripps Memorial Hospital in La Jolla. Additionally, to honor him, there will be a "paddle out" gathering on Saturday, June 9, 2018 at 15th Street, Del Mar, CA, time to be arranged. All are welcome to attend. In lieu of flowers, please send donations to Doctors Without Borders, an organization to which John belonged and which represents his passion for helping all those around him.

Dr. John Serocki

YUMA, Ariz. - A small plane crashed in the Kearny Mesa area of San Diego Wednesday morning, killing the sole occupant on board.

The Cirrus SR22T departed Montgomery-Gibbs Executive Airport and went down around 6:30 a.m. 

The plane crashed shortly after the departure, as witnesses saw the plane travel east at a low altitude before crashing into a construction area at a business, according to the San Diego Medical Examiner. 

We spoke with Robert Serocki, who confirms with us that his brother, Dr. John Serocki, was the sole occupant on the plane. The San Diego Medical Examiner also confirmed the identity of the pilot as Dr. John Serocki. 

"Something was wrong with the plane and he tried to turn around. He was not high enough to deploy a parachute," Serocki added.

Robert Serocki recalls the moment he received a phone call from his brother's San Diego office.

"After this person said he was on his way to Yuma, that's when I said 'oh my God are you telling me he's dead?' I sank to my knees and sank to the floor completely and she cried and said 'yes'," Serocki said with a broken voice. 

There are no reports of people on the ground being injured, according to Ian Gregor, FAA Public Affairs Manager.

The plane was headed to Yuma, according to Gregor.

Online records show that the plane is registered to John Serocki, an orthopedic surgeon based at Scripps La Jolla Hospital. According to the official Scripps site, we've also learned that he has an office at 1763 W. 24th Street in Yuma.

The office in Yuma had a sign on the door this morning that read: "Sorry for any inconvenience due to an emergency we will be closing the office for the rest of the week. Thank you." 

Yuma Regional Medical Center reached out to us, sharing their heartfelt condolences following the tragic death of "a surgeon and friend, Dr. John Serocki."

Dr. Serocki practiced in Yuma part time. His career as an orthopedic surgeon extended more than 25 years. During that time, he was notably recognized for his strong work ethic and compassionate manner with patients and staff, YRMC said. 

“This is a difficult day for everyone at Yuma Regional Medical Center, particularly for our surgery staff, who is grieving the loss of a special colleague and friend,” said Dr. Robert Trenschel, President and CEO of YRMC.

The FAA and NTSB are investigating. 

Original article can be found here ➤  http://www.kyma.com

One person died Wednesday in the crash of a small plane northeast of an airport in Kearny Mesa. 

John Harvey Serocki, 61, a doctor from Del Mar, was piloting a newer model single-engine plane from Montgomery-Gibbs Executive Airport when for unknown reasons the plane crashed into a building under construction near the intersection of Balboa Avenue and Ruffin Road at approximately 6:30 a.m., the San Diego County Medical Examiner's Office said. 

There were no reports of injuries to anyone on the ground at the business, according to a spokesperson for San Diego Fire-Rescue Department. 

Battalion Chief Grace Yamane said two or three witnesses reported the plane was traveling from the west to the east shortly before the crash.

The plane was at “tree-top level, did not get any lift, rolled and then shortly after crashed,” Yamane said. 

The wreckage could be seen from Newschopper 7 in a dirt area near several buildings a few hundred yards from the edge of a runway at Montgomery-Gibbs Executive Airport. 

Serocki, an orthopedic surgeon, was headed to Yuma, Arizona, where one of his three offices is located, the FAA said. He also practices at Scripps Memorial Hospital La Jolla and at Otay Lakes Surgery Center in Chula Vista, according to his personal website.

John's younger brother Robert said that John was a great person who loved to help people.

He said early in John's career, John went to Nepal to help treat underprivileged children. He was also a member of Doctors Without Borders and traveled to Haiti after a devastating earthquake rocked the island in 2010.

John, a graduate of the University of California, San Diego's school of mechanical engineering, even volunteered at a pet hospital, according to Robert.

“He was a really superior person and anyone would be proud to have him as a brother," Robert said.

Robert also said that John loved to stay active by surfing, hiking and running marathons.

To Robert, it never seemed as though John absolutely loved to fly. Instead, it seemed to him like he did it just because it was fast and easy travel.

Robert said he had no knowledge of any previous issues his brother John had with his plane.

It appears John attempted to use a parachute because one was deployed but did not open, Yamane said. 

Andrew Cove was on his way to work and sitting in his car at a nearby stoplight when he noticed the plane.

“I saw the plane going up and all of a sudden it got all quiet and then I see it going nosedive right into the ground,” he said.

Cove said he could not hear the engine of the plane when it crashed.

He and his co-worker pulled into a nearby parking lot to see if they could help.

“There was just no chance,” he said. “All you could see was wreckage.” 

Phylinda Clark Brown works nearby. She didn’t see the crash but heard it and thought it was a large machine at a nearby building. 

“I heard a loud impact,” Clark Brown said. “I thought it was across the street. There’s a lot of big machines and I thought they felt over.”

She added that with the time of day, as people were arriving to work, it is fortunate that no one on the ground was struck by the plane.

The crash was located west of Interstate 15 and east of State Route 163.

Traffic was closed on Ruffin Road between Ridgehaven Court and Balboa Avenue for an unknown duration.

Officials with the FAA and the NTSB were investigating what caused the crash.

Earlier this month, a couple married 48 years died when their single-engine Cessna 182T crashed in Santee. 

John Longhurst, 70, a doctor and professor at the UC Irvine School of Medicine and his wife Cherril Longhurst, 71, were pronounced dead at the scene, less than a mile from Gillespie Field on Feb. 6. 

A cause has not yet been determined in either plane crash. 

Original article can be found here ➤ https://www.nbcsandiego.com

A small plane crashed shortly after taking off from Montgomery Field early Wednesday morning, diving nose-first into a Kearny Mesa parking lot under construction and killing the pilot, authorities said.

Family members identified the 61-year-old victim as Dr. John Serocki. The orthopedic surgeon practiced at the Yuma Regional Medical Center in Yuma, Ariz., and at Scripps Memorial Hospital in San Diego.

“Today we have lost an exceptional physician, colleague and friend, a man who dedicated his life and career to caring for patients,” said Dr. Bharat Magu, chief medical officer at the Yuma Medical Center, in a statement. “Dr. Serocki was an outstanding physician who genuinely cared for people. His compassion and kind nature will be deeply missed.”

The Cirrus SR22T went down in a fenced-off dirt lot next to a building on Ruffin Road near Balboa Avenue shortly after 6:30 a.m., authorities said.

Serocki, who had planned to fly to Yuma, crashed about a half-mile from Montgomery Field shortly after departing the airport, said Ian Gregor, a spokesman for the Federal Aviation Administration. No one on the ground was injured.

According to FAA records, the plane was registered to Serocki. His brother said Serocki had been commuting to Yuma by airplane for work for years.

Witnesses told fire officials that the plane was going from west to east when it went down, San Diego Fire-Rescue Battalion Chief Grace Yamane said.

“Witnesses saw the plane and it appeared it wasn’t getting enough lift,” she said. “It wasn't continuing to rise — it rolled a couple times and then nose dove into the site.”

There was no fire and any fuel that spilled was immediately handled by crews at the scene, said San Diego Fire-Rescue spokeswoman Mónica Muñoz.

“It did not spread beyond the dirt” where the plane went down, she said. “They were able to mitigate it immediately because they were there so quickly.”

A parachute that was extended but unopened was found near the plane. An FAA official said the chute may been have ejected when the plane hit the ground, as opposed to having been deployed by the pilot while it was in the air, Yamane said.

The plane was largely intact with a crushed nose, although its wings broke off upon impact.

The area where the plane crashed in Kearny Mesa is densely developed with office and industrial buildings. Yamane said it was fortunate that no one else was injured.

“We are lucky that there was no damage to structures and no injuries to anyone on the ground,” she said. “If you were here to see, he landed between two trees, too.”

Firefighters waited to make sure there was no danger from the cylinder that propels the parachute before they removed the pilot’s body from the wreckage.

Serocki began his education in mechanical engineering. He earned a degree in applied mechanics and engineering sciences from UC San Diego in three years, but knew he didn’t want to be an engineer. He ended up getting a master’s in mechanical engineering from the Massachusetts Institute of Technology — but only as a spring board to medical school, his brother said.

He went on to earn a medical degree from Northwestern University Medical School in Chicago, later becaming an orthopedic surgeon. He had practiced for 25 years.

“He was passionate about being a doctor,” Robert Serocki said. “It was something he felt he needed to do.”

His profession took him to Kathmandu, Nepal, where he worked with underprivileged children as a clinician and a researcher, as well as Croatia, where he was a volunteer orthopedic surgeon and clinical instructor for an international relief agency.

He was also a member of Doctors Without Borders.

Serocki worked at Mission Bay Hospital and Sharp Memorial Hospital in San Diego. He began working part time in Yuma in 2012.

When he wasn’t practicing medicine, he was living an active life. He ran half-marathons and marathons and had climbed mountains all over the world, including the Matterhorn. He loved to surf.

Although he was always modest about his many accomplishments, he always reminded his younger brother of the pulp fiction character Doc Savage — a genius, jack-of-all-trades physician.

"He was concerned about being the best possible human being he could be," Robert Serocki said.

The pilot was the only person onboard, Gregor said.

The FAA and the National Transportation Safety Board will investigate the crash.

Police closed Ruffin Road between Ridgehaven Court and Balboa Drive as emergency crews worked in the area.

According to FAA records, the plane was manufactured in 2017.

Cirrus aircraft are equipped with whole-airplane parachute systems as standard equipment.

According to the company’s website, a pilot can utilize the parachute during an in-flight emergency by pulling a handle to deploy “a solid-fuel rocket out a hatch” where the parachute is stored. That action is supposed to unfurl a 65-foot-diameter canopy which is designed to control the plane’s rate of descent.

Original article ➤ http://www.sandiegouniontribune.com

KEARNY MESA (KUSI) — A Del Mar physician was killed Wednesday when his private plane plunged into a Kearny Mesa construction site shortly after takeoff from Montgomery Field.

John Serocki, 61, was embarking a solitary flight to Arizona about 6:30 a.m. when his Cirrus SR22T rolled over in the air and went down in the 4400 block of Ruffin Road, according to the county Medical Examiner’s Office and Federal Aviation Administration.

Serocki, an orthopedic surgeon with offices in University City, Chula Vista and Yuma, died at the scene of the crash about a half-mile northwest of the municipal general-aviation airport. Television news footage showed the downed aircraft crumpled in a fenced-in dirt lot, its front end demolished.

Nobody on the ground was injured, according to the San Diego Fire-Rescue Department.

It was not immediately clear what caused the accident, which occurred amid clear skies just after daybreak. At least one witness account suggested that the engine of the fixed-wing plane lost power or quit altogether just prior to the crash.

An aircraft-mounted parachute designed to allow for survivable descents in cases of power loss deployed during the crash but did not fully open, SDFRD Battalion Chief Grace Yamane told reporters. It was unclear if Serocki had tried to utilize the emergency system, or if it might have activated by itself upon impact, she said.

A congestion alert was issued for Ruffin Road between Balboa Avenue and Ridgehaven Court, where all lanes in both directions were closed for the crash investigation, which was being handled by the FAA and National Transportation Safety Board.

The deadly air accident was the second to occur in the county this month. A Feb. 6 plane crash in Santee near Gillespie Field killed 70-year-old Irvine medical school professor John Longhurst and his 71-year-old wife, Cherril.

Original article can be found here ➤ http://www.kusi.com