Sunday, November 4, 2018

Cirrus SR22T GTS, registered to and operated by the pilot, N3636E: Accident occurred October 20, 2017 at San Carlos Airport (KSQL), San Mateo County, California

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entities: 

Federal Aviation Administration / Flight Standards District Office; San Jose, California
Continental Motors; Mobile, Alabama
Cirrus Design Corp; Duluth, Minnesota

Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf


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

http://registry.faa.gov/N3636E

Location: San Carlos, CA
Accident Number: WPR18LA012
Date & Time: 10/20/2017, 1756 PDT
Registration: N3636E
Aircraft: CIRRUS DESIGN CORP SR22T
Aircraft Damage: Substantial
Defining Event: Miscellaneous/other
Injuries: 2 Minor
Flight Conducted Under:  Part 91: General Aviation - Personal 

On October 20, 2017, at 1756 Pacific daylight time, a Cirrus Design Corp SR22T GTS airplane, N3636E, struck a ditch at the end of the runway following a rejected takeoff from San Carlos Airport, San Carlos, California. The private pilot and passenger sustained minor injuries, and the airplane sustained substantial damage. The airplane was registered to and operated by the pilot as a personal flight under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan had been filed. The cross-country flight had a planned destination of Santa Monica Municipal Airport, Santa Monica, California.

The pilot reported that the preflight inspection was uneventful, and that after startup he noticed that the engine was not running smoothly. He was not unduly concerned, as the engine had a habit of vibrating slightly as it warmed up. He then taxied to the runup area, upon which he performed the preflight checks and engine runup. By this time the engine was operating smoothly. He stated that the remaining checks were uneventful, and included setting the elevator trim for takeoff, checking the flight controls, electrical load, fuel level, and the autopilot status.

A short time later he was cleared for takeoff by the tower controller. He began the takeoff roll and initiated the rotation at a speed of about 75 to 77 knots. Immediately after the airplane became airborne, it remained in ground effect longer than usual, during which he perceived a change in engine power. He did not look at the engine instruments, but the airplane did not climb as expected. With runway remaining the pilot decided to abort the takeoff. He reduced engine power, but then instinctively added power again to help the airplane settle rather than land hard. When he realized that this was not a full-length runway landing, he pulled the throttle completely back, and applied full braking. The airplane then passed beyond the runway threshold, into a ditch, and came to rest on the airport perimeter road, about 300 ft beyond the threshold.

The airplanes lap belt airbags deployed as the airplane struck the ditch (Image 1), and both the pilot and passenger were able to egress unaided.

Image 1 - Airplane at Accident Site 

Pilot Information

Certificate: Private
Age: 32, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 08/22/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 06/06/2017
Flight Time:  114 hours (Total, all aircraft), 22.3 hours (Total, this make and model), 22.3 hours (Pilot In Command, all aircraft), 22.3 hours (Last 90 days, all aircraft), 4.9 hours (Last 30 days, all aircraft), 0 hours (Last 24 hours, all aircraft) 

The pilot was issued a private pilot certificate with a rating for airplane single-engine land on June 6, 2017. He held a third-class airman medical certificate issued in August 2016, with no limitations.

He reported a total of 114 hours of flight time, with 22.3 as pilot in command, all in the accident make and model. His last flight review was for the private pilot checkride, and took place in a Cessna 172S.

Aircraft and Owner/Operator Information

Aircraft Make: CIRRUS DESIGN CORP
Registration: N3636E
Model/Series: SR22T GTS
Aircraft Category: Airplane
Year of Manufacture: 2017
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 1591
Landing Gear Type: Tricycle
Seats: 5
Date/Type of Last Inspection: 08/30/2017, Annual
Certified Max Gross Wt.: 3600 lbs
Time Since Last Inspection: 31 Hours
Engines: 1 Reciprocating
Airframe Total Time: 31.2 Hours at time of accident
Engine Manufacturer: Continental Engines
ELT:  C126 installed, activated, did not aid in locating accident
Engine Model/Series: TSIO-550-K1B
Registered Owner: On file
Rated Power: 310 hp
Operator: On file
Operating Certificate(s) Held: None 

The airplane was manufactured in 2017, and purchased new by the pilot about one month before the accident. It was equipped with a six-cylinder turbocharged Continental Motors Inc. TSIO-550-K1B engine, and a Hartzell three-blade composite constant-speed propeller.

The airplane had accrued 31.2 hours of flight by the time of the accident.

The airplane was equipped with a Cirrus Perspective integrated flight instrument system manufactured by Garmin, which was configured to record a series of airframe and engine parameters to an SD memory card at a 1 Hz rate. Recorded engine parameters included fuel flow, manifold pressure, engine speed, and both exhaust and cylinder head temperatures (EGT, CHT). The system also included a series of electronic checklists customized specifically for the SR22. The airplane was also equipped with a crash hardened Recoverable Data Module (RDM), a flight recording device installed in the tail of the airplane. The RDM recorded critical airplane systems and flight parameter information at a 1 Hz rate.



Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KSQL, 5 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1757 PDT
Direction from Accident Site: 69°
Lowest Cloud Condition: Few / 2000 ft agl
Visibility:  10 Miles
Lowest Ceiling: Broken / 20000 ft agl
Visibility (RVR):
Wind Speed/Gusts: 11 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 290°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.13 inches Hg
Temperature/Dew Point: 15°C / 7°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: San Carlos, CA (SQL)
Type of Flight Plan Filed: None
Destination: SANTA MONICA, CA (SMO)
Type of Clearance: None
Departure Time: 1755 PDT
Type of Airspace: Class D 

Airport Information

Airport: SAN CARLOS (SQL)
Runway Surface Type: Asphalt
Airport Elevation: 5 ft
Runway Surface Condition: Dry
Runway Used: 30
IFR Approach: None
Runway Length/Width: 2600 ft / 75 ft
VFR Approach/Landing: None 

The San Carlos airport is at an elevation of 5 ft mean sea level and composed of a single 2,600 ft long by 75 ft wide grooved asphalt runway. The runway is level and designated 12/30. The runway 12 displaced threshold is about 300 ft long. 

Wreckage and Impact Information

Crew Injuries: 1 Minor
Aircraft Damage: Substantial
Passenger Injuries: 1 Minor
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Minor
Latitude, Longitude: 37.515833, -122.253611 

Additional Information

The airplane sustained substantial damage to the forward fuselage and both wings during the collision with the ditch. There was no indication of a catastrophic engine failure, both wing tanks contained fuel, and the flap switch and the flaps were observed in the UP position.

Examination of the data recovered from the RDM and the flight instrument system revealed that electrical power was turned on at 1725:45, followed a few seconds later by the flap switch being moved to the 100% (fully extended) position. For the next 20 minutes the airplane remained in the same location on the ramp until the engine was started, and the flap switch was moved to the 0% (UP) position.

At 1749, the airplane began to taxi southeast along taxiway J, arriving at the runup area adjacent to the entrance of runway 30, two minutes later. For the next 4 minutes the airplane remained in the runup area as the engine speed, manifold pressure, fuel pressure, and EGTs began to rise in a manner consistent with the pilot performing an engine runup.

At 1755, the airplane began to taxi towards runway 30, and within 40 seconds it had lined up on the runway centerline. A few seconds later the airplane began to accelerate until it reached an indicated airspeed of 77 knots after travelling 1,000 ft down the runway. The airplanes nose then pitched up from about 2° to 7°, where it remained for the next 3 seconds as the airplane continued at a speed of about 83 knots. The nose then dropped back to about 2°, and after travelling about 2,050 ft down the runway, the airplane began to veer to the left. It then passed the runway numbers after reaching its maximum speed of 96.7 knots. The airplane then began to veer right, while it decelerated and exited the runway beyond the displaced threshold. It then crossed the grass overrun, passed through the ditch, and came to rest on the airport perimeter road (Image 2).


Image 2 – Airplane Track and Parameters Derived from the RDM and Integrated Flight System.


According to the flight instrument system and RDM, during the takeoff roll, the engine speed remained at a continuous 2,500 RPM, while the manifold pressure was at 38 inches of mercury, and the fuel flow was 42 gallons per hour. All exhaust gas temperatures were stable in the 1,225°F range.

Up until the presumed engine runup, the EGT for cylinder number 2 lagged the other cylinders by a temperature of up to almost 300°F. After the runup was complete the temperature stabilized and began to synchronize with the other five cylinders.

The RDM data revealed that the flap switch remained in the UP position from the time the engine was started through to the time of the accident.

Pilot's Operating Handbook

The SR22T Pilot's Operating Handbook (POH) states that normal and short field takeoffs are accomplished with flaps set at 50%. The handbook further states that takeoffs with the flaps set to 0% are permissible, however, no performance data is available for that configuration. The normal takeoff rotation speed with 50% flaps is 77 KIAS.

The handbook recommended that the flaps be set to 100% during the preflight inspection and walkaround, and then retracted to 0% for taxi. The before takeoff checklist calls for 50% flaps to be selected, and the flap position to be checked by the pilot.

The pilot stated that prior to flight he used both the POH checklist and the electronic checklist included in the integrated flight system, and that he was not distracted while performing any of the checks. He could not recall specifically setting the flap position but stated that he performs takeoffs with the flaps set to 50% and has only used 0% flaps for takeoff during training.

The takeoff ground roll distance at sea level, no wind, a temperature of 20° C, and with the airplane loaded to its maximum gross weight (3,600 lbs) is 1,574 ft. When loaded to 2,900 lbs, the ground roll distance is 564 ft.

The flaps 0% landing distance at the airplane's maximum gross weight under the same conditions was 1,465 ft. No landing distance data was available for lower gross weights.

Video Footage

A surveillance camera located perpendicular to the runway 12 numbers captured video and audio of the final stages of the takeoff roll. As the airplane approached the runway numbers it was on the ground, and a skidding sound could be heard accompanied with puffs of smoke from the main landing gear. The airplane continued skidding along the runway and out of the cameras field of view until a second later when a crashing sound was heard.



NTSB Identification: WPR18LA012
14 CFR Part 91: General Aviation
Accident occurred Friday, October 20, 2017 in San Carlos, CA
Aircraft: CIRRUS DESIGN CORP SR22T, registration: N3636E
Injuries: 2 Minor.

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 may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On October 20, 2017, at 1756 Pacific daylight time, a Cirrus Design Corp SR22T GTS, N3636E, struck a ditch at the end of the runway following an aborted takeoff from San Carlos Airport, San Carlos, California. The private pilot and passenger sustained minor injuries, and the airplane sustained substantial damage. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91. The cross-country personal flight was departing with a planned destination of Santa Monica Municipal Airport, Santa Monica, California. Visual meteorological conditions prevailed, and no flight plan had been filed.

The pilot reported that after being cleared for takeoff by the tower controller, he began the takeoff roll, and initiated the rotation at a speed of about 75 to 77 knots. Immediately after the airplane took off, he perceived a change in engine power. He did not look at the engine instruments to gauge the power change, but the airplane did not climb as expected. With runway remaining he decided to abort the takeoff by reducing the engine throttle, and applying full braking effort. The airplane passed beyond the runway threshold, into a ditch, and came to rest on the airport perimeter road.

The airplane sustained substantial damage to the forward fuselage and both wings during the accident sequence, and both the pilot and passenger were able to egress unaided.

3 comments:

daveyl123 said...

I've flown into San Carlos many times. It's situated between a marsh to the north, and a freeway adjacent to the south. It's fairly close to the "Hump" of the Hayward/San Mateo bridge, which is the location for the "Brijj" Locator Outer Marker for San Francisco International's Runway 28R. The runway is quite adequate, and not sloped or rough. You won't have a lot of room to perform a forced landing if you depart to the northwest, so an abort will be preferable, though you'll run out of runway, just as this incident depicts.

Jim B said...


"He reported a total of 114 hours of flight time, with 22.3 as pilot in command, all in the accident make and model."

This is why I do not let pilots rent the T182T or the PA-28R-201T with less than 175 hours total recent time. I am still not convinced that is enough.

The Cirrus is not a beginners airplane.

One fouled plug and full flaps on takeoff. An expensive mistake. Cirrus insurance must be a very expensive purchase for those who choose to own them.

Anonymous said...

Totalled airframe.

Pilot needed more training. Like the Cirrus program maybe?