Thursday, November 19, 2020

Controlled Flight Into Terrain: Cirrus SR22, N167CB; accident occurred April 02, 2017 in Brinnon, Jefferson County, Washington


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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Renton, Washington
Continental Motors Inc; Mobile, Alabama
Cirrus Aircraft; Duluth, Minnesota

Investigation Docket - National Transportation Safety Board:

Location: Brinnon, Washington
Accident Number: WPR17LA084
Date & Time: April 2, 2017, 15:28 Local 
Registration: N167CB
Aircraft: CIRRUS DESIGN CORP SR22
Aircraft Damage: Substantial
Defining Event: Controlled flight into terr/obj (CFIT)
Injuries: 2 Serious
Flight Conducted Under: Part 91: General aviation - Instructional 

Analysis

The flight instructor and student pilot departed on a planned 3-hour instructional flight. While en route, the flight instructor stated that he wanted to show the student that there was more to flying than just training and that flying was also "fun." The pilots subsequently turned the airplane toward a large river valley in mountainous terrain. The pilots flew into an area of rapidly rising terrain and realized they needed to climb to avoid terrain. The flight instructor applied full power and pitched the airplane up into a climb; however, the terrain rose faster than the airplane was climbing. The flight instructor instructed the student pilot to start a right turn. Shortly thereafter, he felt the turn was too slow, and he took control of the airplane. The flight instructor stated that things were happening too fast for him to recover the airplane. The airplane subsequently impacted terrain in a box canyon, with ridgelines between 100 feet to several hundred feet higher than the accident site. Postaccident examination of the airframe and engine revealed no mechanical malfunctions or failures that would have precluded normal operation.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The flight instructor's decision to fly into a valley without ensuring adequate clearance to avoid the rising terrain. 

Findings

Personnel issues Decision making/judgment - Instructor/check pilot
Aircraft Altitude - Not attained/maintained
Environmental issues Mountainous/hilly terrain - Ability to respond/compensate

Factual Information

History of Flight

Maneuvering Controlled flight into terr/obj (CFIT) (Defining event)

On April 2, 2017, about 1528 Pacific daylight time, a Cirrus Design Corporation SR22, airplane, N167CB, was substantially damaged when it impacted mountainous terrain near Brinnon, Washington.  

The flight instructor and the student pilot sustained serious injuries. 

The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight.

The cross country flight departed from Whidbey Air Park (W10), Langley, Washington, about 1500 with a planned destination of Bremerton National Airport (PWT), Bremerton, Washington.

According to the flight instructor, they had planned a 3-hour instructional flight and planned to accomplish their traffic pattern work at PWT. While enroute, the flight instructor stated that he wanted to show the student that there was more to flying than just training. In his words flying was also "fun." Subsequently, the airplane was turned west towards a large valley in the Olympic Mountain range. While flying in the valley, the flight instructor stated that he believed their altitude was at least 2,000 ft above ground level (agl) and that no wind or turbulence was present. However, at some point, the pilots realized they needed to climb to avoid terrain and the flight instructor applied full power and pitched the airplane up into a climb. However, he realized that even with these control inputs, the terrain was rising faster than the airplane was climbing. The flight instructor instructed the student pilot to start a right turn. Shortly thereafter, he felt the turn was too slow and just as the student pilot was increasing the bank of the turn, he took control of the airplane. The flight instructor stated that things were happening too fast for him to recover the airplane and he knew that they were going to crash. Subsequently, the airplane impacted terrain.

The accident airplane was equipped with an Avidyne Primary Flight Display that contained two flash memory devices. The flash memory devices were recovered from the accident airplane and sent to the National Transportation Safety Board's Vehicle Recorder laboratory for download. The downloaded files captured the accident flight.

The data started with the airplane flying southwest over Puget Sound, about 1,700 ft mean sea level (msl). At 1518, the airplane turned left to a south-southwesterly heading. At 1520, the airplane turned to the west and crossed the shoreline north of Brinnon, Washington. The airplane then flew along the Dosewallips river valley, about 1,600 ft msl. At 1523, the airplane began a climb and at 1526, the airplane's altitude indicated about 2,407 ft msl. The airplane then turned left to fly along the Hungry Creek valley; however, the terrain continued to rapidly rise in height. Subsequently, at 1528, the data was consistent with the airplane impacting terrain, near 5,400 ft msl. The accident site was in a box canyon with ridgelines present in front and on each side of it, that were between 100 ft to several hundred ft higher in elevation, than the accident site. Further, the terrain at the accident site, was about 2,000 ft higher in elevation, than that of the river valley that was about 1.5 miles below it.

No anomalies in the recorded data from the accident flight would have precluded the normal operation of the airplane. The last recorded information before impact, indicated the engine was at 2,620 rpm, the airplane in about 29° of right bank, and an indicated ground speed of about 81 knots.

Flight instructor Information

Certificate: Commercial; Flight instructor
Age: 25,Male
Airplane Rating(s): Single-engine land 
Seat Occupied: Right
Other Aircraft Rating(s): Helicopter
Restraint Used: 4-point
Instrument Rating(s): Airplane 
Second Pilot Present: Yes
Instructor Rating(s): Airplane single-engine 
Toxicology Performed: No
Medical Certification: Class 2 Without waivers/limitations
Last FAA Medical Exam: February 3, 2016
Occupational Pilot: Yes Last Flight Review or Equivalent: November 22, 2016
Flight Time: (Estimated) 1400 hours (Total, all aircraft), 26 hours (Total, this make and model), 1100 hours (Pilot In Command, all aircraft), 70 hours (Last 90 days, all aircraft), 35 hours (Last 30 days, all aircraft), 4 hours (Last 24 hours, all aircraft)

Student pilot Information

Certificate: Student 
Age: 36, Male
Airplane Rating(s): None 
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): None 
Second Pilot Present: Yes
Instructor Rating(s): None 
Toxicology Performed: No
Medical Certification: None
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: (Estimated) 5 hours (Total, all aircraft), 5 hours (Total, this make and model), 5 hours (Last 90 days, all aircraft), 5 hours (Last 30 days, all aircraft), 4 hours (Last 24 hours, all aircraft)

The flight instructor held a commercial pilot certificate with ratings for airplane single-engine land and rotorcraft. He also held ratings for an instrument airplane and instructor single-engine airplane. The pilot was issued a Federal Aviation Administration (FAA) second class airman medical certificate on February 3, 2016, with no limitations or waivers.

The flight instructor reported that he had accumulated 1,400 total hours of flight experience and had logged 70 flight hours in the previous 3 months and 35 flight hours in the previous 30 days. About 26 flight hours and 10 instructor hours were accumulated in the accident airplane make and model. He also reported that he had hundreds of hours experience flying in mountainous terrain.

The flight instructor had recently been hired by the operator and spent the prior week in their standardization training. A review of the operator's training logbooks indicated that the accident flight instructor took 5 training flights and logged 10.2 flight hours in the Cirrus SR22 airplane during his training. Four of the flights were cross country flights. Additionally, 7.6 hours of ground training was accomplished.

The student pilot held a student pilot certificate. The student pilot was issued a Federal Aviation Administration (FAA) third-class airman medical certificate on May 11, 2016, with the limitation that he must wear corrective lenses. The student pilot reported he had accumulated 5 hours of flight experience. The was his third instruction flight.

Aircraft and Owner/Operator Information

Aircraft Make: CIRRUS DESIGN CORP
Registration: N167CB
Model/Series: SR22 NO SERIES
Aircraft Category: Airplane
Year of Manufacture: 2004
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 0822
Landing Gear Type: Tricycle 
Seats: 4
Date/Type of Last Inspection: July 31, 2016 Annual
Certified Max Gross Wt.: 3400 lbs
Time Since Last Inspection: 25 Hrs
Engines: 1 Reciprocating
Airframe Total Time: 841.6 Hrs as of last inspection 
Engine Manufacturer: CONT MOTOR
ELT: C126 installed, activated, aided in locating accident
Engine Model/Series: IO-550 N (27)
Registered Owner:
Rated Power: 310 Horsepower
Operator: 
Operating Certificate(s) Held: None
The low-wing airplane was manufactured in 2004. It was powered by a 310 horsepower Continental IO550 series engine that drove a three-bladed Hartzell constant speed propeller.

A review of maintenance logbooks revealed that the airplane's most recent annual inspection was completed on July 30, 2016, at a Hobbs time of 841.6 hours. The flight meter read 557.1 hours at the accident scene; the Hobbs meter read 1,082.4 hours at the accident site.

The Pilot's Operating Handbook listed the airplane's rate of climb at 6,000 ft pressure altitude and 98 KIAS to be about 1,046 ft per minute at 0° C. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC) 
Condition of Light: Day
Observation Facility, Elevation: KSHN,271 ft msl 
Distance from Accident Site: 32 Nautical Miles
Observation Time: 22:53 Local
Direction from Accident Site: 149°
Lowest Cloud Condition: Clear
Visibility: 10 miles
Lowest Ceiling: None 
Visibility (RVR):
Wind Speed/Gusts: 17 knots / 26 knots
Turbulence Type Forecast/Actual:  /
Wind Direction: 250° 
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.25 inches Hg 
Temperature/Dew Point: 12°C / 1°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: LANGLEY, WA (W10 )
Type of Flight Plan Filed: None
Destination: BREMERTON, WA (PWT )
Type of Clearance: None
Departure Time: 15:00 Local
Type of Airspace: Class G

The closest official weather reporting location to the accident site was PWT, located about 25 miles southeast of the accident site. However, due to unknown reasons, the PWT station was off line the day of the accident.

The next closest official weather reporting station was from William R. Fairchild International Airport (CLM), Port Angeles, Washington, located about 32 miles north-northwest of the accident site. The CLM weather observation at 1453, was wind from 310° at 9 knots, visibility unrestricted at 10 miles or more, few clouds at 3,100 ft ceiling broken at 4,000 ft, overcast at 6,500 ft, temperature 8° C, dew point 4° C, and altimeter 30.31 inches of mercury.

A review of the weather information revealed that no significant weather was reported or forecast in the accident area around the time of the accident. A high-pressure system was located off the northwest pacific coast. The local weather surveillance radars for the 1 hour period before the accident time, detected no significant weather echoes over the area for that period.

The wind speed near the accident area around the time of the accident was estimated to be from the northwest about 11 knots from the surface to about 2,000 ft msl, with little directional variation with height and with winds increasing with height. At 6,300, ft the approximate height of Mount Christie, located about 13 miles west of the accident site, the wind was from 305° magnetic at 16 knots, and would have resulted in a downslope wind over the accident site.

A turbulence model indicated that above the surface, about 700 ft, there was a strong vertical shear of about 8.1 knots per 1,000 ft, and a high probability of moderate turbulence. No defined mountain wave or orographic type clouds were identified from the period between one hour prior, and one hour after, the accident time.

An AIRMET, valid at the time of the accident, was issued for mountain obscuration, occasional moderate turbulence below 15,000 ft, and icing conditions between 2,000 and 12,000 ft in clouds and precipitation was current in the area at the time of the accident.

Wreckage and Impact Information

Crew Injuries: 2 Serious
Aircraft Damage: Substantial
Passenger Injuries:
Aircraft Fire: None
Ground Injuries: N/A 
Aircraft Explosion: None
Total Injuries: 2 Serious
Latitude, Longitude: 47.692222,-123.221946(est)

The airplane impacted on a mountainous slope of about 45° and came to rest upright. The airplane wreckage showed that the airplane was in a right turn during impact. All major components of the airplane were located at the site. The accident site was located about 13 miles east from the summit of Mount Christie, in snow packed mountainous terrain. Mount Christie is the high peak of the Olympic mountains, in the Olympic State Park in Washington.

A postaccident examination of the airframe and engine did not reveal any anomalies with the airframe or engine that would have precluded normal operation. The Cirrus Aircraft Parachute System was not activated.

Additional Information

The FAA's Aviation Safety Program publication "Tips on Mountain Flying," section on ridge and pass crossing, states that "experienced pilots recommend crossing a ridge line or pass, at the ridge elevation plus at least 1,000 ft. The publication also states, "plan to be at that altitude at least three miles before reaching the ridge."

The airplane's turn performance was evaluated using a performance chart from the Aerodynamics for Naval Aviators, NAVAIR 00-08T-80 publication. Based on 30° of bank, the performance chart indicated that the accident airplane would have about an 1,500 ft turn radius. A review of the accident area indicated only about 1,000 ft between the higher terrain on each side of the airplane, was available to complete a turn away from the high terrain in front of the airplane. Additionally, during the first half of the turn, the terrain continued to rise.    


  







 



19 comments:

  1. Three comments. Two negative and one positive.

    1) Negative. Very stupid to fly into a box canyon below terrain. This is the same thing that happened to N4444K and countless other accidents in box canyons.

    2) Negative. They had time to utilize the parachute. Use it!!!

    3) Positive. Very poor decision making led to an accident that shouldn't have occurred in the first place. However, once in this bad position they did a very nice job of landing uphill and dissipating the energy. Also, a very nice job not stalling airplane. Instead they "flew the airplane through the accident." They both survived.

    ReplyDelete
    Replies
    1. Doubtful they had the altitude to deploy the CAPS. If that were the case, they would have had the altitude to turn the airplane around.

      Delete
  2. I guess my question is with only five hours into his training, why is the instructor taking him on a three hour cross-country? At that point in my training, we were still doing touch-and-goes and pattern work.

    ReplyDelete
    Replies
    1. The student pilot may be a 500 hour private pilot. It takes about 20 hours of Cirrus training to get signed off. Likely building time and learning the glass cockpit, which you can't do in the pattern.

      Delete
    2. The report said he only had 5 hours of flight time and that the accident flight was only his 3rd instructional flight. The instructor said he wanted to show the student that ”aviation can be fun” so wouldn't think a 500hr pilot would need that demonstration. However, you might be right about it being a glass cockpit instructional flight of some kind.

      Delete
  3. The occupants were fortunate they were rescued before inhospitable environmental conditions took their lives. I wonder what devices, techniques or operational decisions contributed to a timely rescue. Such commentary could help others flying over similar conditions ensure that their plans and preparations include the benefits these accident victims fortunately had that worked in their favor.

    ReplyDelete
  4. Typical reluctant CFI just in to build time. Explains the idiocy of long x-countries literally taking a clueless off the street and trusting new student for a ride. So close to 1500 and now so far away after his ratings were hopefully yanked out and no airline will touch him with a 1000 ft pole...

    ReplyDelete
    Replies
    1. "Typical reluctant CFI just in to build time."

      You have no factual basis to make that claim. You show a real pattern of trashing CFIs. It's almost like you washed out of pilot training and have to blame someone to make you feel better.

      Delete
  5. Wow dude is still a flight instructor? After such a blunder? SMH
    I hope the innocent student pilot wasn't penalized by insurance and that the CFI's insurance is the one who paid for the loss of the aircraft!!!


    Personal Information
    Print This Page
    ...

    Medical Information:
    Medical Class: First Medical Date: 7/2020
    BasicMed Course Date: None BasicMed CMEC Date: None
    Certificates
    AIRLINE TRANSPORT PILOT

    FLIGHT INSTRUCTOR
    Certificates Description
    Certificate: AIRLINE TRANSPORT PILOT
    Date of Issue: 8/23/2019

    Ratings:
    AIRLINE TRANSPORT PILOT
    AIRPLANE MULTIENGINE LAND
    COMMERCIAL PRIVILEGES
    AIRPLANE SINGLE ENGINE LAND
    PRIVATE PRIVILEGES
    ROTORCRAFT-HELICOPTER

    Type Ratings:
    A/LR-JET


    Limits:
    ENGLISH PROFICIENT.

    ReplyDelete
    Replies
    1. An ATP, AMEL, Rotorcraft rating and Lear type rating. And what are your qualifications, "MarcPilot"?

      Delete
    2. CFI SEL MEL A&P and apprentice lawyer + businessman and 1200 hrs, 300+ in a Cirrus.

      Delete
    3. Also ”MarcPilot” probably doesn't have a CFIT accident in his log book either. I wouldn't want the accident CFI as my instructor. I think he should have had his CFI pulled too. On the other hand, this accident was a couple of years ago so maybe he did lose it for awhile and was able to re-acquire it ?

      Delete
  6. No planning done before randomly exploring the mountain valleys while continuously below the surrounding terrain ridgeline? Ends up closed out in a narrow dead end and can't turn or climb to get out. "Snow braking" saves them from dying in the crash.

    Is this lack of regard to mountain flying hazards caused by a belief that the parachute ride backup plan makes competent airmanship unnecessary? Who in their right mind would want fly with the "instructor"?

    ReplyDelete
  7. Is his employer aware of this accident??? As a FLIGHT INSTRUCTOR and COMMERCIAL PILOT? This is not the same as a honest mistake where someone gets lucky and survives a mishap while being a private pilot with a couple of hundred hours. The FAA has as policies a higher expectation of professionalism and sticking to rules for a more rated and experienced pilot. The fact his ratings were not yanked and him demoted to private pilot is baffling. Did he even get a 709 ride?
    The fact is if he ever kills someone else in another accident his employer will be more so deemed negligent for failing to screen correctly a pilot with a major accident while having all those ratings.
    I call the fact he passed a 709... somehow saved his ratings but also found a way to hide this accident from his employer as PRIA is entirely voluntary and he can omit his employment as flight instructor, probably freelance, for this student.
    The newly minted PRD is supposed to alleviate such issues... as this is exactly how a poorly qualified airman was hired by Atlas Air and crashed Atlas air 3591 after said pilot his employment history and his checkride failures and killed 2 crewmember with the destruction of a cargo aircraft.

    ReplyDelete
    Replies
    1. MarcPilot: "The fact is if he ever kills someone else in another accident his employer will be more so deemed negligent for failing to screen correctly a pilot with a major accident while having all those ratings."
      Quit playing lawyer, Mr. MarcPilot. You are assuming the company is unaware. Don't assume. The FAA is good with him as a pilot. Some people learn more from mistakes than others. And one mistake (yes, it was really stupid) shouldn't ruin a career. Let's hope he's super-cautious from here on out.

      Delete
    2. Well, now we can add Law school graduate to the long list of things you're not, "MarcPilot".

      Delete
    3. Actually I am a lawyer apprentice in California... one of the 4 states that offers that option. That aside it's not about him learning about his mistakes or becoming a better pilot... rather the liability any employer will incur AUTOMATICALLY if he is ever involved in another mishap vs. hiring someone with a clean record. The Tort system is what it is and the road to a summary judgement is pretty easy if any participant leading to a liability situation did that one before...

      Delete
  8. less than 30 miles was Naval Air Station Whidbey Island (NASWI)is a naval air station of the United States Navy located near Oak Harbor, Whidbey Island, Washington. The air stations maintains a Search and Rescue Unit that flies two Sikorsky MH-60S Nighthawks. With the addition of the MH-60S, Navy Search and Rescue provides 24-hour day and night maritime, inland and mountainous rescue support for Department of Defense personnel and the greater Pacific Northwest community. The SAR Unit provides 15-minute alert coverage Monday through Thursday from 0800–0200 or last plane on deck, Friday 0800-2200 or last plane on deck and 30-minute alert coverage at all other times of the year. Additionally, SAR has organic SAR Medical Technicians on all missions it performs. NASWI SAR primarily serves military aircrews, but missions to help civilians in distress are often approved and executed.[5]

    ReplyDelete
  9. This guy now has his ATP cert. OMG! And he is type rated in one of the Bombardier LearJet models. He may be a FO In a part 135 operation as we speak. I hope the 135 carriers conduct proper due diligence.

    ReplyDelete