The National Transportation Safety Board did not travel to the scene of this accident
Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Lubbock, Texas
Cirrus Aircraft; Duluth, Minnesota
Continental Aerospace Technology; Mobile, Alabama
Hartzell Engine Technologies Inc; Montgomery, Alabama
Investigation Docket - National Transportation Safety Board:
Location: Midland, Texas
Accident Number: CEN19LA002
Date & Time: October 12, 2018, 10:45 Local
Registration: N729TG
Aircraft: Cirrus SR22
Aircraft Damage: Substantial
Defining Event: Loss of engine power (partial)
Injuries: 2 Minor
Flight Conducted Under: Part 91: General aviation - Personal
Analysis
The pilot and passenger departed on a cross-country flight in a single-engine airplane. Shortly after takeoff and about 500 ft above ground level, the engine "surged." The pilot turned the airplane back toward the airport; however, the engine lost power. The pilot recognized the airplane would not make it back to the airport, so he deployed the airplane's parachute. The airplane descended under the parachute into a parking lot and impacted a parked automobile, which resulted in substantial damage to the airplane.
The engine examination and test run noted that the engine fuel flow was high and above specified engine and airframe manufacturers' limits.
Data from the airplane's data monitor also indicated that the airplane engine's fuel flow was high on the accident flight and on previous flights, although the maximum fuel flow recorded varied. A review of maintenance records revealed that the engine manifold pressure and fuel flow were adjusted in accordance with the manufacturer's maintenance manual about 3 months before the accident.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The loss of engine power due to excessive fuel flow.
Findings
Aircraft (general) - Not specified
Environmental issues Ground vehicle - Contributed to outcome
Factual Information
On October 12, 2018, about 1045 central daylight time, a Cirrus SR22 airplane, N729TG, impacted a parking lot shortly after departing the Midland Airpark (MDD), Midland, Texas. The pilot and passenger received minor injuries, and the airplane was substantially damaged. The airplane was registered to and operated by TJG Equipment, LLC under the provisions of Title 14 Code of Federal Regulations Part 91 as a cross-country flight.
The pilot reported that after departure and about 500 ft above ground level, the engine "surged". He turned back toward the airport and the engine lost power. The pilot recognized the airplane would not make it back to the airport, so he deployed the Cirrus Airframe Parachute System (CAPS). The airplane descended under the parachute into a parking lot and impacted a parked automobile.
The airplane was recovered to a salvage facility. An engine examination was then conducted by the NTSB Investigator in Charge (IIC), and technical representatives from the engine and airframe manufacturers. A visual inspection and borescope examination of the engine was conducted: a damaged propeller and minor damage to the exhaust system was noted. In order to facilitate an engine test run, a
replacement propeller was installed, and a fuel can was plumbed into the airplane fuel system. An engine run was then conducted, and the engine started without hesitation. The engine was operated about 1,000 rpm to bring the engine up to operation temperatures. During the engine test run, full throttle was applied: manifold pressure stabilized at 39 inHg and fuel flow reached 49 gph. [The engine manufacturer specifications are 36.6 inHg and 37.5 gph, with Cirrus specified a 40.5gph limit].
After the engine run, the turbocharger controller and wastegate actuator were removed from the airplane and sent to the manufacturer for additional testing. It was also noted that during the wastegate actuator removal, the wastegate valve appeared "stuck". After moving the valve, it appeared to move normally.
The airplane's parachute was also removed and sent to Cirrus for a performance and conformity inspections.
The airplane's recoverable data module (RDM) was downloaded, and a review of the data noted that on the accident flight and previous flights, the engine's fuel flow was high, including near or above the maximum limit. A review of the airplane's maintenance records revealed a maintenance entry dated July 18, 2018, that annotated the manifold pressure was set to 36.5, and fuel flow to 41gph, and rpm to 2,500, per Cirrus aircraft maintenance manual 5-30. There were no additional entries that indicated the fuel flow was later changed.
The wastegate actuator and turbocharger controller were bench tested at Hartzell's Engine Technologies (HET) facility, in Montgomery, Alabama, with representatives from the NTSB, FAA, and HET present. Both units operated normally, with no discrepancies noted that would have affected normal performance.
The engine was removed and shipped to the manufacturer's facility where it was placed in an engine test cell. The NTSB IIC and technical representative from the airframe and engine manufacturers conducted the test. The engine was started and ran at various power settings. It was noted that fuel flows were high, enough so that the engine would run rough, but did not experience a total loss of power. A small amount of black smoke was also observed during portions of the engine test run. Later during the test run, adjustments were made that lowered fuel flow; the engine appeared to run normally, without black smoke nor roughness.
A review of Cirrus support publications revealed two publications that address potential issues with engine high fuel flows:
Service Advisory SA19-01, Subject: High Boost/Prime Altitude Lockout Software Condition, which advises that high boost/prime mode be avoided in-flight, below 10,000 ft.
Service Bulletin SB2x-42-17, Subject: 42-20 INTEGRATED MODULAR AVIONICS - Perspective S/W Update, which provides a 10,000 ft altitude lockout feature; and a high fuel flow CAS message, at 42 gph.
History of Flight
Enroute-climb to cruise Loss of engine power (partial) (Defining event)
Emergency descent Off-field or emergency landing
Emergency descent Collision with terr/obj (non-CFIT)
Pilot Information
Certificate: Airline transport
Age: 33
Airplane Rating(s): Single-engine land; Multi-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane multi-engine; Airplane single-engine; Instrument airplane
Toxicology Performed: No
Medical Certification: Class 1 Without waivers/limitations
Last FAA Medical Exam: September 1, 2017
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: 3979 hours (Total, all aircraft), 1468 hours (Total, this make and model), 3941 hours (Pilot In Command, all aircraft), 67 hours (Last 90 days, all aircraft), 16 hours (Last 30 days, all aircraft), 2 hours (Last 24 hours, all aircraft)
Aircraft and Owner/Operator Information
Aircraft Make: Cirrus
Registration: N729TG
Model/Series: SR22T
Aircraft Category: Airplane
Year of Manufacture: 2016
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 1347
Landing Gear Type:
Tricycle Seats:
Date/Type of Last Inspection: June 26, 2018 Annual
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: Reciprocating
Airframe Total Time: 582.5 Hrs as of last inspection
Engine Manufacturer: Continental
ELT: Installed
Engine Model/Series: TIO-550
Registered Owner:
Rated Power:
Operator:
Operating Certificate(s) Held: None
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual (VMC)
Condition of Light: Day
Observation Facility, Elevation: KMDD
Distance from Accident Site:
Observation Time: 15:35 Local
Direction from Accident Site:
Lowest Cloud Condition:
Visibility: 10 miles
Lowest Ceiling: Visibility (RVR):
Wind Speed/Gusts: 9 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 180°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30 inches Hg
Temperature/Dew Point: 20°C / 19°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Midland, TX
Type of Flight Plan Filed: IFR
Destination: Andrews, TX (E11)
Type of Clearance: Unknown
Departure Time:
Type of Airspace:
Airport:
Runway Surface Type:
Airport Elevation:
Runway Surface Condition:
Runway Used:
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Forced landing
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: 32.034442,-102.104721(est)