Lynn Ann Anderson Simonsen and her husband Christian Clinton Simonsen.
The National Transportation Safety Board traveled to the scene of this accident.
Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Salt Lake City, Utah
Cirrus Aircraft; Duluth, Minnesota
Continental Motors; Mobile, Alabama
Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Salt Lake City, Utah
Cirrus Aircraft; Duluth, Minnesota
Continental Motors; Mobile, Alabama
Investigation Docket - National Transportation Safety Board:
Tierra Grande Aviation LLC
Location: Grover, Utah
Accident Number: WPR19FA154
Date & Time: May 24, 2019, 11:16 Local
Registration: N809SR
Aircraft: Cirrus SR22
Aircraft Damage: Destroyed
Defining Event: Structural icing
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General aviation - Personal
Analysis
The pilot departed on an instrument flight rules cross-country flight and climbed to a cruise altitude of 14,000 ft mean sea level (msl). About 30 minutes into the flight, he requested a climb to 16,000 ft msl. Radar data indicated that over the next several minutes, the airplane climbed to 14,500 ft, then began an increasingly rapid descent as its groundspeed decayed from about 111 knots (kts) to about 64 kts before radar contact was lost. Witnesses reported that they heard the airplane and looked up to see it descending nose down like a corkscrew before it impacted terrain. Postaccident examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation.
AIRMET Zulu for moderate icing conditions was valid for the area of the accident site at the time of the accident, and an atmospheric sounding supported the likely formation of moderate rime and mixed-type icing in the area. The sounding also indicated the potential for supercooled large droplet icing formation near the top of the cloud layer near 15,000 ft msl. Satellite imagery depicted cumulus and cumulus congestus type clouds with vertical development over the flight track and accident site, and weather radar imagery depicted the airplane entering an area of light-to-moderate intensity echoes just before radar contact was lost. Immediately before and after the accident, two other aircraft operating at similar altitudes reported encountering light clear to mixed icing conditions. The pilot had received preflight weather information containing the relevant forecasts and advisories. In addition, the airplane was equipped with a TKS ice protection system, but it was heavily fragmented during the accident sequence and the investigation was unable to determine if the system was activated or working at the time of the accident.
It is likely that, during the last minutes of the flight, the airplane encountered moderate-to-severe icing conditions, which adversely affected the airplane's handling characteristics and likely resulted in a loss of control.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's encounter with moderate to severe icing conditions during cruise flight, which resulted in structural icing and a subsequent loss of control. Contributing to the accident was the pilot’s decision to continue a flight route through known moderate to severe icing conditions.
Findings
Environmental issues Conducive to structural icing - Effect on operation
Personnel issues Aircraft control - Pilot
Personnel issues Decision making/judgment - Pilot
Environmental issues Conducive to structural icing - Decision related to condition
Factual Information
History of Flight
Enroute Structural icing (Defining event)
Enroute-change of cruise level Loss of control in flight
Enroute-change of cruise level Collision with terr/obj (non-CFIT)
On May 24, 2019, about 1116 mountain daylight time, a Cirrus SR22 airplane, N809SR, was destroyed when it was involved in an accident near Grover, Utah. The private pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.
The airplane departed Canyonlands Field Airport (CNY), Moab, Utah, about 1042. Shortly after takeoff, the pilot contacted air traffic control, opened his instrument flight rules flight plan to Henderson Executive Airport (HND), Las Vegas, Nevada, and was assigned a cruise altitude of 14,000 ft mean sea level. About 1111, the pilot requested to climb to 16,000 ft msl; this was the last communication from the pilot. The airplane climbed from 13,900 ft to 14,500 ft at an average rate of 300 ft per minute and an average groundspeed of 111 knots. Shortly thereafter, the airplane's average groundspeed was 95 knots. The airplane then descended from 14,500 ft to 14,000 ft at an average rate of 833 ft per minute and an average groundspeed of 81 knots. The descent then increased to 2,000 ft per minute at an average groundspeed of 64 knots. Radar contact was lost at 1116.
Witnesses reported to law enforcement that they heard the airplane, then looked up and saw it nose down, descending like a corkscrew. The airplane descended behind a hillside and shortly thereafter, they heard an explosion and saw smoke.
Data recovered from the airplane's Avidyne multifunction display revealed that the engine was producing power until the time of the accident and that cylinder head and exhaust gas temperatures, fuel flow, oil temperature, and oil pressure values were consistent throughout the flight.
Pilot Information
Certificate: Private
Age: 66, Male
Airplane Rating(s): Single-engine land
Seat Occupied: Unknown
Other Aircraft Rating(s): None
Restraint Used: 3-point
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: August 15, 2017
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: 930 hours (Total, all aircraft)
Aircraft and Owner/Operator Information
Aircraft Make: Cirrus
Registration: N809SR
Model/Series: SR22 Undesignated
Aircraft Category: Airplane
Year of Manufacture: 2006
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 2129
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: April 16, 2019 100 hour
Certified Max Gross Wt.:
Time Since Last Inspection: 36 Hrs
Engines: Reciprocating
Airframe Total Time: 2672 Hrs as of last inspection
Engine Manufacturer: Continental Motors
ELT: Installed, not activated
Engine Model/Series: IO-550-N
Registered Owner:
Rated Power: 310 Horsepower
Operator: On file
Operating Certificate(s) Held: None
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual (VMC)
Condition of Light: Day
Observation Facility, Elevation: HVE,4463 ft msl
Distance from Accident Site: 30 Nautical Miles
Observation Time: 10:55 Local
Direction from Accident Site: 62°
Lowest Cloud Condition: Clear
Visibility: 10 miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 6 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 170°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.04 inches Hg
Temperature/Dew Point: 15°C / 2°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Moab, UT (CNY)
Type of Flight Plan Filed: IFR
Destination: Las Vegas, NV (HND)
Type of Clearance: IFR
Departure Time: 10:42 Local
Type of Airspace: Unknown
The National Weather Service issued AIRMET Zulu, valid for the area of the accident site about the time of the accident, for moderate icing conditions between around 7,000 ft to 9,000 ft up to 21,000 ft msl. The High Resolution Rapid Refresh numerical model sounding over the accident site depicted a freezing level of 9,755 ft msl and a supported layer of clouds with bases at 10,860 ft msl with tops near 15,000 ft msl; this cloud layer had a greater than 90% probability of producing moderate rime-to-mixedtype icing. The sounding also indicated a mean vertical motion varying from 8 to 14 meters per second, which would enhance the growth of supercooled large droplet formation near the top of the cloud layer. The sounding wind profile supported a high probability of moderate turbulence due to strong vertical wind shear within the cloud environment.
The GOES-17 visible imagery depicted cumulus to cumulus congestus clouds with vertical development over the flight track and accident site, which would also support the formation of larger supercooled water droplets, and vertical motion in the clouds, which would enhance the icing potential. Weather radar imagery depicted several small areas of light-to-moderate intensity echoes of 25 to 35 basic reflectivity values (dBZ) scattered over the area, with most of the echoes within 25 miles of the radar site in the range of 10 to 15 dBZ, or very light intensity. When overlaid with the airplane's flight track, imagery indicated that just before radar contact was lost, the airplane passed through one of these small cells with a maximum intensity of 25.5 dBZ.
Immediately before and after the accident, two other aircraft operating at similar altitudes reported encountering light clear-to-mixed icing conditions.
The pilot filed an instrument flight rules flight plan through ForeFlight before departure and received a corresponding route briefing, which included a description of the conditions and provided the advisory regarding potential icing conditions along the route of flight.
Wreckage and Impact Information
Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 1 Fatal
Aircraft Fire: On-ground
Ground Injuries:
Aircraft Explosion: Unknown
Total Injuries: 2 Fatal
Latitude, Longitude: 38.174446,-111.24861
The airplane impacted remote mountainous terrain. The debris field was about 330 ft long and was oriented on a magnetic heading of 217°. The airplane was heavily fragmented and scattered perpendicular to a cliffside.
Flight control continuity was established throughout the airframe. The elevator and rudder controls were continuous. The aileron control cable was fracture separated at the control panel and the aileron actuation pulley. Both fractures were consistent with overload. The airplane’s TKS icing protection system, which was not certified for flight into known icing, was found fragmented and scattered throughout the debris field.
The engine was separated from the airframe and came to rest about 211 ft from the initial impact crater. Several components were fracture separated from the engine and scattered throughout the debris field. The crankcase exhibited impact-related damage; there were no signs of catastrophic engine failure. The crankshaft was bent just aft of the propeller flange. The crankshaft gear displayed normal operating signatures. All six cylinders remained attached to the cylinder bays; the right-side cylinders exhibited more damage than the left side cylinders. Borescope examination of the cylinder bores, piston faces, and valve heads displayed normal operating signatures. The fuel pump was removed from the engine and the driveshaft was rotated; residual fuel pumped through the line. The upper and lower spark plugs exhibited normal operating signatures. The oil filter was removed from the engine and cut open; no metallic material was noted. The propeller assembly remained attached to the engine and the three blade shanks remained attached to the hub.
Postaccident examination of the airframe and engine revealed no anomalies that would have precluded normal operation.
Medical and Pathological Information
The Office of the Medical Examiner from the Utah Department of Health, Taylorsville, Utah performed an autopsy of the pilot and determined the cause of death to be "multiple injuries".
The FAA Forensic Sciences Laboratory performed forensic toxicology on specimens from the pilot with positive results for cetirizine which is not considered a hazard to flight safety.
Christian Clinton Simonsen
Tragic accident...I question if there was a ballistic chute...why was it not deployed ?
ReplyDeleteThere was - they're on all -20s and -22s as they're required. I recently completed the chute training and Cirrus very much stresses pulling it the moment you lose control or spatial orientation. That I'm sure comes from years of folks thinking they could fly it out and not wanting to admit failure by pulling the chute. Ego will get you killed in this business (see above).
DeleteLooks like an airplane with a thick heavy coating of ice develops all the flying characteristics of a brick. Judging from the photos the impact speed must have been terrific. A very sad end to the pilot and his wife. RIP>
ReplyDeleteRetard the throttle, pull the chute!
ReplyDeleteOne would think that Cirrus would have designed an automatic deployment trigger if flight dynamics exceed design limit and no action by a certain time is taken by the pilot to 1) recover or 2) pull the CAPS. It could be easily done with sensors tied from the avionics to the CAPS system. And the trigger could also be set based on AGL remaining and not just time when out of control. Possibly could have saved their lives here. An airfoil ruined by ice sending the aircraft out of control has a slim to none chance of recovery. Never mind the Cirrus is not certified for spins. So sorry for their family and friends.
ReplyDeleteHard to fathom why they did not deploy the chute that would have saved them. Possibly, they could not overcome the centrifugal forces in the spin. Maybe the wife had taken off her belt and was thrown onto him? They had nearly 5 minutes to find the handle. You would think you would find the handle, but the handle was still in its home position. Nice looking couple. RIP.
ReplyDeleteNot to invalidate the expertise of the investigators but I'm curious if this might not have been a medical. Here's why: 1 - Autopsy results show severe trauma, which might not allow an examiner to detect certain medical causes of incapacitation. For example, a stroke might not be detectable if the entire brain was severely traumatized upon impact. 2 - no mayday, no declaration of emergency, no other calls for assistance. It's a long way down from 14,500. There was no sign of communication failure in the post crash examination. There's an eternity of time to key the mic. 3 - The BRS was not activated. Even Maverick pulled the handle when there was no chance of recovery. If you're in a Cirrus, you know the BRS is there. 4 - the aileron control cable was fractured at both ends consistent with overload. Witnesses described the aircraft as spinning in. This brings me to question whether or not the non-pilot passenger (the wife) was possibly trying to recover from a spin using aileron inputs. When putting all 4 of those factors together I can speculate (guess) that this crash could have been caused by a medical incapacitation of the pilot, which led to a sudden loss of control of the aircraft. The non-pilot passenger is instantly struck with the incapacitation of her husband along with a rapidly descending aircraft that she cannot fly. In a spin the natural instinct of any untrained individual is to react with aileron control inputs rather than rudder. They did not own this plane, it belonged to a pool. She may not have known to key the mic to signal an emergency, and may not have known how to pull the BRS (or forgot in a panic). In any event, may they rest in peace.
ReplyDelete