National Transportation Safety Board
Aviation Accident Final Report

 

 

Location:

Gordonville, FL

Accident Number:

ERA17LA201

Date & Time:

06/11/2017, 1200 EDT

Registration:

N592BC

Aircraft:

CIRRUS DESIGN CORP SR22

Aircraft Damage:

Substantial

Defining Event:

Loss of engine power (total)

Injuries:

1 Serious

Flight Conducted Under:

Part 91: General Aviation - Personal

Analysis

 

The private pilot stated that he had "disoriented" himself by holding the airport diagram "upside down" as the airplane approached the destination airport. Once oriented, he turned the airplane onto the downwind leg of the traffic pattern, noticed the airplane was "high," and disconnected the autopilot. During the final approach, the airplane was descending rapidly, and the pilot added power to complete the landing. However, nothing happened because he had not properly set the mixture control, which resulted in a loss of engine power once he advanced the throttle. With little time and altitude remaining, the pilot was unable to regain engine power before the airplane struck the ground about 1/2 mile from the runway threshold. A postaccident test-run and examination of the engine revealed no evidence of any preimpact 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 pilot's failure to properly configure the mixture control for landing due to disorientation because he had the airport diagram upside down, which resulted in a total loss of engine power.

 

Findings

Aircraft

Mixture control - Incorrect use/operation (Cause)

Personnel issues

Use of equip/system - Pilot (Cause)

Visual illusion/disorientation - Pilot (Cause)

Factual Information

 

On June 11, 2017, about 1200 eastern daylight time, a Cirrus SR22, N592BC, was substantially damaged when it impacted a power pole, trees, and terrain while on approach to Bartow Municipal Airport (BOW), Bartow, Florida. The private pilot, who was also the owner of the airplane, was seriously injured. Visual meteorological conditions prevailed and no flight plan was filed for the flight which departed Gainesville Regional Airport (GNV) about 1120. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91.

The pilot was not immediately available due to his injuries, but was later interviewed by a police detective. During that interview, the pilot stated that he had "disoriented" himself by holding the airport diagram "upside down" as the airplane approached BOW. Once oriented, he turned the airplane on to the downwind leg of the traffic pattern, noticed he was "high" and disconnected the autopilot. During the final approach, the airplane was descending "rapidly" and the pilot added power to complete the landing, but "nothing happened" as he "hadn't reset [the] mixture." According to the pilot, he lacked the time and the altitude to "remedy the problem."

In a telephone interview, an air traffic controller stated that the accident airplane contacted the tower north of BOW and was instructed to report entering a left base for landing on runway 9L. Instead, the pilot reported the airplane was on a left downwind for runway 9L and was cleared to land. There were no further communications from the pilot. The final radar target was recorded about 1 mile from the threshold of runway 9L at 700 feet and 130 knots groundspeed. The airplane came to rest in a church yard about 1/2 mile from the threshold of runway 9L.

On-scene examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed substantial impact damage to the entire airframe, but no fire damage. There was evidence of fuel, and control continuity was established from the cockpit to the flight control surfaces. Initial visual examination of the engine did not reveal any anomalies. The engine was forwarded to the manufacturer for a detailed examination. Flight and multifunction displays, as well as components from the autopilot system were retained for examination in the NTSB recorders laboratory.

The pilot held a private pilot certificate with a rating for airplane single-engine land. His most recent FAA third class medical certificate was issued on March 9, 2011. The pilot reported 750 total hours of flight experience on that date.

The four-seat, low-wing, tricycle-gear airplane was manufactured in 2005 and was powered by a Continental IO-550, 310-horsepower engine. The airplane's hobbs meter displayed 2101.6 aircraft hours. The maintenance records were not reviewed, and the maintenance history could not be verified. The aircraft recovery company in possession of the airplane requested the maintenance records from the owner. He reported that the records were "in a storage facility" and that he could not access them due to his injuries. A copy of the most recent annual inspection forwarded by the pilot's attorney revealed the inspection was completed October 28, 2016 at 2065.3 total aircraft hours.

At 1545, weather reported at BOW included a broken ceiling at 3,000 ft, wind from 050° at 4 knots, and 10 statute miles of visibility. The temperature was 27° C, the dew point was 21° C, and the altimeter setting was 30.15 inches of mercury.

The engine was removed from the airframe and placed in a test cell at the engine manufacturer's facility in Mobile, Alabama. The engine started immediately, accelerated smoothly, and ran continuously at all power settings with no anomalies noted.

 

 

History of Flight

Approach-VFR pattern final

Miscellaneous/other

Loss of engine power (total) (Defining event)

Landing

Collision with terr/obj (non-CFIT)

 

 

Pilot Information

Certificate:

Private

Age:

61, Male

Airplane Rating(s):

Single-engine Land

Seat Occupied:

Left

Other Aircraft Rating(s):

None

Restraint Used:

Unknown

Instrument Rating(s):

None

Second Pilot Present:

No

Instructor Rating(s):

None

Toxicology Performed:

No

Medical Certification:

Class 3 With Waivers/Limitations

Last FAA Medical Exam:

03/09/2011

Occupational Pilot:

No

Last Flight Review or Equivalent:

 

Flight Time:

750 hours (Total, all aircraft), 100 hours (Total, this make and model)

 

 

Aircraft and Owner/Operator Information

Aircraft Make:

CIRRUS DESIGN CORP

Registration:

N592BC

Model/Series:

SR22 NO SERIES

Aircraft Category:

Airplane

Year of Manufacture:

2005

Amateur Built:

No

Airworthiness Certificate:

Normal

Serial Number:

1519

Landing Gear Type:

Tricycle

Seats:

 

Date/Type of Last Inspection:

10/28/2016, Annual

Certified Max Gross Wt.:

 

Time Since Last Inspection:

36 Hours

Engines:

1 Reciprocating

Airframe Total Time:

2065 Hours as of last inspection

Engine Manufacturer:

CONT MOTOR

ELT:

 

Engine Model/Series:

IO-550 SERIES

Registered Owner:

On file

Rated Power:

310 hp

Operator:

On file

Operating Certificate(s) Held:

None

 

Meteorological Information and Flight Plan

Conditions at Accident Site:

Visual Conditions

Condition of Light:

Day

Observation Facility, Elevation:

BOW, 125 ft msl

Distance from Accident Site:

1 Nautical Miles

Observation Time:

1145 EDT

Direction from Accident Site:

270°

Lowest Cloud Condition:

 

Visibility

10 Miles

Lowest Ceiling:

Broken / 3000 ft agl

Visibility (RVR):

 

Wind Speed/Gusts:

4 knots /

Turbulence Type Forecast/Actual:

/

Wind Direction:

50°

Turbulence Severity Forecast/Actual:

/

Altimeter Setting:

 

Temperature/Dew Point:

27°C / 21°C

Precipitation and Obscuration:

No Obscuration; No Precipitation

Departure Point:

Ganesville, FL (GNV)

Type of Flight Plan Filed:

None

Destination:

Bartow, FL (BOW)

Type of Clearance:

None

Departure Time:

1120 EDT

Type of Airspace:

Unknown

 

 

Wreckage and Impact Information

Crew Injuries:

1 Serious

Aircraft Damage:

Substantial

Passenger Injuries:

N/A

Aircraft Fire:

None

Ground Injuries:

N/A

Aircraft Explosion:

None

Total Injuries:

1 Serious

Latitude, Longitude:

27.945556, -81.798611 (est)

 


 


Administrative Information

Investigator In Charge (IIC):

Brian C Rayner

Report Date:

04/04/2019

Additional Participating Persons:

Rob Lasky; FAA/FSDO; Orlando, FL

Brad Miller; Cirrus; Duluth, MN

Kurt Gibson; Continental; Mobile, AL

Publish Date:

04/04/2019

Note:

The NTSB did not travel to the scene of this accident.

Investigation Docket:

http://dms.ntsb.gov/pubdms/search/dockList.cfm?mKey=95342