Chilling In-Flight Transcript Released On SR22 IFR Disorientation Accident | Aero-News Network
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Wed, Feb 02, 2005

Chilling In-Flight Transcript Released On SR22 IFR Disorientation Accident

The NTSB has updated the preliminary report on the fatal crash of N889JB, a single-piloted SR22 being flown during a series of practice approaches by a relatively new instrument-rated pilot. The aircraft went down in a residential area, killing the pilot and damaging two occupied houses, with no injuries to person on the ground.

The updated report is chilling -- especially for anyone with any real IFR time under their belt who has ever fought any form of disorientation, whether aided by equipment failure or not. The details are included below for your perusal... but we must note that this aircraft, if it was suffering PFD failure (for which the pilot's wording seems to offer some uncertainty on this issue), the aircraft still had a series of backup gauges (including a whole AH), a rate based autopilot (which would not have been affected by either attitude system's potential failure), and of course, the parachute. The use of any of these three "outs" might have saved this pilot (and this accident seems quite similar to another last year in which a chute WAS used)... but the confusion (if not outright terror) of an in-flight disorientation is hard to counter once it starts to take hold.

A caveat... despite the inference below, it is highly unlikely that the chute was in the process of being deployed. The details alluded to, below, are consistent with damage involved in a fire and impact scenario such as that experienced by N889JB.

Finally: Repeat after me... in the event of ANY potential confusion over orientation -- LEVEL The Wings, LEVEL The Nose, FLY The Airplane... everything else can wait until those goals are attained. 

NTSB Identification: IAD05FA032
14 CFR Part 91: General Aviation
Accident occurred Saturday, January 15, 2005 in Coconut Creek, FL
Aircraft: Cirrus Design Corp. SR-22, registration: N889JB
Injuries: 1 Fatal.

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.

HISTORY OF FLIGHT

On January 15, 2005, at 1223 eastern standard time, a Cirrus Design Corporation SR-22, N889JB, was destroyed when it impacted a house, then terrain, in Coconut Creek, Florida. The certificated commercial pilot was fatally injured. Instrument meteorological conditions prevailed, and the airplane was operating on an instrument flight rules flight plan from Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida, to Naples Municipal Airport (APF), Naples, Florida, and back to Fort Lauderdale Executive. The personal flight was conducted under 14 CFR Part 91.

According to preliminary information received from the Federal Aviation Administration (FAA), the airplane departed Fort Lauderdale Executive at 1217.

Preliminary radar and transponder data revealed that after the airplane departed Fort Lauderdale Executive, it climbed to the northwest, to 1,600 feet, before beginning a right turn toward the northeast. The airplane then climbed to 1,800 feet, continued the right turn, and once on a southeast heading, descended to 1,000 feet. Subsequently, the airplane turned left, and headed northeast, climbing to 1,900 feet. It then made a right turn to the south, and descended to 400 feet during a 12-second period, followed by a climb to 1,400 feet during the next 12-second period. The airplane subsequently made one more left turn, through north, to the northwest, and its last altitude readout, at 1223:17, was 1,100 feet. The last radar contact was about 500 feet southeast of the accident site.

A review of air traffic control transmissions revealed:

At 1219:13, the pilot stated: "(blocked), cirrus november eight eight nine juliet bravo is through a thousand, ah (blocked)."

At 1219:59, the controller responded: "eight eight niner juliet bravo you're radar contact, turn left heading two seven zero." The pilot then responded with: "ah, two seven zero, nine zero, ah, nine juliet bravo.

At 1220:07, the controller stated (to another pilot): "seven eight five, turn right, heading zero niner zero."

At 1220:11, an unidentified voice, similar to the accident pilot's, responded: "ah, did you say a right turn to two seven zero?"

At 1220:15, the controller stated: "turn right zero niner zero seven eight five."

The pilot from that airplane did not respond.

At 1220:21, the controller stated: "three six seven eight five, turn right heading zero niner zero."

At 1220:27, there was a sound similar to two pilots blocking each other's transmissions.

At 1220:30, the controller stated: "eight juliet, correction, niner juliet bravo, turn left, two seven zero."

At 1220:34, the pilot responded: "two seven zero for nine juliet bravo"

At 1220:37, the controller stated: "turn now please."

At 1220:39, the controller stated: "november six niner xray, turn left, heading one five zero," and that pilot responded with: "one five zero, six niner xray."

At 1220:44, the controller stated: "november nine juliet bravo, turn left, heading two seven zero, two seventy the heading niner juliet bravo. you've turned the wrong way."

At 1220:51, the pilot responded: "you told me to turn ninety; i'm turning back to two seventy now."

At 1220:54, the controller stated: "negative sir, that was for a seven eight five. november niner juliet bravo, continue in the turn heading of zero niner zero. traffic alert. traffic eleven o'clock, one mile, indicates two thousand, he's southbound."

At 1221:08, the pilot responded: "zero nine zero on the heading, nine juliet bravo."

At 1221:15, the controller stated: "november niner juliet bravo, just continue on a ninety heading. november six niner xray, turn right, heading of zero, correction, turn right, heading two seven zero." That pilot responded: "two seven zero, six niner x."

At 1221:25, the controller stated: "november seven eight kilo, turn left, turn left, heading zero niner zero, maintain three thousand," and the pilot responded: "zero nine zero, seven eight kilo."

At 1221:32, the controller stated: "cirrus niner juliet bravo, climb and maintain two thousand, over."

At 1221:36, the pilot responded: "climbing to two thousand (pause), and you happen (transmission cut off)."

At 1221:41, the controller stated: "november niner juliet bravo, just continue on a ninety heading, heading zero niner zero. i'm trying to get you away from a cessna."

There was no response from the pilot.

At 1221:51, the controller stated: "november niner juliet bravo, fly heading zero niner zero, over."

There was no response from the pilot.

At 1222:00, the controller asked: "november eight eight niner juliet bravo, how do you hear, over?"

At 1222:05, the pilot responded: "i'm hearin' ya. i'm hearin' ya. i'm, i'm, i gotta get, ah, my act together here."

At 1222:12, the controller stated: "november niner juliet bravo, fly heading zero niner zero. i have aircraft off your left, will be on the approach at pompano. just fly a ninety heading, climb and maintain two thousand."

There was no answer from the pilot.

At 1222:30, the controller stated: "seven eight kilo, turn left, three six zero, it's going to be a short vector, i've got a cirrus disorientated out to the of, ah, east of you. i have to get him under control again." That pilot responded: "three six zero, seven eight kilo."

At 0222:39, the controller stated: "thank you. november seven eight five, turn right, heading one eight zero. this will be vectors across the localizer for aircraft that's just going to be coming across pompano at two thousand feet." There was no response from that pilot.

At 1222:53, the controller asked: "cirrus eight eight niner juliet bravo, miami, how do you hear?"

At 1222:57, the pilot responded: "i hear you, but i've got, i've got problems, i've got avionics problems."

At 1223:03, the controller stated: "cirrus niner juliet bravo, roger. do you have a gyro?"

At 1223:09, the pilot responded: "i'm trying to get the plane, ah, level, nine juliet bravo."

At 1223:13, the controller asked: "okay, november niner juliet bravo, do you see the ground?"

At 1223:18, the pilot responded: "negative, I do not see the ground, nine juliet bravo."

At 1223:21, the controller asked: "all right, you have your wings level?"

At 1223:23, the pilot responded: "the wings are level, nine juliet bravo."

At 1223:26, the controller asked: "november niner juliet bravo, roger, do you have a directional gyro?"

At 1223:30, the pilot stated: "i'm losin', i'm losin' it again here."

There were no further transmissions from the pilot.

A witness, an airline transport pilot who was at a park near the accident site, reported that he heard the airplane flying southeast at a very low altitude. He looked up, but couldn't see it through the low overcast and mist. The airplane didn't sound like it had any engine problems, but as it flew farther away, it sounded as if it was maneuvering.

A second witness, who was outside his home near the accident site, stated that he heard an airplane above the clouds that sounded like it was conducting acrobatics, climbing and descending. Suddenly, it descended out of the clouds, then banked and headed back up into the clouds in northeasterly direction. As it ascended, the witness heard "an rpm change, like it was climbing." The witness then heard the engine get louder, followed by the sound of an explosion. The witness did not see the airplane exit the clouds a second time due to trees in his line of sight.

Another witness, who did see the airplane descend from the clouds the second time, stated that when it did so, the airplane was perpendicular to the ground, "but on a slant."

The accident occurred during daylight hours, in the vicinity of 26 degrees, 15.5 minutes north latitude, 080 degrees, 10.4 minutes west longitude.

PILOT INFORMATION

The pilot held a commercial pilot certificate. According to certificates found in his logbook, the pilot obtained his private pilot certificate on June 1, 2003, his instrument rating on October 6, 2003, and his commercial certificate on March 25, 2004.

The pilot had logged 483 hours of flight time, with 405 hours between two SR-22s. He began flying the first SR-22, N97CT, on June 5, 2003, and logged 304 hours in it. He began flying the accident SR-22 on June 2, 2004.

The pilot had also logged a total of 15 hours of actual instrument time, and 61 hours of simulated instrument time. His last flight before the accident flight was 1.6 hours on January 7, 2005, in which he also logged one instrument approach and 0.2 hours of actual instrument time.

On December 30, 2004, the pilot logged a flight in which he flew two ILS, one VOR, and one GPS approach. According to the flight instructor on that flight, one of the approaches was flown partial panel, without the PFD. The flight instructor also noted that it wasn't the first time they had practiced partial panel; they had done it a number of times previously.

The pilot's latest FAA first class medical certificate was issued on April 16, 2004.

AIRPLANE INFORMATION

The airplane was manufactured in 2004, and was the second Cirrus SR-22 that the pilot's company had owned. The airplane was equipped with an Avidyne FlightMax Entrega-Series Primary Flight Display (PFD). Information provided by the PFD included airplane attitude, airspeed, heading and altitude, a horizontal situation indicator, and a vertical speed indicator.

According to maintenance records, the PFD had been replaced on June 4, 2004, at 12.2 hours, on September 14, 2004, at 55.2 hours, and on December 20, 2004, at 80.6 hours.

Below the PFD, on a "bolster panel" in front of the pilot, were backup altimeter, airspeed, and attitude indicators, to be used "in case of total or partial PFD failure."

The airplane was also equipped with a Cirrus Airplane Parachute System (CAPS).

According to the SR-22 Pilot's Operating Handbook:

"CAPS [is] designed to bring the aircraft and its occupants to the ground in the event of a life-threatening emergency. The system is intended to save the lives of the occupants but will most likely destroy the aircraft and may, in adverse circumstances, cause serious injury or death to the occupants.

CAPS is initiated by pulling the activation T-handle installed in the cabin ceiling on the airplane centerline just above the pilot's right shoulder. A placarded cover, held in place with hook and loop fasteners, covers the T-handle and prevents tampering with the control. The cover is removed by pulling the black tab at the forward edge of the cover. Pulling the activation T-handle removes it from the o-ring seal that holds it in place and takes out the approximately six inches of slack in the cable connecting it to the rocket. Once this slack is removed, further motion of the handle arms and releases a firing pin, igniting the solid-propellant rocket in the parachute canister."

There were no flight data or cockpit voice recording devices installed on the airplane.

METEOROLOGICAL INFORMATION

Fort Lauderdale Executive Airport was located about 4 miles to the south of the accident site. Weather, recoded there at 1153, included winds from 340 degrees true, at 4 knots, surface visibility 10 statute miles, and an overcast cloud layer at 600 feet.

Weather, recorded at 1253, included winds from 310 degrees true, at 5 knots, surface visibility 5 statute miles, light rain and mist, and an overcast cloud layer at 600 feet.

WRECKAGE AND IMPACT INFORMATION

The airplane's wreckage was located in a back yard of one house, next to another house. The right wing tip was broken off in the roof of the second house. The wreckage, which displayed no ground impact marks consistent with forward motion, was consumed in a post-impact fire.

All flight control surfaces were accounted for at the scene, and control cable continuity was confirmed from the cockpit, to where all flight surface attach points would have been.

The engine sustained impact damage. The three-bladed propeller, and the front of the engine, including the crankshaft to just aft the number six connecting rod, were separated from the rest of the engine and buried in the ground. One of the propeller blades was broken off about 5 inches from the hub, another blade exhibited deep chordwise scratching, and the third was bent aft.

There was no evidence of any pre-impact anomaly to either the engine or airframe. All flight instruments were destroyed in either the ground impact or the post-impact fire.

The CAPS parachute bag extended, by attached risers, about 40 feet from the wreckage, and came to rest in front of a fence. The parachute was still in the parachute bag. The CAPS cover was located near the airplane, and exhibited a circular impact mark on the inside, consistent with rocket activation. The squib had also been fired. The rocket motor and lanyard were found near the parachute bag.

The CAPS T-handle safety pin was found in the wreckage, away from the T-handle, with its red safety flag wrapped around it. The T-handle was found pulled out of its housing by about 2 1/2 inches; however, it could not be determined if the pilot had pulled it, or if it had been displaced by impact forces.

FMI: www.ntsb.gov, www.cirrusdesign.com

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