NTSB Factual Report

"THIS CASE WAS AMENDED MARCH 5, 2008."

HISTORY OF FLIGHT

On October 25, 2006, at 1208 mountain standard time (MST), a Cirrus SR22, N121LD, reported icing conditions at approximately 12,000 feet mean sea level (msl) and impacted terrain about 24 nautical miles (nm) northeast of Meadview, Arizona. The pilot was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. The instrument rated private pilot and three passengers sustained fatal injuries; the airplane was destroyed. A combination of visual and meteorological conditions prevailed along the route of flight and a pop-up instrument flight rules (IFR) flight clearance was issued at 1150. The pilot departed from Lake Tahoe Airport (TVL), South Lake Tahoe, California, about 1030 Pacific daylight time, and was destined for the Grand Canyon National Park Airport (GCN), Grand Canyon, Arizona.

According to family friend, the pilot met his wife and two children in the San Francisco, California area on October 23. They flew to South Lake Tahoe, spent the night, and then planned to depart for the Grand Canyon to go hiking. The morning of the accident, the pilot was delayed due to an overnight frost accumulation on the airplane. About 1015, the pilot told the family friend that they were going to the Grand Canyon and would call when they arrived. Following the trip to the Grand Canyon, they had plans to travel to Phoenix, Arizona.

Review of flight service station (FSS) data showed that the pilot contacted flight service to file an instrument flight plan. At the conclusion of filing the flight plan, the specialist asked if the pilot needed any additional services. The pilot stated that, "It's beautiful weather so I got weather on board, and we're set." There was no record of the pilot obtaining a weather briefing from FSS or via direct user access terminal (DUAT) service for the accident flight.

A fixed base operator employee at Lake Tahoe Airport stated that the pilot arrived at the airport the day prior from Reno, Nevada. The airplane was secured at the ramp and no fueling services were provided. The pilot returned to the airport the following morning and found frost on the airplane. He and his family waited while the sun rose and melted the frost accumulation. They departed about 1030. The employee indicated that the weather conditions at the Lake Tahoe Airport were "very good" with clear skies.

PERSONNEL INFORMATION

The pilot held a private pilot certificate with an instrument rating. The pilot's last medical was issued on July 2, 2005, and was a third class. It had no limitations or waivers.

The pilot attended the Cirrus transition course at the Cirrus factory from November 15- 21, 2005. The pilot accrued 20.4 dual hours, 6.0 oral instruction hours, 1.5 dual day hours, 8.4 instrument hours, 34 landings, and 8.7 pre/post flight briefing hours.

The pilot's personal flight logbook was recovered from the accident site. The entries in the logbook were dated from July 1996 to October 2006. Excluding the last four entries that were for future planned flights, the pilot's total logged time was about 892 hours. The pilot obtained an instrument rating in July of 2005 which equated to his most recent flight review as outlined in FAR 61.56 (d). The pilot had accrued about 384 hours in the accident airplane. In the pilot's logbook, he logged almost all flights in the accident airplane under "actual instrument conditions." An accurate estimate of his actual instrument flight time could not be determined.

From April 25 to 29, 2006, the pilot logged a trip from Atlanta, Georgia, round trip via Gulfport and Tunica, Mississippi. In the remarks section he noted that thunderstorms were encountered.

AIRPLANE INFORMATION

The airplane was a Cirrus SR22 manufactured in 2005. The pilot purchased the airplane from the factory in November 2005. A Teledyne Continental Motors (TCM) IO-550-N equipped with a Harztell PHC-J3YF-1RF powered the airplane. The pilot had previously owned a Cessna 172M, which his logbook indicated was purchased in June 2004. Federal Aviation Administration records showed that the pilot sold the Cessna 172M on April 15, 2005.

The airplane's production flight testing was completed on October 30, 2005, and its airworthiness certificate was issued on November 7, 2005. The first annual inspection was due no later than November 30, 2006. The last maintenance performed on the airplane was on October 12, 2006, at a total time of 406.2 hours.

The airplane was last refueled at a fixed base operator at the Reno/Tahoe International Airport on October 23. The fueling invoice indicated that the right and left fuel tanks were filled with the addition of 24.1 total gallons of fuel. On the invoice, the pilot's estimated departure time from the airport was noted as 1000 on October 24.

METEOROLOGICAL INFORMATION

Meteorological Factual Report

A Safety Board meteorologist reviewed weather data surrounding the time and location of the accident. The area forecast issued on October 25, at 0345 MST and valid until 1645 MST reported that the northern half of Arizona was forecast to have cloud layers from 7,000 to 8,000 feet broken, and 11,000 feet broken, with cloud tops at 14,000 feet. After 1300, winds were forecast to be westerly at 17 knots gusting to 27 knots.

The local weather included AIRMETS (Airman's Meteorological Information) for icing, approximately 65 nautical miles northeast of the accident site, and moderate turbulence (within the accident site area).

A convective SIGMET (Significant Meteorological Information) was issued for an area encompassing the accident site. Area thunderstorms were moving from 290 degrees at 20 knots with cloud tops to 28,000 feet mean sea level (msl). A convective SIGMET implies severe or greater turbulence, severe icing, and low-level wind shear.

XM Satellite Weather

The airplane was equipped with an XM Satellite Weather System. According to the supplement in the pilot's operating handbook, the XM Satellite Weather System enhances situational awareness by providing the pilot with real time, graphical weather information depicted on the MFD. The weather information is not an FAA-approved weather source.

The company that supplies weather information for the unit provided data showing that weather data, including the convective SIGMET, was available to the pilot. When the information is displayed to the pilot, it is shown on a specific page of the multi-function display (MFD). Although the unit has non-volatile memory, the page(s) of data that the pilot was viewing during the flight is not a recorded parameter.

Comparison of the weather radar data available to the pilot using the airplane's onboard weather display, with recorded weather radar information obtained following the accident, showed that the images available on the pilot's weather display did not compare exactly with radar images obtained by the Safety Board meteorologist. According to the weather provider, both the recorded radar and pilot's radar display showed similar locations of precipitation, but had the pilot's display lacked some of the lighter precipitation. The data that the pilot had displayed at the time of the accident is not a recorded parameter.

WRECKAGE AND IMPACT

The Safety Board investigator, a Safety Board specialist from the Office of Research and Engineering, and investigators from Cirrus, Ballistic Recovery Systems, AmSafe, and Teledyne Continental Motors, responded to the accident site on October 26, 2007. Two Federal Aviation Administration (FAA) inspectors from the Las Vegas Flight Standards District Office (FSDO) and one investigator from the FAA Aircraft Accident Investigation division also responded to the site.

The airplane impacted 20-degree sloped desert terrain at a terrain elevation of 4,520 feet mean sea level. All of the control surfaces were attached or partially attached to the structure. There was no fire.

The parachute was out of its enclosure, and the rocket and the deployment bag were located approximately 288 feet east of the main wreckage. Shards of Plexiglas were located near the fuselage. The activation cable was continuous from the activation handle aft through the fuselage to the rocket igniter.

MEDICAL AND PATHOLOGICAL INFORMATION

The Mohave County Medical Examiner determined that the cause death for all occupants was multiple blunt force traumatic injuries due to an accident. The Federal Aviation Administration Bioaeronautical Research laboratory completed testing on specimens of the pilot. The results were negative for volatiles and all tested drugs.

TESTS AND RESEARCH

The wreckage was recovered and brought to Air Transport, Inc., located in Phoenix, Arizona. Investigators convened there on October 28, 2006.

Airframe

The airplane was destroyed upon impact. The wings remained attached through the center section, and the flaps and ailerons were secured. Measurement of the flap actuator was 3.5 inches, consistent with the flaps in the fully retracted position.

Control cables were traced from the empennage section forward to the master aileron actuator pulley attachment. The control rods extending out to the control yoke assemblies were fractured at the rod ends and bent in the deformed structure. The cables to the elevator bellcrank were continuous and the control rods to the control yoke assembly were fractured. The rudder aileron interconnect was connected. All parts and safeties were present. The mass balances for the flight controls were present and in their design locations. The roll trim and pitch trim actuators were in the approximate neutral positions.

The airplane was equipped with an XM weather/radio, a stormscope, Skywatch, EMax (engine monitoring system), CMax (electronic approach plates), flight director, TKS anti-icing system, and E-TAWS (enhanced terrain awareness system). The airplane was also equipped with dual Garmin 430 GPS units, a Garmin GTX 327 transponder, and an S-TEC 55X autopilot. The Hobbs hour meter showed 436.1 hours.

The TKS switches were on and in the max flow positions. The ice protection system was documented and sustained various breaks throughout the system in the fluid lines, including a fluid line that connected by design to the Horizontal Proportioning Unit. There was no evidence of fluid leakage on the surrounding airplane structures. Fluid was located at the pump and at the tee assembly for the wings and propeller. The TKS panels sustained impact damage. The ice protection system components were removed for further functional testing.

Engine

The TCM engine was examined. The engine case was cracked in several places. The exhaust system, induction system, and oil sump were crushed against the engine. The magnetos were manually rotated and spark was obtained from each lead of the ignition harness. Both alternators sustained impact damage. The standby alternator separated upon impact and would not rotate by hand. The primary alternator, mounted to the front side of the engine, was removed by investigators; it was rotated freely by hand.

The fuel pump was removed and the drive was rotated by hand. The drive coupler was intact. The fuel manifold valve was disassembled and fuel was present in the screen area. The screen was clear of debris and the gasket was pliable.

The cylinder rocker covers were removed and residual oil was found on the valve train. The oil filter was removed and cut open. The filter was free of contaminants. Spark plugs were removed and examined. The coloration was light gray and according to the Teledyne Continental representative, they showed normal wear conditions. The spark plug type was Champion RHB-32S. The cylinders were borescoped and light gray deposits were identified in all of the cylinders.

Propeller

The 3-bladed Hartzell propeller, model PHC-J3YF-1RF, was examined. The blades were numbered by investigators in a clockwise direction as viewed from the aft. The number 1 blade was undamaged and intact at the hub. The number 2 blade had multi-directional gouges and scratches on the cambered face of the blade. Leading edge damage was found from the tip to the hub and the blade was found loose in the hub. The front portion of the deice propeller boot had been torn off. The number 3 blade had multi-directional gouging and scratching on the cambered side with trailing edge and tip damage. The deice propeller boot was ripped along the leading edge. All of the slinger tubes at each of the propeller blades were intact. The lower half of the spinner sustained crush damage.

Cirrus Airframe Parachute System (CAPS)

BRS manufactures the entire emergency parachute system, which Cirrus identifies as the Cirrus Airframe Parachute System (CAPS). All Cirrus airplanes are equipped with CAPS. CAPS utilizes a mechanically activated solid propellant rocket motor to extract the parachute from the airplane in emergency situations.

The activation handle used to fire the CAPS was present and located unstowed from the activation handle holder located at the roof of the airplane. The safety pin and its "remove before flight" tag were not in the activation handle and handle holder; it was located near the instrument panel (Cirrus preflight procedures require the removal of this safety pin from the activation handle prior to flight). The activation cable sheath was broken and stretched apart near the activation handle holder assembly. Continuity of the activation cable was verified on scene.

The remainder of the CAPS was documented. According to the BRS representative, the condition of the CAPS was consistent with the parachute deploying upon the airplane's impact with the ground.

Anti-Ice System

The airplane was equipped with a TKS ice protection anti-ice system. The system was certified as a non-hazardous system, indicating that the system is provided as a means of escape during inadvertent icing encounters. The system consists of six porous panels, a propeller slinger ring, four proportioning units, a metering pump, filter, strainer, fluid tank, activation switch, filler cap, system plumbing, and attaching hardware.

Components of the ice protection system were sent to CAV Aerospace, located in Consett, England, under the oversight of an accredited representative from the Air Accidents Investigation Branch (AAIB). Rig testing of the components showed that they were capable of operation pre-impact. One of fluid line fittings at the Horizontal Proportioning Unit showed an anomaly during testing. A system pressure was applied, and the fluid line was forced from the fitting at 70 pound per square inch (psi).

According to Cirrus, at minus 30 degrees, Celsius pressure at the horizontal proportioning unit would not exceed a range of 40 to 48 psi. Warmer temperatures would result in lower pressures. According to multi-function flight display data obtained from the accident airplane, the lowest outside air temperature for the accident flight was minus 11 degrees Celsius. If this fluid line became disconnected during operation of the system on the airplane, testing showed that the majority of the fluid would be lost and drain out at the fitting.

Remnants of a blue torque stripe remained on the line fitting to the Horizontal Proportioning Unit. According to the Cirrus representative, this system had been reworked on the flight line following its initial assembly (where it would have been given an orange torque stripe). Review of build records show that the right TKS panel on the horizontal stabilizer was repaired and a porous panel leak check performed. Company procedures require "production flight" personnel to utilize blue torque seal.

Review of Cirrus service history showed no similar reports of problems at the anti-icing system fittings. Additionally, the manufacturer indicated that based on CAV's findings, had the line been disconnected prior to the accident flight, the preflight checks on the system would have been unsatisfactory.

Cockpit Displays Factual Report

The airplane was equipped with an Avidyne EXP5000 primary flight display (PFD) and an Avidyne EX5000 multi-f

NTSB Probable Cause

The pilot's inadequate weather evaluation and continued flight into forecasted icing conditions. Contributing to the severity of the accident was the pilot's failure to follow proper operating procedures and deploy the CAPS when the airplane entered a spin. The flight service specialist's failure to follow published procedures to provide adverse weather or forecast potential hazardous conditions along the intended route of flight, as well as the air traffic controller's failure to provide the pilot with radar-displayed weather information were factors.