NTSB Factual Report

HISTORY OF FLIGHT

On October 20, 2017, at 1756 Pacific daylight time, a Cirrus Design Corp SR22T GTS airplane, N3636E, struck a ditch at the end of the runway following a rejected takeoff from San Carlos Airport, San Carlos, California. The private pilot and passenger sustained minor injuries, and the airplane sustained substantial damage. The airplane was registered to and operated by the pilot as a personal flight under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan had been filed. The cross-country flight had a planned destination of Santa Monica Municipal Airport, Santa Monica, California.

The pilot reported that the preflight inspection was uneventful, and that after startup he noticed that the engine was not running smoothly. He was not unduly concerned, as the engine had a habit of vibrating slightly as it warmed up. He then taxied to the runup area, upon which he performed the preflight checks and engine runup. By this time the engine was operating smoothly. He stated that the remaining checks were uneventful, and included setting the elevator trim for takeoff, checking the flight controls, electrical load, fuel level, and the autopilot status.

A short time later he was cleared for takeoff by the tower controller. He began the takeoff roll and initiated the rotation at a speed of about 75 to 77 knots. Immediately after the airplane became airborne, it remained in ground effect longer than usual, during which he perceived a change in engine power. He did not look at the engine instruments, but the airplane did not climb as expected. With runway remaining the pilot decided to abort the takeoff. He reduced engine power, but then instinctively added power again to help the airplane settle rather than land hard. When he realized that this was not a full-length runway landing, he pulled the throttle completely back, and applied full braking. The airplane then passed beyond the runway threshold, into a ditch, and came to rest on the airport perimeter road, about 300 ft beyond the threshold.

The airplanes lap belt airbags deployed as the airplane struck the ditch (Image 1), and both the pilot and passenger were able to egress unaided.

PERSONNEL INFORMATION

The pilot was issued a private pilot certificate with a rating for airplane single-engine land on June 6, 2017. He held a third-class airman medical certificate issued in August 2016, with no limitations.

He reported a total of 114 hours of flight time, with 22.3 as pilot in command, all in the accident make and model. His last flight review was for the private pilot checkride, and took place in a Cessna 172S.

AIRPLANE INFORMATION

The airplane was manufactured in 2017, and purchased new by the pilot about one month before the accident. It was equipped with a six-cylinder turbocharged Continental Motors Inc. TSIO-550-K1B engine, and a Hartzell three-blade composite constant-speed propeller.

The airplane had accrued 31.2 hours of flight by the time of the accident.

The airplane was equipped with a Cirrus Perspective integrated flight instrument system manufactured by Garmin, which was configured to record a series of airframe and engine parameters to an SD memory card at a 1 Hz rate. Recorded engine parameters included fuel flow, manifold pressure, engine speed, and both exhaust and cylinder head temperatures (EGT, CHT). The system also included a series of electronic checklists customized specifically for the SR22. The airplane was also equipped with a crash hardened Recoverable Data Module (RDM), a flight recording device installed in the tail of the airplane. The RDM recorded critical airplane systems and flight parameter information at a 1 Hz rate.

AIRPORT INFORMATION

The San Carlos airport is at an elevation of 5 ft mean sea level and composed of a single 2,600 ft long by 75 ft wide grooved asphalt runway. The runway is level and designated 12/30. The runway 12 displaced threshold is about 300 ft long.

ADDITIONAL INFORMATION

The airplane sustained substantial damage to the forward fuselage and both wings during the collision with the ditch. There was no indication of a catastrophic engine failure, both wing tanks contained fuel, and the flap switch and the flaps were observed in the UP position.

Examination of the data recovered from the RDM and the flight instrument system revealed that electrical power was turned on at 1725:45, followed a few seconds later by the flap switch being moved to the 100% (fully extended) position. For the next 20 minutes the airplane remained in the same location on the ramp until the engine was started, and the flap switch was moved to the 0% (UP) position.

At 1749, the airplane began to taxi southeast along taxiway J, arriving at the runup area adjacent to the entrance of runway 30, two minutes later. For the next 4 minutes the airplane remained in the runup area as the engine speed, manifold pressure, fuel pressure, and EGTs began to rise in a manner consistent with the pilot performing an engine runup.

At 1755, the airplane began to taxi towards runway 30, and within 40 seconds it had lined up on the runway centerline. A few seconds later the airplane began to accelerate until it reached an indicated airspeed of 77 knots after travelling 1,000 ft down the runway. The airplanes nose then pitched up from about 2° to 7°, where it remained for the next 3 seconds as the airplane continued at a speed of about 83 knots. The nose then dropped back to about 2°, and after travelling about 2,050 ft down the runway, the airplane began to veer to the left. It then passed the runway numbers after reaching its maximum speed of 96.7 knots. The airplane then began to veer right, while it decelerated and exited the runway beyond the displaced threshold. It then crossed the grass overrun, passed through the ditch, and came to rest on the airport perimeter road (Image 2).

According to the flight instrument system and RDM, during the takeoff roll, the engine speed remained at a continuous 2,500 RPM, while the manifold pressure was at 38 inches of mercury, and the fuel flow was 42 gallons per hour. All exhaust gas temperatures were stable in the 1,225°F range.

Up until the presumed engine runup, the EGT for cylinder number 2 lagged the other cylinders by a temperature of up to almost 300°F. After the runup was complete the temperature stabilized and began to synchronize with the other five cylinders.

The RDM data revealed that the flap switch remained in the UP position from the time the engine was started through to the time of the accident.

Pilot's Operating Handbook

The SR22T Pilot's Operating Handbook (POH) states that normal and short field takeoffs are accomplished with flaps set at 50%. The handbook further states that takeoffs with the flaps set to 0% are permissible, however, no performance data is available for that configuration. The normal takeoff rotation speed with 50% flaps is 77 KIAS.

The handbook recommended that the flaps be set to 100% during the preflight inspection and walkaround, and then retracted to 0% for taxi. The before takeoff checklist calls for 50% flaps to be selected, and the flap position to be checked by the pilot.

The pilot stated that prior to flight he used both the POH checklist and the electronic checklist included in the integrated flight system, and that he was not distracted while performing any of the checks. He could not recall specifically setting the flap position but stated that he performs takeoffs with the flaps set to 50% and has only used 0% flaps for takeoff during training.

The takeoff ground roll distance at sea level, no wind, a temperature of 20° C, and with the airplane loaded to its maximum gross weight (3,600 lbs) is 1,574 ft. When loaded to 2,900 lbs, the ground roll distance is 564 ft.

The flaps 0% landing distance at the airplane's maximum gross weight under the same conditions was 1,465 ft. No landing distance data was available for lower gross weights.

Video Footage

A surveillance camera located perpendicular to the runway 12 numbers captured video and audio of the final stages of the takeoff roll. As the airplane approached the runway numbers it was on the ground, and a skidding sound could be heard accompanied with puffs of smoke from the main landing gear. The airplane continued skidding along the runway and out of the cameras field of view until a second later when a crashing sound was heard.

NTSB Probable Cause

The pilot's failure to follow the Before-Takeoff checklist and properly set the flaps before takeoff, which altered the airplane’s flight characteristics, and the pilot’s failure to recognize the problem and abort the takeoff in a timely manner, which resulted in a runway overrun. Contributing to the accident was the pilot’s lack of experience in the high-performance airplane.