NTSB Factual Report

HISTORY OF FLIGHT

On September 15, 2006, at 1332 mountain daylight time, a Cirrus Design Corp SR20, N787SL, owned by East End Aviation LLC, and piloted by a private pilot, was destroyed when it impacted terrain 50 nautical miles (nm) north northwest of Maybell, Colorado. Visual meteorological conditions prevailed at the time of the accident. The personal flight was being conducted under the provisions of Title 14 Code of Federal Regulations Part 91 on an instrument flight rules flight (IFR) plan. The private pilot and private pilot rated passenger were fatally injured. The cross-country flight departed Bolinder Field - Tooele Valley Airport (TVY), Tooele, Utah, approximately 1150 and was en route to Lincoln, Nebraska (LNK).

The pilot and his passenger were returning from a business meeting in California and had departed Metropolitan Oakland International Airport (OAK) approximately 0640 Pacific daylight time. A flight log found within the wreckage indicated that they landed at TVY. According to a receipt from Tooele Valley Airport, the passenger paid for 36.26 gallons of fuel at 1120.

At 1221:13, the pilot contacted Cedar City radio with a request to file an IFR flight plan from his present position (10 miles east of FFU VOR) to LNK. The flight plan was filed for 14,000 feet. Afterwards, the briefer mentioned Airman's Meteorological Information (AIRMETS) along the route of flight for mountain obscuration, turbulence, and icing, and advised them to contact Flight Watch if they needed further weather information.

At 1320:20, the pilot reported to Denver (DEN) Air Route Traffic Control Center (ARTCC) that they were at 13,800 feet and "need a (unintelligible) altitude… [they] picked a little bit of ice." The controller issued an altimeter setting of 29.65. At 1323:29, the controller asked about the flight's assigned altitude. The pilot responded 14,000 feet and stated that he was unable to maintain that altitude. Several altitude assignments were issued by the controller and ultimately a block altitude from 12,000 feet to 13,000 feet was assigned.

At 1330:51, the pilot reported to ARTCC that they were having "serious" icing issues and were unable to maintain 12,000 feet. The controller asked the pilot if he had terrain in sight and the pilot responded in the affirmative. The controller cleared the pilot to descend to 11,000 feet and maintain his own terrain separation. At 1331:57, the controller asked the pilot what type of icing he was encountering. No further transmissions were received from the pilot.

National Track Analysis Program (NTAP) radar data depicted the airplane on a northeasterly heading at an encoded altitude of 12,500 feet mean sea level (msl). At 1329:40, the airplane reversed course to a northerly direction and continued to descend. Radar contact was lost at 1332:13. No encoded altitude was available for this time stamp.

An Alert Notification (ALNOT) was issued at 1349 and search and rescue operations were initiated. The wreckage and debris path were located approximately 1440 by law enforcement personnel from the Sweetwater County Sheriff's office. A witness in the area observed a portion of the fuselage being drug by the aircraft recovery parachute. They did not witness the actual impact.

PERSONNEL INFORMATION

The pilot, age 48, held a private pilot certificate with airplane single and multi-engine land, and instrument ratings, initially issued on October 30, 2004. He had been issued a second class airman medical certificate on May 24, 2006. The certificate contained no limitations.

According to the Cirrus Factory Training Course records, the pilot attended aircraft familiarization training from September 16 through September 19, 2005. The pilot logged 12.2 hours of flight training and 8.0 hours of ground school during this time. All areas of training were completed with a satisfactory rating.

A copy of the pilot's logbook was provided to the National Transportation Safety Board (Safety Board) investigator-in-charge (IIC) for review. The pilot had logged no less than 583.6 hours; 88.3 in multi-engine airplanes and 495.3 hours in single engine airplanes. A total of 275.8 hours had been logged in a Cirrus SR-20, all but 1.2 hours of which were in the accident airplane. In addition, the pilot had logged 95.8 hours of instrument time; 35.7 of which were in actual instrument conditions, and 28 hours of which were in the accident airplane. The pilot successfully completed the requirements of a Flight Review on July 4, 2005.

The passenger, age 46, held a private pilot certificate with an airplane single engine land rating which was issued on May 2, 2005. He had been issued a third class airman medical certificate on September 10, 2003. The certificate contained no limitations.

According to a flight log located within the wreckage, the passenger had flown the previous leg from California. There was no record that the passenger had attended the Cirrus Factory Training Course.

AIRCRAFT INFORMATION

The accident airplane, a Cirrus Design Corp (serial number 1556), was manufactured in 2005. It was registered with the FAA on a standard airworthiness certificate for normal operations. The airplane was equipped with a Teledyne Continental Motors IO-360-ES engine rated at 210 horsepower at 2,800 rpm. The engine was equipped with a Hartzell 2-blade, constant speed propeller.

The pilot purchased the airplane in September of 2005. The airplane was registered to and operated by East End Aviation, LLC., and was maintained under an annual inspection program. A review of the maintenance records indicated that a 100-hour inspection had been completed on April 4, 2006, at an airframe total time of 259.9 hours. The airplane had flown approximately 243.5 hours between the last inspection and the accident and had a total airframe time of 503.4 hours.

METEOROLOGICAL CONDITIONS

On September 15, 2006, a Surface Analysis chart, prepared by the National Weather Service (NWS), National Center for Environmental Prediction, depicted a stationary front that extended from a low pressure area, located in southwest North Dakota, diagonally through Wyoming and into northern Utah and Nevada. A high pressure ridge extended from western Colorado into northern New Mexico. The accident site was located to the south of the stationary front and near the ridge of high pressure.

The NWS Freezing Level chart issued on the day of the accident depicted the freezing level along the route of flight ranging from 11,600 feet to 14,200 feet msl. Doppler weather radar (approximately 120 miles south-southeast of the accident location) scanned the accident area at 1322. Data indicated reflectivity values of 25 to 34 dBz, or moderate intensity precipitation, in the accident area around the accident time. According to NTAP data, the accident airplane was in the immediate vicinity of a 35 dBz cell when the pilot first reported icing conditions.

An Aviation area forecast was issued for eastern Utah, southern Wyoming, and northern Colorado by the Aviation Weather Center (AWC) in Kansas City, Missouri, the day of the accident, at 0445. The forecast for the route from Utah into Colorado and Wyoming was for scattered to broken clouds at 10,000 feet, broken to overcast clouds at 15,000 feet, southerly winds gusting to 30 knots, widely scattered light rain showers with scattered thunderstorms, and rain showers, thunderstorms possibly severe, cumulonimbus cloud tops to 40,000 feet.

Multiple pilot reports (PIREPS) had been issued for the Colorado/Wyoming area regarding icing. Reports given for icing included light to moderate clear and rime icing from 8,500 feet msl to 19,000 feet msl. The NWS Current Icing Potential chart valid at the time of the accident depicted a 90 percent chance of icing conditions at 14,000 feet, 70 percent chance of icing conditions at 13,000 feet, and less than 40 percent chance of icing below 12,000 feet, all in the vicinity of the route of flight.

AIRMETs for mountain obscuration (SIERRA), turbulence (TANGO), and icing (ZULU) were all issued by AWC for areas in Utah, Colorado, and Wyoming, including the accident airplane's route of flight. AIRMET SIERRA stated to expect mountains occasionally obscured by clouds, precipitation, mist, and fog. AIRMET TANGO stated to expect occasional moderate turbulence below flight level (FL) 180. AIRMET ZULU stated to expect occasional moderate rime and mixed icing between the freezing level and FL 260. Convective Significant Meteorological Information (SIGMET) 34W was issued for Wyoming, Colorado, and Utah for an intensifying area of thunderstorm moving northeastward at 35 knots with tops to 38,000 feet. The NWS Severe Storm Prediction Center also issued a Weather Watch number 766 for the potential for severe thunderstorms. The watch area extended over the flight route from Utah to the accident site.

The closest official weather observation station was Rock Springs, Wyoming (RKS), located 50 nautical miles (nm) north of the accident site. The elevation of the weather observation station was 6,760 feet msl. The routine aviation weather report (METAR) for RKS, issued at 1254, reported, winds 180 degrees at 24 knots, gusting to 29 knots; visibility 10 statute miles; sky condition clear; temperature 15 degrees Celsius (C); dewpoint 7 degrees C; altimeter 29.65 inches.

The METAR for RKS, issued at 1354, reported, winds 170 degrees at 23 knots, gusting to 28 knots; visibility 10 statute miles; sky condition, ceiling broken a 7,500 feet; temperature 15 degrees C; dewpoint 6 degrees C; altimeter 29.64 inches; remarks, peak wind from 190 degrees at 31 knots measured at 1341; lightning distant west and northwest.

The METAR for Vernal, Utah, issued at 1312, reported, winds 260 degrees at 9 knots, gusting to 18 knots; visibility 2 ½ miles in thunderstorm and heavy rain; sky condition, few clouds at 2,800 feet, ceiling broken at 4,900 feet, overcast at 7,000 feet; temperature 10 degrees C; dewpoint 6 degrees C; altimeter 29.69 inches. Remarks: peak wind from 310 degrees at 29 knots recorded at 1301, wind shift at 1255, lightning distant all quadrants, and rain began at 1304.

FLIGHT RECORDERS

The accident airplane was equipped with an Avidyne Primary Flight Display (PFD) (part number 700-0004-0008) and an Avidyne Multi-Function Display (MFD) (part number 700-0006-000). The avionics computing resource from the PFD and the flash memory device from the MFD were removed and sent to Avidyne for extraction of flight data associated with this accident. The information was downloaded on September 25, 2006, under the auspices of the NTSB.

The PFD contained seven fault codes and no flight parameters. The first two fault codes were not related to this event. An "Attitude Heading Reference System (AHRS) invalid" message was recorded at 1931:48 Universal Time Coordinated (UTC). According to Avidyne, this message could indicate any of the following conditions - the value of the calculated pitch, roll, magnetic heading, or rate of turn is considered invalid, or the AHRS has ceased sending data for one second. A cluster of four fault codes was recorded at 1932:12. According to Avidyne, these fault codes were consistent with a loss of power to the unit.

The MFD was capable of receiving XM satellite weather information. The MFD does not store the weather information; however, the message type and time received is stored in the Compact Flash Card. No engine or other parameters were recorded.

WRECKAGE AND IMPACT INFORMATION

The National Transportation Safety Board investigator-in-charge (IIC) arrived on scene approximately 1400 on September 16, 2006. The accident site was located in uneven terrain vegetated with sagebrush. Several ravines and gullies were located between the initial impact point and the last portion of the airplane wreckage. A global positioning system (GPS) receiver recorded the coordinates of the initial impact point as 40 degrees, 59 minutes, 04.9 seconds north latitude, and 108 degrees, 48 minutes, 00.2 seconds west longitude. A GPS receiver recorded the coordinates of the last portion of the airplane wreckage as 41 degrees, 00 minutes, 16.6 seconds north latitude, and 108 degrees, 47 minutes, 11.7 seconds west longitude. The accident site elevation varied from 7,120 feet to 6,900 feet msl and the airplane impacted on a magnetic heading of 015 degrees.

The Safety Board IIC identified the initial impact point 1.07 miles south of the Colorado/Wyoming border. Fragments from the nose wheel pant were located within the north most portion of the ground scar. A debris path extended, in a north-northeast direction from the initial point of impact, for 500 feet. The engine cowling, fuselage doors, main landing gear assemblies, the propeller assembly, various engine components, the Kevlar Cirrus Airframe Parachute System (CAPS) strap covers, fragmented composite material, and various personal effects were located within the initial debris path.

A periodic ground scar and debris path extended from this point, across rough uneven terrain, down a 100-foot embankment, to the wing assembly. The ground scars varied in length and width and were consistent with an object being drug. Sagebrush was bent and crushed in a north-northwesterly direction. The CAPS deployment system (including the rocket housing, and parachute cover), the CAPS fuselage cover, the engine assembly, the right aileron, and various personal effects were located within the second debris path.

The wing assembly was located 1,542 feet from the initial impact point at an elevation of 7,072 feet msl. It consisted of both the left and right wing, both flaps, the right aileron, both front seats, and portions of the instrument panel. The leading edges of both wings were crushed aft and exhibited broken composite material. The trailing edges of both flaps were wrinkled and the aileron separated from the right wing. The leading edges of both wings were clean and the airfoil just aft of both leading edges exhibited aft particle streaking consistent with structural icing. Control continuity to both ailerons was confirmed.

A periodic ground scar and debris path extended from the wing assembly over rough, uneven terrain, across several gullies and ravines, over several barbed wire fences, and across highway 430, into the state of Wyoming. Portions of the elevator, rudder, and horizontal stabilizer were located within the debris path. An 8.5-foot section of the aft fuselage and portions of the empennage came to rest 1.55 miles north northwest of the initial impact point. The CAPS canopy remained partially attached to the fuselage and was tangled in a barbed wire fence.

The CAPS activation handle, the rudder pedals, the rudder and elevator control cables, and an aft seat remained with this portion of the fuselage. The CAPS activation handle was in the stowed position. An on scene examination of the handle revealed mud impacted within the securing pinhole and around the handle groove. The safety pin was not located. Control cable continuity was established through the rudder and elevator cables.

MEDICAL AND PATHOLOGICAL INFORMATION

The autopsy was performed on the pilot and passenger in the Jefferson County Coroner's office on September 20, 2006, as requested by the Moffett County Coroner's office. The autopsy revealed the cause of death for the pilot due to "head and internal injuries secondary to blunt force trauma sustained in the airplane crash." The cause of death for the passenger was due to "exsanguination secondary to lacerations involving the heart and aorta secondary to blunt force trauma sustained in the airplane crash."

During the autopsy, specimens were collected for toxicological testing to be performed by the FAA's Civil Aerospace Medical Institute (CAMI), Oklahoma City, Oklahoma (CAMI Reference #200600218001 and 200600218002). Tests for carbon monoxide, cyanide, ethanol, and drugs were all negative.

TESTS AND RESEARCH

The airplane wreckage was recovered on September 17, 2006, and relocated to a hangar in Greeley, Colorado, for further examination. The Safety Board IIC, Safety Board survival factors investigators, the FAA AAI-100 IIC, and representatives from Am Safe Aviation, and Teledyne Con

NTSB Probable Cause

The pilot's improper in-flight planning and decision making resulting in an inadvertent encounter with severe icing conditions during cruise flight and subsequent loss of aircraft control. Contributing factors include the pilot's failure to obtain a weather briefing, the thunderstorm, conditions conducive for structural icing, and the pilot's failure to deploy the parachute recovery system.