NTSB Factual Report

HISTORY OF FLIGHT

On July 23, 2011, about 1233 eastern daylight time, a Cirrus Design Corporation SR22, N122HB, registered to N122HB LLC, and operated by a private individual, experienced a loss of engine power and sustained substantial damage during an attempted forced landing to an open field near Palm Bay, Florida. Visual meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal flight from Albert Whitted Airport (SPG), St. Petersburg, Florida, to Melbourne International Airport (MLB), Melbourne, Florida. The private pilot and one passenger were fatally injured, and one passenger sustained minor injuries. The flight originated from SPG about 1145.

The rear seat passenger stated that before takeoff, the pilot, “…checked the airplane on the outside as well as all the instruments inside the airplane.” She reported the takeoff was perfect and was very smooth and she felt very safe.

According to a chronological summary of flight communications, at 1146, or approximately 1 minute after takeoff, the pilot established contact with Tampa Air Traffic Control Tower (Tampa ATCT), and advised the controller that the flight was at 700 feet climbing to 1,600 feet. The controller vectored the pilot to overfly Tampa International Airport runway 28, and air traffic control communications were transferred to a different sector of the Tampa ATCT. The pilot established contact with that sector and at 1201, he advised the controller that his new destination was Valkaria Airport (X59) in order to make a fuel stop. Communications were then transferred to Central Florida Terminal Radar Approach Control Facility (Orlando Approach Control).

The transcription of communications with Orlando Approach Control indicates the pilot established contact while proceeding towards the destination airport. At 1227:13, the controller directed the pilot to descend and maintain 1,500 feet which he acknowledged. The flight continued and at 1231:16, the pilot declared “mayday mayday mayday” followed by a declaration, “…with smoke coming from out of the engine and engine flutter.” The controller advised the pilot that Melbourne International Airport was located at his 9 o’clock position and about 9 miles and his destination airport (X59) was located at his 12 o’clock position and 7 miles. The pilot acknowledged the communication but advised the controller that he could not make either airport and he was looking for an off airport site. As the flight proceeded the controller advised the pilot the location and distance from MLB, but at 1232:12, he advised the controller, “we got fire we doing an off site landing.” The controller acknowledged the comment from the pilot and at 1233:27, broadcast on the frequency for the pilot that radar contact was lost. The pilot did not respond and there were no further recorded transmissions from the pilot.

The rear seat passenger later stated that shortly after turning to the south she felt the airplane shudder, then it became quite. After hearing the pilot tell the right front seat passenger to get into a position, she ducked to make herself as small as possible.

Three witnesses who were located about ½ nautical mile northwest from the crash site reported the airplane flew over their position about 400 to 500 feet in a direction that was determined to be about 100 degrees magnetic. They reported that the engine was sputtering and “coughing”, but they did not see any smoke trailing the airplane. The airplane kept descending, and at the last minute banked hard to the right with the wings reported to be vertical. The nose pitched down, and they lost sight behind trees. They heard an impact, saw white colored smoke, called 911, and proceeded to the site where they rendered assistance until first responders arrived.

The rear seat passenger also stated that the airplane bounced twice then began to flip. When the airplane came to rest, she unbuckled herself and ran away from the airplane to begin looking for help, but noted “…miles and miles of field….”

The pilot and passenger were removed from the wreckage, and all occupants were transported to a hospital for medical intervention.

The airplane crashed during daylight conditions.

PERSONNEL INFORMATION

The pilot, age 65, held a private pilot certificate with rating(s) airplane single engine land, instrument airplane, and held a third class medical certificate issued June 5, 2011, with a limitation to have available glasses for near vision.

Review of the pilot’s logbook which was designated as being Logbook Number “3”, revealed the first entry was dated January 12, 2004, and the last entry was dated July 19, 2011. The carry forward time was 1,606.8 hours, of which all were in “Airplane SEL” column. The pilot-in-command (PIC) carry forward time was recorded to be 1,517.7 hours. He recorded time in a Cessna 182 airplane (N228JA) beginning January 12, 2004, through November 27, 2006, a LC-42 (Colombia N358DM) beginning December 5, 2006, through March 30, 2010, a Piper PA-28 (N3035D) beginning June 2, 2010, through July 25, 2010, and the accident airplane exclusively from October 28, 2010, through the last logged flight. His logged total time was 3,043.4 hours. His last logged flight review in accordance with 14 CFR Part 61.56 (a) occurred on May 21, 2010. His total logged flight time in the accident airplane from the No. 3 logbook was 153.4 hours. His total time in the last 90 days was recorded to be 63.6 hours all as PIC in the accident airplane. His total time in the last 30 days was recorded to be 14.2 hours all as PIC in the accident airplane.

The No. 3 logbook total time as PIC was recorded to be 2,744.6 hours. All of the hours listed for the make and model airplane were recorded to be as PIC, with 3 entries dated October 31, 2010, November 1, 2011, and November 3, 2010, also listed as dual received.

Safety Board interview with a friend of the accident pilot revealed that with respect to the CAPS, he and the pilot had a conversation. The accident pilot advised that he would try to fly the airplane to the ground and would only deploy the CAPS in the event of structural failure or if there was an issue of inability to control the airplane.

AIRCRAFT INFORMATION

The airplane was manufactured by Cirrus Design Corporation in 2003, as model SR22, and was designated serial number 0517. It was powered by a 310 horsepower Continental Motors IO-550-N engine and equipped with a single acting constant speed three-bladed Hartzell propeller.

Engine rpm, oil pressure, oil temperature, manifold pressure, fuel flow, voltage, and amperage were displayed on analog instruments located on the right side of the instrument panel. The combination analog gauge for the oil temperature and oil pressure depicted the green arc (normal) range, red line maximum for oil temperature, and also red line minimum and maximum oil pressure. The analog oil pressure indicator receives a pressure signal from an oil pressure sensor mounted at the aft end of the engine below the oil cooler. Discoloration of the markings on the analog oil pressure gauge faceplate were noted during the postaccident investigation; however, the markings for the caution range, and red line maximum and minimum oil pressure were in the location as depicted in Section 2 of the Pilot’s Operating Handbook and FAA Approved Flight Manual (POH/AFM).

Engine indications were also displayed on the “MAP” or “ENGINE” pages of the Avidyne multi-function display (MFD), which was installed to the right of the primary flight display (PFD), or about the center of the instrument panel. The engine parameters displayed on the MFD’s “ENGINE” or “MAP” pages are derived from analog signals from sensors for cylinder head temperature (CHT), exhaust gas temperature (EGT), manifold pressure (MAP), oil pressure, oil temperature, and rpm which are converted to digital units by a data acquisition unit (DAU). The oil pressure display on the MFD depicts the red line minimum value of 10 psi, green arc (normal) range of 30 to 60 psi, yellow arcs (caution) range for 10 to 30 psi and 60 to 100 psi, and red line maximum limit of 100 psi (cold). The oil temperature display on the MFD depicted the green arc (normal) range of 100 to 240 degrees Fahrenheit, and a maximum (red line) value of 240 degrees Fahrenheit.

A representative of the MFD manufacturer reports that the MFD installed in the airplane at the time of the accident based on the installed software would not display a text alert message on the MFD when engine parameters go into the yellow (caution) or red (maximum) range(s); however, the digits on the “ENGINE” or “MAP” pages instrument displays for the parameters would turn yellow or red as appropriate when the recorded values are in the yellow (caution) or red line (minimum or maximum) range(s). Additionally, engine data is only displayed when the “MAP” or “ENGINE” pages are selected, and the single value for EGT and CHT displayed on the “MAP” page depicts the maximum value from any of the six cylinders. No determination can be made as to what page is selected at the time of an accident or incident.

Flight parameters display on the PFD installed on the pilot’s instrument panel.

The POH/AFM indicates that the PFD provides the functions of the attitude indicator, heading indicator, airspeed indicator, altimeter, vertical speed indicator (VSI), directional gyro, course deviation indicator, and altitude pre-select controller in a single display. In addition, the PFD communicates with the GPS1, GPS2, NAV1, NAV2, multi-function display, and autopilot system. The POH/AFM also indicates that CHT and EGT indications are not required by certification standards, and there is no limitation for EGT or CHT. Rather, the engine limitations are specified to be maximum rpm (2,700), maximum oil temperature (240 degrees Fahrenheit), minimum oil pressure (10 psi), and maximum oil pressure (100 psi).

The airplane was also equipped with a light emitting diode (LED) illuminated annunciator panel located to the left of the PFD, which consist of lights and 6 separate annunciators. One of the six annunciators is a red colored “OIL” warning light which illuminates to indicate either high oil temperature or low oil pressure. The light is illuminated by a switch in the oil temperature gauge/data acquisition unit (DAU) if the oil temperature reaches 240 degrees Fahrenheit or if the oil pressure drops to 10 PSI or less. If the oil light illuminates in-flight, the systems description section of the POH/AFM indicates to refer to the oil temperature and pressure gauges to determine the cause.

The POH/AFM was located in the pilot’s hangar during a postaccident inspection of it; however, a spiral bound excerpts of the POH/AFM was found in the wreckage.

Review of the engine logbook revealed the engine installed at the time of manufacture by serial number was the same engine installed at the time of the accident; there was no record that it had been removed. The engine was manufactured on February 26, 2003, and the first entry dated March 13, 2003, indicated the engine was serviced with 8 quarts of Phillips 20W 50 straight mineral oil. An entry in the engine logbook dated May 27, 2011, at airplane hour meter 1234.9, engine total time 1234.9, indicates an “annual inspection” was performed. The same entry indicates that new cylinder assemblies kit P/N 655465-A4, #1 S/N AC10LA424, #2 S/N AC10JB625, #3 S/N AC10JB633, #4 S/N AC10JB623, #5 S/N AC10LA395, #6 S/N AC11AB077” were installed. The entry also indicates that new piston pin and plug assemblies P/N 630046 were installed in accordance with (IAW) TCM overhaul maintenance manual and TCM maintenance manual. The engine was serviced with 9 quarts AeroShell 100 mineral oil. New induction boots were installed on the Nos. 3 and 4 cylinders. The work was performed by Santa Fe Aero Services, and signed off by an A&P/IA.

Review of paperwork provided by Santa Fe Aero Services dated May 26, 2011, associated with the annual inspection and work performed revealed discrepancy 1.18 indicating, “Cylinder Piston Pins Sheared.” The resolution or corrective action indicates, “Installed New Piston Pins P/N 630046 On all Cylinders as Required.” Additional paperwork from Santa Fe Aero Services indicates discrepancy 1.1 in which the, “…Avidyne EX5000 MFD Shut Down.” The resolution indicates that the MFD was removed and sent to the manufacturer for warranty replacement. The MFD they received from the manufacturer was defective out of the box and was returned to the manufacturer. The 2nd MFD received was installed into the airplane and was operational.

Correspondence from Sante Fe Aero Services to the pilot in response to a reported e-mail from him indicates that their inspection of the engine while at their facility discovered, “…three cracked cylinder heads, a very serious matter….” Following removal of the cylinders they found, “…three severed piston rods, which is typically the type of internal damage caused by extended incorrect operation.” The correspondence also indicated that after the defective MFD was removed from the airplane it was sent to the manufacturer; however, no data could be retrieved from the unit. Also, the correspondence reiterates a comment from the pilot in which he reportedly indicates that the defective MFD had just been installed 2 weeks earlier, and, “had never worked since installation.” Postaccident review of the airframe logbook revealed the previous entry specifying the MFD was dated February 2, 2011, which indicates that software release 7 was installed into MFD per Avidyne Service Bulletin (SB) 10, and the functional check was satisfactory.

Postaccident follow-up with Sante Fe Aero Services confirmed that the 3 cracked cylinders each had cracked piston pin plugs and not three severed piston pins as reported in the paperwork.

Calculations revealed that based on the hour meter reading at the time of the accident (1281.6), the engine had accumulated 46.7 hours since the new cylinder assemblies were installed.

METEOROLOGICAL INFORMATION

A surface aviation observation taken at Lakeland Linder Regional Airport at 1150, or approximately 15 minutes before the MFD recorded the oil pressure to be below the lower end of the normal operating range, indicates the wind was from 140 degrees at 5 knots, the visibility was 15 statute miles, broken clouds existed at 2,700 feet, and 25,000 feet. The temperature and dew point were 32 and 23 degrees Celsius, respectively, and the altimeter setting was 30.19 inches of Mercury.

A surface aviation observation taken at Melbourne International Airport (MLB), Melbourne, Florida, at 1214, or approximately 18 minutes before the accident indicates the wind was from 090 degrees at 9 knots, the visibility was 10 statute miles with thunderstorms in the vicinity. Scattered clouds existed at 1,700 feet, the temperature and dew point were 32 and 24 degrees Celsius respectively, and the altimeter setting was 30.16 InHg. The crash site was located about 10 nautical miles and 200 degrees from MLB.

A center weather advisory from Jacksonville Air Route Traffic Control Center valid for the day of the accident until 1320 hours local, indicated that from Ormond Beach Municipal Airport (OMN) to Vero Beach Municipal Airport (VRB), a line 25 nautical miles wide of widely scattered thunderstorms with heavy precipitation moving little. The maximum tops were at 38,000 feet, and expect gradual increase in coverage and intensity in eastern Florida thru the period.

COMMUNICATIONS

The pilot was last in contact with the Central Florida Terminal Radar Approach Control facility. There were no reported communication difficulties.

FLIGHT RECORDERS

The airplane was not equipped nor was it required to be equipped with a cockpit voice recorder (CVR) or flight data recorder (FDR). The airplane however was equipped with components that record and retain non-volatile memory (NVM) associated with flight. The components that retained NVM consisted of the PFD, MFD, and also the

NTSB Probable Cause

The pilot’s failure to maintain adequate airspeed while maneuvering for a forced landing, resulting in an inadvertent aerodynamic stall. Contributing to the accident were the pilot’s failure to secure the oil gauge rod and cap assembly before flight and his decision not to land immediately following loss of oil pressure, which resulted in the total loss of engine power due to oil starvation.