NTSB Factual Report

HISTORY OF FLIGHT

On April 28, 2009, at 1615 eastern daylight time, a Cirrus SR22, N504MD, piloted by an instrument rated private pilot, was destroyed during a collision with trees and terrain near Mayfield Village, Ohio. The flight was being conducted under 14 Code of Federal Regulations Part 91 on an instrument flight rules (IFR) flight plan. Instrument meteorological conditions prevailed at the time of the accident. The pilot and sole passenger on-board sustained fatal injuries. The cross-country business flight departed Cuyahoga County Airport (CGF), Cleveland, Ohio, at 1612, with an intended destination of Buffalo Niagara International Airport (BUF), Buffalo, New York.

The pilot and passenger flew from BUF to CGF earlier in the day, arriving at CGF about 1319. According to personnel working at the fixed base operator (FBO) at the time, the pilot and passenger attended a meeting at the airport and then left the airport for approximately 1 hour, before returning for the accident flight. The pilot requested that the airplane be fueled to capacity ("topped off") prior to departure and FBO personnel fueled the airplane with 40 gallons of aviation gasoline.

The CGF air traffic control tower (ATCT) issued a takeoff clearance for the flight from Runway 6 at 1611, instructing the pilot to fly the runway heading and climb to 3,000 feet mean sea level (msl). The controller observed the airplane takeoff and enter the clouds. Takeoff and initial climb appeared to be normal. At 1612, the controller instructed the pilot to contact departure control. The pilot acknowledged the instruction; however, the pilot never established communications with the departure controller. At 1614, the pilot transmitted “were having trouble getting” on the CGF tower frequency. At 1615, the pilot transmitted “having trouble mike delta.” There were no subsequent transmissions from the pilot. At 1616, the departure controller relayed a low altitude alert in the blind to the accident flight.

Flight track data recovered from the on-board avionics indicated that the airplane entered a right turn shortly after takeoff. It remained in that right turn until it completed nearly 1-1/2 complete turns; 540 degrees of heading change. The airplane subsequently rolled out on a south heading, and began to climb from 1,200 feet msl to 2,700 feet msl over the next 17 seconds. The airspeed decreased to 50 knots and the airplane’s heading transitioned from the south to the north-northwest. The airplane subsequently descended to about 1,600 feet msl before beginning another climb.

Over the next 30 second time period, the altitude increased again to about 2,900 feet msl, and the airspeed decreased to about 60 knots. At this point, the airplane’s heading transitioned from the east-northeast to the west-northwest. The airplane subsequently entered a right turn ultimately reversing course. It then climbed approximately 1,300 feet, to a maximum altitude of 3,200 feet msl before descending again. The airspeed decreased to 50 knots during this time. The final data point was recorded at 1615:44. At that time, the airplane’s position was approximately 0.20 miles north of the accident site, at 2,000 feet msl. (Detailed information regarding the airplane’s flight attitude is included later in this report.)

A witness located 1/4 to 1/2 mile from the accident site reported that he was outside and heard the airplane for about 1 minute. He noted that it “sounded like it was circling around and . . . doing tricks in the air.” However, he was unable to actually see the airplane. About 20 seconds after the sound faded he heard a “boom.” At the time he thought it might have been thunder but later realized it was likely the impact.

A witness located in a nearby residential subdivision approximately one-tenth mile from the accident site, reported that the airplane flew over his car about 150 feet above ground level (agl). He stated that it banked to the left and dove toward the ground. He responded to the accident site; however, the airplane was engulfed in flames when he got there.

The accident site was located approximately 3 miles east of CGF in a wooded area adjacent to a church.

PERSONNEL INFORMATION

The pilot, age 51, held a private pilot certificate with single-engine land, multi-engine land, and instrument airplane ratings. He was issued a third-class airman medical certificate on June 27, 2007, with a limitation for corrective lenses. On the application for that medical certificate, the pilot reported a total flight time of 1,350 hours, with 50 hours in the previous 6 months. The pilot’s logbook was not available to the NTSB.

The pilot completed Cirrus Aircraft transition training at the time he took delivery of the accident airplane. Records indicated that the pilot completed visual flight rules (VFR) transition training from October 6, 2008 through October 8, 2008. The course consisted of 15.0 hours of flight time, 0.8 hours in a flight training device (simulator), 3.0 hours of ground instruction, and 5.0 of pre and post flight instruction. All of the course flight time was with a flight instructor (dual instruction).

The pilot provided information to Cirrus regarding his flight experience prior to the transition training course. He noted that his most recent flight review was completed on March 23, 2007, and that his most recent instrument proficiency check was completed 10 months prior to the training. He reported a total flight time of 1,344 hours total flight time, with 1,280 hours as pilot-in-command, 1,250 hours in high performance/complex airplanes, and 400 hours instrument flight time. He reported 20 hours flight time within the one year period prior to the training, with 4 hours of instrument flight time. Within the 90-day period prior to the training course, he reported accumulating 5 hours total time, with no instrument flight time. He reported experience in Beech model 60 (Duke), Mooney, and Cessna 172 airplanes.

AIRCRAFT INFORMATION

The accident airplane was a 2007 Cirrus Design SR22, serial number 2695. It was a four place, low wing, fixed tricycle landing gear configuration; primarily of composite (fiberglass) construction. The airplane was powered by a 310-horsepower Teledyne Continental Motors IO-550-N50B engine, serial number 691346, and installed with a Hartzell PHC-J3YF-1N/N7605B propeller, serial number FP6011B.

A normal category, standard airworthiness certificate was issued for the airplane on September 12, 2007. The accident pilot purchased the airplane on October 7, 2008. The maintenance log entry for the most recent annual inspection was dated the same day. The airplane had accumulated 224.1 hours at the time of last maintenance entry dated October 9, 2008. The logs did not contain a record of any unresolved maintenance issues.

The minimum published power off stall speed for the accident airplane with the wing flaps retracted was 67 knots calibrated airspeed. This speed corresponded to a wings level (zero bank angle), maximum gross weight, and aft most center-of-gravity flight condition.

METEOROLOGICAL CONDITIONS

The closest weather reporting facility to the accident site was located at the departure airport. At 1545, weather conditions at CGF were recorded as: Wind 360 degrees at 8 knots; visibility 4 miles in light rain and mist; overcast clouds at 300 feet above ground level (agl), temperature 7 degrees C, dew point 6 degrees C, altimeter 30.38 inches of Hg.

At 1616, wind 010 degrees at 8 knots; visibility 4 miles in light rain and mist; overcast clouds at 200 feet agl; temperature 7 degrees C; dew point 6 degrees C; altimeter 30.38 inches of Hg.

At 1645, wind 010 degrees at 7 knots, visibility 4 miles in light rain and mist, overcast clouds at 300 feet agl, temperature 7 degrees C, dew point 6 degrees C, altimeter 30.40 inches of Hg.

AIRPORT INFORMATION

The Cuyahoga County Airport (CGF) was served by a single runway. Runway 6-24 was 5,102 feet long by 100 feet wide. Runway 6 was supported by non-precision runway markings, Runway End Identifier Lights (REIL), and a Precision Approach Path Indicator (PAPI) set to a 3-degree approach path angle. Runway 24 was supported by precision runway markings, a Medium Intensity Approach Lighting System (MALSR), and a Precision Path Lighting System (PAPI) set to a 3-degree approach path angle. The published airport elevation was 879 feet.

Instrument approaches to CGF included the Instrument Landing System (ILS) Runway 24, the Localizer Back Course (LOC BC) Runway 6, and the Global Positioning System (GPS) Runway 6 procedures. The decision altitude (DA) for the ILS Runway 24 approach was 1,079 feet msl (200 feet agl). The minimum descent altitudes (MDA) for the LOC BC Runway 6 and GPS Runway 6 approaches were 1,380 feet msl (507 feet agl) and 1,360 feet msl (481 feet agl), respectively. The FAA Airport Facility Directory noted that the runway 24 localizer was unusable below 3,000 feet msl beyond a range of 10 nm.

WRECKAGE AND IMPACT INFORMATION

The accident site was located approximately 3 miles east of CGF in a small wooded area adjacent to a church. The debris field was oriented on an approximate magnetic heading of 300 degrees and extended approximately 60 feet. The initial ground impact scar was about 15 feet long by 6 feet wide and up to 3 feet deep. Fresh breaks in the tree limbs were observed about 40 feet southeast of the impact point. The heights of the initial tree breaks were estimated to be 65 feet.

The main wreckage, which included the fuselage and wings, was located about 45 feet from the initial ground impact. The fuselage was destroyed by impact forces and post-impact fire. The engine was separated from the fuselage and came to rest approximately 5 feet from the fuselage. The propeller hub remained attached to the engine. However, all three propeller blades had separated from the propeller hub near the blade root. Two propeller blades were located in the initial impact ground scar. The third propeller blade was located in the debris field near the engine.

The wings were reduced by the post impact fire. The wing spar was located in position relative to the fuselage. Both the ailerons and flaps were separated from the wing. They were located in the debris field between the impact ground scar and the main wreckage. Aileron control cable continuity was confirmed with one exception. The left aileron control cable was separated between the actuator pulley and the crossover cable turnbuckle. The cable strands were frayed at the separation point consistent with an overload failure. The aileron (roll) trim motor was observed to be in approximately the neutral position. The flap actuator shaft was extended approximately 4 inches, which was consistent with a full UP (0-degree) flap position. The landing gear assemblies with sections of the mating support structure were separated from the wing. The nose landing gear was located at the initial ground impact scar. The left and right main landing gear assemblies were located in the debris field near the ground scar.

The horizontal stabilizer was separated from the airframe and located near the impact scar. It was deformed consistent with impact damage and discolored consistent with thermal exposure due to the post impact fire. The right elevator and the inboard section of the left elevator remained attached to the stabilizer. The outboard section of the left elevator was located in the debris field. Elevator control cable continuity was confirmed from the elevator control torque tube to the bellcrank at the fuselage station 306 bulkhead and continuing to the forward pulley gang. The elevator (pitch) trim motor was observed in approximately a neutral position.

The vertical stabilizer exhibited thermal and impact damage. The upper section of the vertical was separated from the empennage. The rudder, which exhibited thermal and impact damage, remained attached to the empennage at the lower hinge. Rudder control cable continuity was confirmed from the rudder pedal torque tube to the rudder bellcrank at the fuselage station 306 bulkhead and continuing to the forward pulley gang.

The engine crankcase was fractured consistent with impact. The crankshaft exhibited signatures consist with a spiral fracture aft of the propeller flange near the forward thrust bearing. The cylinders remained secured to the crankcase. Examination of the cylinders, pistons, and valve faces using a lighted borescope did not reveal any anomalies. Appearance of the cylinders and pistons was consistent with normal operating signatures. The spark plugs appeared intact and the electrodes exhibited a light gray appearance consistent with normal operation. The magnetos were partially disassembled and produced a spark at the magneto points. The fuel pump exhibited operation when the mixture control was operated through its full range of travel. The oil filter element appeared free of debris.

The Cirrus Airframe Parachute System (CAPS) components were located with the fuselage wreckage. The parachute remained packed in the deployment bag and the activation handle was observed in the stowed position relative to the activation handle holder. The CAPS ground safety pin was not installed. (Pre-flight procedures specify removal of the safety pin prior to flight in order to ready the system for use in the event of an in-flight emergency.)

No anomalies consistent with a pre-impact failure or malfunction associated with the airframe or engine were observed.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy of the pilot was conducted on April 29, 2009, at the Cuyahoga County Coroner’s Office in Cleveland, Ohio. The cause of death was attributed to blunt impact sustained in the accident.

The Federal Aviation Administration Civil Aero Medical Institute toxicology report was negative for all substances in the screening profile.

TESTS AND RESEARCH

The autopilot and PFD in the accident airplane were integrated. The pilot selected and armed autopilot modes on the autopilot unit. Heading and altitude selections were made on the PFD. In addition, autopilot status and mode information was displayed to the pilot on the PFD, as well as on the face of the autopilot unit.

The autopilot was capable of maintaining a set heading or tracking navigation signals such as an instrument approach course. In addition, the autopilot can maintain a preset altitude, or a specified climb or descent rate (vertical speed) to intercept a preset altitude. Heading, altitude and vertical speed settings are input by the pilot via the PFD. They are referred to as “bug” settings.

The altitude hold mode is selected by pressing the ALT button on the face of the autopilot unit. When pressed, the autopilot will capture airplane’s current altitude in the altitude bug and will set the vertical speed bug to zero. These are displayed to the pilot on the PFD.

The vertical speed mode is selected by pressing the VS button on the face of the autopilot unit. When pressed, the autopilot will capture and attempt to maintain the current vertical speed bug setting. The pilot is able to adjust the climb/descent rate by adjusting the vertical speed bug setting.

In addition, the autopilot has ability to maintain a specified climb or descent rate and intercept a pre-set altitude; known as the altitude pre-select mode. The pilot enters the desired altitude and vertical speed values into the corresponding bug settings via the PFD. Once entered, the pilot will press and hold the VS button on the autopilot unit, followed by the ALT button. This button combination will engage the vertical speed mode and arm the altitude hold mode. In the event that the altitude pre-set mode is selected with the altitude bug set below the airplane’s current altitude, the autopilot will set a descent rate into the vertical speed bug in order to intercept the pre-set altitude.

Flight and engine data was recovered from non-volatile memory contained in the primary flight display (PFD). In addition, the unit recorded autopilot mode information.

The takeoff roll began at 1611:34 on runway 6 and t

NTSB Probable Cause

The pilot’s failure to maintain control of the airplane while operating in instrument meteorological conditions due to spatial disorientation. Contributing to the accident was the pilot’s inattention to basic aircraft control while attempting to program the autopilot system.