NTSB Factual Report

HISTORY OF FLIGHT

On May 16, 2013, about 1120 central daylight time, a Cirrus Design Corp (CDC) SR22, N715CD, airplane ballistic parachute was activated by the pilot during flight near Dallas, Texas, following a loss of control in cruise flight. The parachute pack remained in its compartment, its rocket was deployed, and the rocket propellant was expended. The airplane received no damage. The private pilot was uninjured. The airplane was registered to Jeramiah 2911 Inc and operated by the pilot under the provisions of 14 Code of Federal Regulations (CFR) Part 91. Marginal visual flight rules conditions prevailed and the flight was operating on instrument flight rules (IFR) plan for the flight that originated from Addison Airport (ADS), Dallas, Texas, about 1055 and was destined for Independence Municipal Airport (IDP), Independence, Kansas. The flight returned to ADS and landed without further incident.

The pilot said that he did not have any pressure that resulted from any need to arrive at IDP. He said that he received a weather briefing in the morning of the incident day. He delayed his original planned departure time of 1000 for about 45 minutes because he waited for a weather cell to move.

He said that the cloud ceilings were 1,200 feet and he did not remember and did not know the height of the cloud tops. Shortly after takeoff from ADS, he encountered IFR weather conditions. He received radar vectors around the back of a thunderstorm, flying direct to IDP at a cruise altitude of 7,000 feet mean sea level, which was beneath the cloud tops.

He said that he did not remember the altitude at which he engaged the autopilot (AP). He said that the AP was set to the heading mode (HDG), and he switched over to navigation (NAV) mode. The autopilot was not selected to track airspeed and was not selected to GPS steering mode (GPSS). The airplane encountered moderate turbulence, which he said was not unusual, while it was in dark clouds. He said that he felt like he and the airplane were "porpoising"/"bouncing." He was using his seat belt and was not being thrown around in the cockpit, but the airplane was going up and down. He said he experienced a loss of control of the airplane based upon instrument indications, the airplane bouncing, and the horizontal situation indicator (HSI) was spinning in circles. He said there was a horizontal situation indicator (HSI) flux gate excitation failure message, the HSI turned red, the HSI card started turning in circles, and there was an "X" at the bottom of the HSI, which he said meant that heading information was not being received. There were no annunciations, cautions, or warnings, only the flux gate excitation message. There were no problems with the multi-function display (MFD).

The attitude indicator (AI) appeared as if it was caged or stuck and was not moving around as the airplane porpoised. He said that the blue and brown colored segments of the AI formed an "X." The brown portion of the AI was on the bottom, and the blue portion of the AI was on the top. He said that he knew that the airplane was in level flight at the time of this AI indication. The airplane's wet compass was not spinning. When the pilot was asked how he knew that the airplane attitude was not being displayed correctly on the AI, he said that he does not know and it was based on his memory. The pilot did not know whether the AI was electrically or pneumatically powered.

The pilot said he realized that he was "fighting spatial disorientation, he was in over his head and pulled the chute" after he turned the airplane away from a red weather cell off the airplane's right wing because he did not want the airplane to float into that cell. He slowed the airplane from 167 knot to about 120-127 knots by pulling back on the control yoke to pitch up using the altimeter and vertical speed indicators, which were working, as speed/pitch references. He was asked what he used for bank attitude reference so that he would not pitch into a turn; he said he did not know. He had taken his hands off the controls when he activated the parachute. He said that he did not know the pitch attitude because he did not have an instrument to indicate pitch nor did he know the bank attitude of the airplane. The airspeed decreased to 120 knots "pretty quick". He heard the rocket motor fire, but the parachute did not deploy.

He then nosed over the airplane to descend below the cloud ceiling, which he did not know the height of. He was in "hard IMC," getting "knocked around," and was extremely nauseous and sweating profusely. He said he did not trust himself and did not know if he was going to have a heart attack. He preferred to descend the airplane below the cloud ceilings rather than be in this situation. He reduced throttle and lowered pitch to descend below the overcast layer to visual meteorological conditions, which he encountered about 800 feet above ground level. He said that the HSI started working after the airplane exited instrument meteorological conditions. He said that the HSI and AI started working again "shortly" after that exit. He had not reset any of the airplane circuit breakers. He did not climb back into the clouds since he did not trust the airplane instruments. He requested a visual approach to runway 15 at ADS for the flights return because he had not previously flown into Denton Municipal Airport (DTO), Denton, Texas.

METEOROLOGICAL INFORMATION

The closest official NWS reporting location to the incident site was from Denton Municipal Airport (DTO), Denton, Texas, located approximately 15 miles southwest of the incident site at an elevation of 642 feet. The airport had an Automated Surface Observation System (ASOS) and reported the following conditions near the time of the accident:

At 1053 CDT, wind from 170° at 10 knots, visibility 10 miles, ceiling overcast at 1,200 feet, temperature 21° C, dew point temperature 18° C, altimeter 29.81 inches of mercury (Hg).

The pilot said that he had weather depicted on a tablet using Anywhere Map, and he was about 20 miles on the backside of the cell. He said that Anywhere Map showed that the cell was moving east, "fairly fast."

The pilot was asked what the delay of weather information on Anywhere Map was, he said that was a good question and he could not provide an answer. He said it changes and that a critical decision making class taught to use a minimum of 10 minutes.

PERSONNEL INFORMATION

Pilot Information

The pilot, age 50, held a private pilot certificate with airplane single-engine and instrument airplane ratings.

The pilot did not have a Federal Aviation Administration (FAA) record of previous accidents, incidents, or enforcement actions.

The pilot stated that his total flight experience in N715CD was about 1,425 hours, of which about 136 hours were in actual instrument conditions, and 44 hours were in simulated instrument conditions. He said that he had flown about 400 hours a year, mostly from the Dallas area.

The pilot said that he has used Cirrus Standardized Instructor Pilots for his pilot training and had practiced flying partial panel and using various AP configurations. He said that they would cover up his AI, and have him look away and recover the airplane from unusual attitudes. He was not required by his aircraft insurer to receive annual pilot training due to the number of hours he flies.

Private Pilot Certificate

On November 28, 2001, he passed the private pilot airplane airman knowledge test on his third attempt with a score of 77 percent. The subject matter knowledge codes in which questions were incorrectly answered were:

G11 - Initial Notification of Aircraft Accidents, Incidents, and Overdue Aircraft

H300 - Forces Acting on the Airplane in Flight

H307 - Engine Operation

H308 - Propeller

H312 - The Pitot-Static System and Associated Instruments

H348 - Radio Navigation

I22 - Atmospheric Pressure and Altimetry

I56 - Pilot and Radar Reports, Satellite Pictures, and Radiosonde Additional Data (RADATs)

J08 - Controlled Airspace

J13 - Airport Operations

J27 - Wake Turbulence

J37 - Sectional Chart

On February, 28, 2002, he was issued a private pilot certificate with a single-engine land rating, after passing the practical test for the certificate on his first attempt using a Cessna 150. At the time of the test, the pilot reported a total time of 66 hours, all of which were in Cessna 150 airplanes.

Instrument Airplane Rating

The pilot said that he received instrument training that was 5 ½ - 6 weeks in duration at ATA Flight School, Miami, Florida. He said they attempted to fly IFR [IMC], if it was available, during training. He flew with his primary instrument instructor about two years ago using the incident airplane. During that training, they had an emergency while 13,000 feet and 100 miles from shore over the Atlantic where they lost the alternator and later landed without incident. The pilot said that his primary instrument flight instructor told him that he was cool under pressure, and the instructor also said that he knew guys in the military that would have not been that cool under pressure.

The pilot's primary instrument instructor stated that the pilot's instrument training began January 7, 2011 and was about a month in duration. Training consisted of about 30-40 hours of ground instruction and about 24 flights. He said the training was not "quick and dirty," and the flights were in excess of one hour. He said the pilot received partial panel instrument instruction, which he had to demonstrate during his instrument check ride. The flight instructor's flight experience in Cirrus airplanes was a "couple of hours" and "not many." The flight instructor did not have any experience in the Sandel avionics system, and he had another instructor, who was Cirrus certified, come in to provide instruction on the Sandel system for several hours to the pilot. The pilot's instrument instructor said that the pilot was a "good" and "cautious" instrument pilot and "very confident."

On January 30, 2011, the pilot passed the instrument airplane rating airman knowledge test on his first attempt with a score of 73 percent. The subject matter knowledge codes in which questions were incorrectly answered were:

PLT052 - Interpret information on a Departure Procedure Chart

PLT058 - Interpret information on a Low Altitude Chart

PLT083 - Interpret information on an Instrument Approach Procedures

PLT088 - Interpret speed indicator readings

PLT091 - Interpret VOR / ADF / NDB / CDI / RMI - illustrations / indications / procedures,

PLT102 - Recall aeronautical charts - terminal procedures

PLT128 - Recall aircraft performance - effects of icing

PLT141 - Recall airport operations - markings/signs/lighting

PLT161 - Recall airspace classes - limits/requirements/restrictions/airspeeds/equipment

PLT274 - Recall icing - formation / characteristics

PLT296 - Recall instrument procedures – holding/circling

PLT300 - Recall instrument/navigation system checks/inspections - limits/tuning/identifying/ logging

PLT354 - Recall radio - GPS / RNAV / RAIM

PLT379 - Recall regulations - alternate airport requirements

On February 2, 2011, the pilot was issued an instrument airplane rating, after passing the practical test for the rating on his first attempt using a Cirrus SR22. The pilot had a total time of 1,762 hours, of which 793 hours were in Cirrus SR22 airplanes at the time of test. The test was conducted by a designated pilot examiner (DPE).

Pilot's Instrument Instructor and Designated Pilot Examiner

The NTSB IIC requested the FAA to provide the pass rates, number of pilots recommended for examination, and any enforcement actions, accidents, and incidents for three or more years for the pilot's primary instrument instructor and DPE. FAA inspector comments related to the DPE's checks were also requested.

Provided information showed that on November 7, 1994, the primary instrument instructor had his commercial pilot certificate revoked. On August 19, 2009, he received a "waiver penalty ASRP" on commercial pilot certificate. On September 2, 2010, he had his commercial pilot certificate suspended for 30 days.

Records pertaining to the number of pilots that passed or failed an examination for an aircraft certificate/rating that were recommended by the primary instrument instructor from 2009 – 2012, showed the following:

2009: 5 records - 4 pass and 1 fail

2010: 9 records – 7 pass and 2 fail

2011: 14 records – 14 pass and 0 fail

2012: 16 records – 14 pass and 2 fail

Records pertaining to the number of pilots that passed or failed an examination for an aircraft certificate/rating that was conducted by the DPE from 2009 – 2012, showed the following:

2009: 218 records – 190 pass and 28 fail

2010: 246 records –213 pass and 33 fail

2011: 258 records –235 pass and 23 fail

2012: 342 records – 319 pass and 23 fail

On March 25, 2013, the DPE's examining authority was removed as a result of action taken under the provisions of 49 CFR Part 44709 (Amendments, modifications, suspensions, and revocations of certificates) of two of his applicants.

Pilot's Post-Incident Training

Following the incident, CDC loaned the pilot an airplane equipped with an Avidyne primary flight display (PFD). CDC wanted the pilot to undergo transition training and receive an Instrument Proficiency Check in order for him to fly the Avidyne-equipped airplane under IFR.

The pilot's post-incident flight instructor stated that she had been flying for about 10 years and provided flight instruction for about 7 years. Her total flight time was about 3,500 hours and more than 2,000 hours of dual instruction given. In 2004, she owned her first Cirrus airplane, and the majority of her flight time was in Cirrus airplanes. The flight instructor expected the pilot to be proficient IFR pilot and the flight instructor's goal was to train the pilot on the Avidyne system. The flight instructor wanted him to learn how to set up the Avidyne system based upon how he set up his avionics in his airplane, which was equipped with a Sandel system. The flight instructor planned for the pilot to complete transition training in 1 – 1 ½ days. The flight instructor said that he trained for 2 days and did not complete the transition training. The flight instructor said that the pilot said he had a business meeting to attend, and the flight instructor had no further contact with him again.

AIRCRAFT INFORMATION

The 2001 Cirrus SR22, serial number 0016, was registered to Jeramiah 2911 Inc., which the pilot was listed as president on the Aircraft Registration Certificate with an issue date of November 5, 2007.

The airplane avionics included an ARNAV multifunction display, two WAAS Garmin navigators, a Sandel HSI, and a VOR indicator.

The airplane was equipped with an L-3 Avionics Systems Model 1100 AI (28.0 Vdc unit) that used an electrically driven two-degree-of –freedom vertical gyroscope. Gyroscope verticality was maintained by pneumatic erection and provided for the manual fast-erect with caging knob.

The rocket motor was labeled with the following information:

First line was unreadable due to label damage

Serial number: 0580

Manufacturing date: January 4, 2012

Expiration date: January 4, 2022

The deployment bag was labeled with the following information:

Cirrus Design Corporation part number: 14242-101

Serial number: 00465-R1

Repack due: December 2021

Date: December 2011

A logbook entry dated January 19, 2012 indicated the airplane underwent an annual inspection at a total time since new of 2,419.4 hours and at a Hobbs time of 2,419.4 hours. The entry also stated that parachute assembly, serial number 00309, and rocket assembly, serial number 00162, were removed and parachute assembly, part number 14242-101, serial number 00465-R1, after being repacked by CDC was installed.

Autopilot Modes and Unusual Attitude Recovery

The post-incident flight instructor stated that new autopilots have a straight and level button, which levels the airplane's roll and pitch and ca

NTSB Probable Cause

The failure of the airplane’s parachute to deploy when activated during a loss of control in cruise flight due to the dynamic maneuvering of the airplane at the time of the activation, which exceeded the parachute system’s certification requirements.