NTSB Factual Report

HISTORY OF FLIGHT

On March 14, 2008, at 2350 eastern daylight time, a Cirrus Design Corp. SR22, N141SR, owned and operated by the private pilot, was destroyed when it impacted mountainous terrain during initial climb from Front Royal-Warren County Airport (FRR), Front Royal, Virginia. The personal flight was conducted under 14 Code of Federal Regulations Part 91. Night marginal visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the planned flight to Baltimore Washington International Airport (BWI), Baltimore, Maryland. The certificated private pilot and a passenger were killed. The flight departed from FRR at 2348.

According to the airport manager at FRR, the pilot previously flew IFR from BWI to FRR, and landed uneventfully about 2135. The pilot picked up his son, and departed on runway 27. The airplane subsequently impacted a mountain ridge approximately 3 miles west of FRR.

A National Transportation Safety Board investigator and a Federal Aviation Administration (FAA) inspector viewed video from an airport surveillance camera, with the FRR airport manager. Review of the video revealed that runway lights illuminated about 2348, followed by lights consistent with the accident airplane, rising from runway 27. A fireball was observed on a mountain to the west, about 1 minute 20 seconds after the airplane lights rose from the runway. The airport manager subsequently stated that when he later attempted to download the video, the recording system purged the data.

Review of FAA air traffic control (ATC) data, and Lockheed Martin communication data, revealed that the accident pilot telephoned the Raleigh/Durham, North Carolina flight service station (FSS) at 1930. He requested a standard weather briefing and filed an IFR flight plan from BWI to FRR.

At 2228, the pilot called the Lansing Michigan FSS, to cancel his IFR flight plan. He advised that he landed safely at FRR, but his mobile phone had "died."

At 2319, the pilot called the Kankakee, Illinois FSS, to file an IFR flight plan for his return trip to BWI.

At 2324, the pilot telephoned Potomac Clearance Delivery for his return flight. The ATC specialist then provided the pilot with an IFR clearance, which included initial instructions to fly direct COGAN intersection, climb and maintain 4,000 feet mean sea level (msl), expect 5,000 feet msl 10 minutes after departure. The pilot's release time was 2350, with a clearance void time of 2355. No further communications from the pilot were received by Potomac terminal radar approach control (TRACON).

Potomac TRACON recorded two radar targets, with the accident airplane's transponder code. The first target was recorded at 2348:35, with an indicated altitude of 1,700 feet msl. The second target was recorded at 2348:39, with an indicated altitude of 1,800 feet msl. The targets depicted the accident airplane approaching a mountain ridge, traveling west toward the accident site.

PILOT INFORMATION

The pilot, age 54, held a private pilot certificate, with ratings for airplane single-engine land and instrument airplane. His most recent FAA third-class medical certificate was issued on October 15, 2007. At that time, he reported a total flight experience of 180 hours. The pilot obtained his instrument rating on September 20, 2006.

The pilot's logbook was not recovered; however, he maintained an aircraft usage log with a partner, for the accident airplane. Review of the usage log revealed that since August 27, 2006, through March 9, 2008, the pilot flew the accident airplane 113 hours. The pilot flew the accident airplane 13 hours since October 15, 2007, when he reported his total flight experience for the third-class medical certificate. The pilot flew 8.5 hours and 4.6 hours during the 90-day period and 30-day period preceding the accident, respectively. The pilot's flight times extrapolated from the usage log assumes that he swapped legs and pilot-in-command time with his partner, when both pilots' initials were listed in the "code" field for a singular entry.

The accident pilot's total experience in actual and simulated instrument meteorological conditions could not be determined. Further review of the usage log did not reveal any previous flights to FRR.

AIRCRAFT INFORMATION

The four-seat, low-wing, fixed-gear airplane, serial number 1971, was manufactured in 2006. It was powered by a Teledyne Continental Motors IO-550-N, 310-horsepower engine and equipped with a Hartzell propeller.

The pilot owned and operated the accident airplane, which he purchased new in 2006. A review of the maintenance logbooks revealed that the airplane's most recent annual inspection was completed on June 13, 2007. At that time, the airplane had accumulated 157.7 total hours of operation. An airworthiness directive was complied with 9 days prior to the accident. At that time the airplane had accumulated 267.8 total hours of operation.

METEOROLOGICAL INFORMATION

Winchester Regional Airport (OKV) was located about 15 miles north of the accident site. The reported weather at OKV, at 0000, was: wind from 340 degrees at 4 knots; visibility 3 miles in rain; broken ceiling at 2,400 feet; overcast ceiling at 3,000 feet; temperature 10 degrees Celsius (C); dew point 8 degrees C; altimeter 29.59 inches of mercury.

WRECKAGE INFORMATION

The airport elevation at FRR was 709 feet msl. The wreckage was located on the mountain ridge, about 1200 feet msl. An approximate 100-feet debris path was observed through trees, extending on a 170-degree magnetic course, to the main wreckage. The trees ranged in height from approximately 60 to 80 feet. Portions of the left wing were found near the beginning of the debris path. The left and right ailerons were found toward the end of the debris path, near the main wreckage. The airplane came to rest inverted, oriented about a 340-degree magnetic heading, and had been subjected to a postcrash fire. The cockpit and cabin were consumed by fire, and the only recognizable instrument recovered was the standby attitude indicator. The Cirrus Airframe Parachute System (CAPS) parachute remained stowed and its respective charge had burned, consistent with the postcrash fire.

Portions of the right and left elevator, horizontal stabilizer, and empennage were located several feet to the west of the main wreckage. The wing spar was located in the main wreckage, and the rudder was located a few feet south of the main wreckage. Flight control continuity was confirmed from the rudder pedals and elevator control torque tube, to their respective bellcranks, at the rear of the airplane. Aileron control continuity was confirmed from the cockpit area, to the left and right inboard flap hinges, respectively. The elevator trim was an electric system, and the elevator trim motor was destroyed by fire.

The propeller was partially separated from the engine. All three propeller blades exhibited s-bending, chordwise scratching, and leading edge gouging. The engine sustained impact damage, portions of the No. 5 cylinder were separated, and the crankshaft could not be rotated by hand. The top spark plugs were removed for inspection; their electrodes were intact and light gray in color, except for the No. 5 spark plug, which sustained impact damage. The fuel manifold contained fuel, and its fuel screen was absent of debris. The engine driven fuel pump coupling remained intact, and the engine driven fuel pump moved liquid freely when tested via an electric drill. Both magnetos produced spark at all towers when rotated by hand. The oil pump remained attached to the engine, and oil was noted throughout the engine.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by the Commonwealth of Virginia, Department of Health, Office of the Chief Medical Examiner, Fairfax, Virginia, on March 18, 2008. According to the autopsy report, the cause of death was listed as "Blunt head, torso, and extremity trauma."

Toxicological testing was performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma. The testing revealed ethanol detected in liver; however, putrefaction was noted as yes, and the ethanol was "from sources other than ingestion." The testing was negative for drugs.

TESTS AND RESEARCH

The engine multifunction display (MFD) and primary flight display (PFD) were retained for further examination by the Safety Board Vehicle Recorders Laboratory, Washington, DC. Both units were damaged, and data could not be recovered from the MFD. The airplane was also equipped with a terrain awareness and warning system (TAWS), which was destroyed during the impact.

Data was successfully recovered from the PFD and plotted. Review of the data revealed that for the approximate first-half of the 1 minute 20 second flight, the airplane flew runway heading and initially climbed about 900 to 1,000 feet-per-minute (fpm). About mid-way through the flight, the heading bug was set to approximately runway heading, and the vertical speed (and pitch attitude) began to oscillate. During an approximate 25-second period, the vertical speed decreased to about 0, then increased to about 2200 fpm up, then decreased again and settled about 700 to 750 fpm up. During the oscillation, the vertical speed indicator bug changed from 0 to 700 fpm, where it remained for about 16 seconds, until it changed to 850 fpm up. During controlled flight just prior to impact, the airplane was climbing and accelerating, reaching a pressure altitude of approximately 2,200 feet msl and an indicated airspeed of 140 knots. About 6 seconds before the end of the recording, the airplane began a steep descending turn to the left (roll attitude reached a peak value of 95 degrees left wing down, pitch attitude reach a peak of about 27 degrees airplane nose down).

Prior to takeoff, the "Desired Course" parameter was set to about 050 degrees, where it remained throughout the flight. The course selection was consistent with a magnetic course from FRR to COGAN. Just after the airplane began its takeoff roll, a global positioning system (GPS) waypoint of COGAN was selected. The primary navigation source was set to GPS No. 1. The airplane did not fly toward COGAN, consistent with the global positioning system steering (GPSS) mode of the autopilot system not being selected.

NTSB Probable Cause

The pilot's failure to maintain clearance from rising mountainous terrain, and his failure to turn toward his assigned course during initial climb. Contributing to the accident were the low ceiling, reduced visibility, dark night conditions, and rising mountainous terrain.