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Appendix A

VIEWS: 71 PAGES: 94

									Technically Advanced Aircraft
            Safety and Training



      Appendix A
         Edited National Transportation Safety Board
     (NTSB) reports. The following reports have been
   edited slightly for space without altering pertinent
              facts. Full reports may be viewed online
               (www.asf.org) in the accident database.
AppendixA

                          Cirrus Accidents

                          LAX01FA145

                          Date/Time         Aircraft              N Number          Operation        Accident             Aircraft
                                                                                                     Phase                Damage
                          04/10/2001 Cirrus SR20                  N116CD            Personal         Maneuvering          Destroyed
                          1850 MST          IO-360-ES


                          Injuries                Fatal                   Serious               Minor                 None
                          Crew                    1                       0                     0                     0
                          Passengers              2                       0                     0                     0
                          Ground                  0                       0                     0                     0


                          Location          Sierra Vista, AZ                        Flight Plan          None
                          Itinerary         Tucson, AZ—Belen, NM                    Runway               N/A
                          Airport           N/A


                          Weather             IFR                Precipitation      None                   Wx Briefing          Yes
                          Visibility          10 sm; Mtn.        Clouds             Few 6,000              Type                 DUATs
                                              obscuration                           SCT 8,000
                          Wind                290/12             Ceiling            None
                          Gusts               None               Lighting           Dusk


                          Experience                              Hours
                          Certificate                 Private    Total               1567           Last 90 Days          UNK
                          Instrument                  None       Make                167            Last 30 Days          UNK
                          Curr. Medical               Yes        Instmt              0

                         SUMMARY                                                    departure control. Departure control instructed
                         A Cirrus SR20 collided with mountainous terrain            the pilot to make a left turn to a heading of 030
                         northwest of Sierra Vista, Arizona. The airplane           degrees. The controller then verified the pilot’s
                         was destroyed, and the noninstrument-rated pri-            requested heading and cleared the flight to turn on
                         vate pilot and two passengers received fatal               course. At 1843, radar service was terminated and
                         injuries. The flight originated from the Tucson            the pilot was instructed to squawk VFR (transpon-
                         International Airport (TUS) at 1830, with                  der code 1200), to which the pilot acknowledged.
                         Alexander Municipal Airport (E80) in Belen, New
                         Mexico, as the intended destination. Instrument            Concerned family members reported the aircraft
                         meteorological conditions prevailed at the acci-           overdue when it failed to arrive as scheduled.
                         dent site and no flight plan had been filed.               Civil Air Patrol initiated a search and personnel
                                                                                    located the accident site on April 14, 2001. The
                         The pilot radioed the Tucson Clearance Delivery            burned wreckage was located approximately 150
                         requesting a VFR clearance, with a heading of 100          feet below the crest of a ridgeline in the
                         degrees at 3,800 feet to E80. After takeoff, the pilot     Whetstone Mountains, at 5,200 feet mean sea
                         was instructed to turn to a heading of 120 degrees         level (msl). The accident site was approximately
                         and to expect an on-course clearance from the              52 nautical miles southeast of Tucson. Belen is
                         next controller, and was then instructed to contact        located northeast of Tucson.

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AOPA Air Safety Foundation                                                                                             AppendixA



Personal information                                  observation had remarks that indicated snow
The noninstrument-rated pilot held a private          showers were over the mountains, northeast
pilot certificate with 1,450 hours of flight time.    through the southeast, and they were moving
Utilizing the aircraft maintenance records, NTSB      east.
investigators estimated that the pilot had accu-
mulated approximately 116.6 hours of flight time      The pilot reports (pireps) were reviewed and the
in the accident airplane.                             following were selected from the Tucson area:

According to Cirrus Design, the pilot received        At 1704, over Tucson, the flight crew of a Boeing
SR20 familiarization training between February 3      727 at 2,700 feet, reported “low-level windshear
and February 6, 2000.                                 plus-or-minus 10 knots indicated airspeed dur-
                                                      ing climb [from] Runway 29R.”
Meteorological information
One of the local sheriff’s deputies, who is a pilot   At 1710, at a location 12 nautical miles on a 090-
and lives approximately 2 miles from the base of      magnetic bearing from Tucson, the flight crew of
the Whetstone Mountains, said the weather the         a MD80 reported light to moderate clear icing at
day of the accident was “terrible” with icing,        11,000 feet.
sleet, snow, rain, and wind, and he could not see
the base of the mountains from his home.              Review of weather radar data at 1846, 1851, and
                                                      1856, revealed that precipitation reflectivity in
According to Flight Service Station (FSS) archived    the accident area did increase during these
information, the pilot obtained DUATs weather         observations, however, no significant weather
information at 0709 and 0926 on the morning of        radar returns were shown in the vicinity of the
the accident.                                         accident site.

The 700-millibar analysis chart showed narrow         The area forecast for Arizona, specifically south
temperature-dew point spreads at Albuquerque,         and east of TUS, reported a chance of broken
Tucson, and Flagstaff, which indicated a nearly       clouds at 6,000 feet, broken clouds at 11,000
saturated atmosphere at these locations.              feet with tops at flight level 220, and scattered
                                                      light rain showers. The forecast indicated the
The closest weather reporting facility was located    conditions would slowly improve from the west,
at Safford Regional Airport (SAD), which was 11       becoming scattered clouds at 8,000 feet over the
nautical miles south-southeast of the accident        entire Arizona area around 2100.
site. At 1850, the weather observation facility
reported the wind from 290 degrees at 12 knots;       There were Airmets for moderate turbulence,
visibility 10 statute miles; a few clouds at 6,000    mountain obscurement and icing for the
feet agl, and scattered clouds at 8,000 feet agl;     departure airport and surrounding the accident
temperature 4 degrees Celsius; dew point 1-           site.
degree Celsius; and an altimeter setting of 29.94
inches of mercury. The remarks section of the         According to the forecast: wind from 270 degrees
1850 report indicated that the rain began at 1755     at 14 knots gusting to 24 knots; visibility greater
and ended at 1834.                                    than 6 miles; and clouds broken 6,000 feet. The
                                                      forecast also indicated temporary conditions
At 1855, the weather observation facility at          between 1700 and 1900, which included light rain
Tucson International Airport, located approxi-        showers, small hail, and cumulonimbus clouds
mately 34 nautical miles northeast of the acci-       broken at 3,500 feet. There is no indication the
dent site, reported the wind from 280 degrees at      pilot obtained this TAF prior to departing since
10 knots gusting to 17 knots; visibility 10 statute   the last recorded DUATs information was
miles; broken clouds at 7,500 feet agl; tempera-      obtained at 0926.
ture 11 degrees Celsius; dewpoint minus
5 degrees Celsius; and an altimeter setting of        Wreckage and impact information
29.99 inches of mercury. The remarks section of       On April 16, 2001, the NTSB investigator exam-
that report indicated rain and snow showers were      ined the wreckage at the accident site with the
in the distant northeast-east moving east.            assistance of investigators from Cirrus Design
                                                      and Ballistic Recovery Systems (BRS). The
Review of the 1555, 1655, 1755, and 1855 weather      wreckage distribution was localized within
observations for TUS and the Davis Monthan Air        about a 50-foot radius of a single ground distur-
Force Base (DMA, which is located approximately       bance scar on the approximate 35-degree slope
6 nautical miles northeast of TUS), revealed each     of the mountain.

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AppendixA                                                                                                    AOPA Air Safety Foundation




                            It was noted that the Cirrus Airplane Parachute         is difficult to detect. The onboard GPS unit,
                            System (CAPS) was not deployed. Although the            which was capable of displaying critical terrain
                            CAPS rocket fuel was expended, there was no             elevations to a surprisingly fine scale of accuracy,
                            apparent impact damage noted on the door that           was either not utilized or given weight in the
                            covers the parachute and rocket launching sys-          decision to continue this flight into deteriorating
                            tem. The rocket motor strike plate on the door          weather. A key point for the VFR-only pilot to
                            did not show any signs of rocket motor impact           remember: If the takeoff and departure was con-
                            and the door was found in the main wreckage             ducted in VFR conditions, any time during the
                            area. The parachute remained packed in its con-         flight IMC is encountered, a 180 degree turn will
                            tainer and remained attached to the Kevlar para-        usually assure a return to VMC. Area Forecasts
                            chute harness. Approximately                            (FAs) and Terminal Area Forecasts (TAFs) some-
                            8 to 10 feet of the suspension lines were laid out      times paint a picture of gloom that doesn’t neces-
                            among the wreckage. The parachute was pulled            sarily materialize with 100-percent accuracy.
                            away from the wreckage and the remaining                However, pireps and observed weather combined
                            length of the suspension lines extended easily          with the METARs seldom lie. In this account,
                            with no binding noted.                                  both these sources of weather reporting at best
                                                                                    indicated MVFR weather over the area of intend-
                            Tests and research                                      ed flight.
                            Cirrus Design personnel examined an exemplar
                            aircraft with the same ARNAV/Garmin 430 unit
                            and database as the accident aircraft. The acci-
                            dent site location was entered into the system
                            and it was noted that the ARNAV database dis-
                            played the terrain elevations correctly.

                            Probable cause
                            The pilot’s inadvertent flight into instrument
                            meteorological conditions and failure to main-
                            tain clearance with the terrain.

                            Factors
                            A contributing factor was the pilot’s failure to
                            obtain an updated preflight weather briefing.

                            ASF comments
                            VFR into IMC is always a bad idea. While fore-
                            casts are sometimes in error, once the pilot actu-
                            ally sees the clouds ahead, it’s time to divert. With
                            daylight fading rapidly in mountainous terrain,
                            the visual difference between terrain and clouds




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AOPA Air Safety Foundation                                                                                                 AppendixA




NYC02LA071
Date/Time         Aircraft             N Number         Operation        Accident Phase Aircraft
                                                                                        Damage
03/16/2002 Cirrus SR20                 N244CD           Personal         Climb                 Substantial
1240 EST          IO-360-ES


Injuries          Fatal                Serious          Minor            None
Crew              0                    0                1                0
Passengers        0                    0                1                0
Ground            0                    0                0                0


Location          Lexington, KY                         Flight Plan      IFR
Itinerary         Lexington, KY—Lexington, KY           Runway           N/A
Airport           Blue Grass (LEX)


Weather           IFR                  Precipitation    Light rain       Wx Briefing           Commercial
                                                                                          weather service
Visibility        5 sm                 Clouds           OVC              Type                  Internet
Wind              360/07               Ceiling          600 feet
Gusts             N/A                  Lighting         Daylight


Experience                             Hours
Certificate       Private              Total            371              Last 90 Days          22
Instrument        Yes                  Make             110              Last 30 Days          8
Curr. Medical Yes                      Instmt           78



SUMMARY                                                 1,400 feet, then set the autopilot to fly the “head-
                                                        ing bug,” and the “VS” to climb. He then initiated
A Cirrus SR20 was substantially damaged during          a climbing right turn by setting the heading bug
an emergency landing in Lexington, Kentucky.            to 090 degrees, and entered the overcast layer
The certificated private pilot and a pilot-rated        about 1,600 feet. Air traffic control (ATC) then
passenger sustained minor injuries. Instrument          cleared the airplane to the initial approach fix for
meterological conditions prevailed and an IFR           the “GPS RW 04” approach. The pilot was in the
flight plan had been filed for the flight that          process of selecting the approach in the air-
departed Blue Grass Airport (LEX), Lexington,           plane’s GPS, when he noticed that the turn coor-
Kentucky.                                               dinator was “pegged to the left, with no flag,” and
                                                        that the airplane was losing altitude rapidly. The
The instrument-rated pilot stated he had intend-        pilot disengaged the autopilot and attempted to
ed to perform some practice instrument                  stabilize the airplane. In a written statement, he
approaches in actual instrument meteorological          further added:
conditions. The passenger was a friend of the
pilot and also held a private pilot certificate, with   “I let [the passenger] know I was disengaging the
an instrument rating.                                   autopilot. By then we were in a steep dive. At this
                                                        moment, I had no confidence in the instruments
According to the pilot, after a normal preflight        other than airspeed, altimeter, and vertical speed
check, the airplane departed from Runway 04, at         indicator. The airspeed was high, perhaps in the
LEX. The pilot maintained runway heading until          yellow arch. When we broke out of the clouds, I

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AppendixA                                                                                                     AOPA Air Safety Foundation




                            pulled up hard and the plane responded. Our             system consisted of a parachute, a solid-propellant
                            momentum carried us back into the clouds and            rocket to deploy the parachute, a rocket activation
                            somewhere near 3,000 feet, I had control of the         handle, and a harness imbedded within the fuse-
                            altitude momentarily and thought for a minute we        lage structure. The activation handle was located in
                            might be able to recover. I tried to fly straight and   the headliner of the cabin between the forward
                            level, which I believe we did for a short time and      crew seats. The igniter system employed a 25-
                            then everything started to unravel again. The atti-     pound spring, to arm and trigger the igniter. The
                            tude indicator [AI] was now unreliable. I suspect       pilot was required to pull on the handle, and con-
                            the AI tumbled during recovery from the previous        tinue to pull for a short period of time to allow the
                            dive. Next we were climbing and probably turning        spring to compress, arm and fire the charge.
                            and generally out of control....”                       Yanking the handle in short strokes would not
                                                                                    allow the spring to compress completely, and
                            The airplane was equipped with a Cirrus Airplane        would fail to activate the igniter.
                            Parachute System (CAPS). The pilot indicated he
                            pulled the CAPS activation handle repeatedly;           On February 25, 2002, Cirrus Design issued
                            however, the cable did not extend and “nothing          Service Bulletin (SB) 22-95-01. The SB was also
                            seemed to happen.” He further stated:                   the subject of FAA Airworthiness Directive (AD)
                                                                                    2002-05-05, which became effective on March
                            “Finally I decided that it must have already            19, 2002. The service bulletin and subsequent
                            deployed, but still we were carrying 120 to 140         AD, entailed the installation of a cable clamp
                            knots of airspeed and descending faster than I          external to the rocket cone adapter which
                            expected we would if the chute had deployed.            would provide positive retention of the activa-
                            After we broke out [of the cloud layer] we began        tion cable housing.
                            to search for a suitable landing site. We were still
                            uncertain as to whether or not we were under the        On February 28, 2002, Cirrus Design issued SB
                            canopy, but continued to fly as if we were not....”     20-95-02, after it was discovered that some pro-
                                                                                    duction airplanes might exhibit a condition
                            The airplane touched down in field and struck           where the pull force required to activate the
                            trees, about 3 miles northeast of LEX. Witnesses        CAPS system may by greater than desired. The
                            near the accident reported that the CAPS para-          SB entailed the installation of a clamp to posi-
                            chute deployed after ground contact.                    tively restrain the cable housing at the CAPS
                                                                                    Handle Adapter, loosen and straighten the acti-
                            With regards to the turn coordinator, the pilot         vation cable above the headliner, and to remove
                            rated passenger stated “It was banked to the left,      an Adel clamp securing the activation cable
                            and regardless of control inputs, remained in a         adjacent to the rocket cone adapter.
                            position indicating a left bank.”
                                                                                    The accident airplane was purchased new by
                            On-site examination of the wreckage by a                the pilot in April 2001, and had been operated
                            Federal Aviation Administration (FAA) inspector         for about 150 hours since new. On March 4,
                            did not reveal any pre-impact instrumentation,          2002, maintenance was performed on the air-
                            or autopilot failures; however, the turn coordi-        plane which included compliance with SB 22-
                            nator, autopilot control box, autopilot roll trim       95-01/AD 2002-05-05. SB 20-95-02, had not
                            actuator, and the horizontal situation indicator        been completed at the time of the accident.
                            (HSI) were removed from the airplane for fur-
                            ther testing. The CAPS system also functioned           The pilot reported he had experienced the exact
                            normally, however, it was noted that the pull           same type of turn coordinator failure on a pre-
                            forces to activate the CAPS parachute varied            vious occasion. Maintenance records revealed a
                            significantly during post accident testing.             turn coordinator was replaced on the airplane
                                                                                    on June 25, 2001, after 57 hours of operation.
                            Additional testing conducted by the manufactur-
                            er on production line aircraft revealed that the        The weather reported at LEX at 1254, was: wind
                            manner in which the activation handle was               from 360 degrees at 7 knots, visibility 5 miles in
                            pulled made a difference in how easily the CAPS         mist, ceiling 600 feet overcast, temperature 6
                            system could be activated.                              degrees Celcius, dewpoint 6 degrees C, altimeter
                                                                                    30.18 inches of mercury.
                            According to the airplane manufacturer, the
                            CAPS system was designed to bring the aircraft          The pilot reported 371 hours of total flight
                            and its occupants safely to the ground in the           experience, with 110 hours in make and model.
                            event of a life-threatening emergency. The CAPS         He also reported 54 hours of simulated, and 24

A-6 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                             AppendixA



hours of actual flight experience in instrument       ASF comments
meteorological conditions.                            A failed turn coordinator is in itself not cause for
                                                      loss of control of an airplane operating in IMC.
As a result of this accident, and the subsequent      The problem lies however in determining which
testing, Cirrus Design issued SB 20-95-03, which      instrument has failed—the turn coordinator or
required replacement of the CAPS handle access        the attitude indicator? With only two instruments
cover. The new cover incorporated an expanded         to compare to each other, there is no “tie break-
description for the CAPS activation handle use.       er” to cinch the deal. The pilot reported a previ-
Additionally, on July 10, 2002, SB 20-95-05, was      ous failure of the turn coordinator so perhaps he
issued and required the replacement of the CAPS       suspected a repeat offense by the same instru-
activation cable in order to further reduce the       ment.
pull forces required to deploy the CAPS system.
Cirrus Design also issued similar service bulletins   Deployment of the CAPS system for an instrument
for the SR22 series airplanes, which were also        malfunction on the surface seems like overkill.
equipped with a CAPS system.                          Recall, however, that many vacuum system and
                                                      instrument failures in general aviation end much
Probable cause                                        less favorably than this one. The decision to
The pilot’s failure to maintain aircraft control.     deploy the BRS was the pilot’s alone to make. In
                                                      his judgment it was the only way to successfully
Factors                                               terminate the flight. Unfortunately, the failure of
Factors in this accident were the undetermined        the system to deploy only compounded his prob-
failure of the turn coordinator, as reported by       lems. His fortuitous exit from the overcast and the
the pilot, and the instrument meteorological          subsequent appearance of a somewhat suitable
conditions.                                           off-airport landing area saved him.




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AppendixA                                                                                                   AOPA Air Safety Foundation




                             NYC02FA089
                             Date/Time        Aircraft             N Number        Operation        Accident Phase Aircraft
                                                                                                                   Damage
                             04/24/2002 Cirrus SR22                N837CD          Personal         Maneuvering          Destroyed
                             1906 EST         IO-550-N


                             Injuries         Fatal                Serious         Minor            None
                             Crew             1                    0               0                0
                             Passengers       1                    0               0                0
                             Ground           0                    0               0                0


                             Location         Parish, NY                           Flight Plan      None
                             Itinerary        Syracuse, NY—Rochester, NY           Runway           N/A
                             Airport          N/A


                             Weather          VFR                  Precipitation   None             Wx Briefing          No
                             Visibility       10 sm                Clouds          FEW FL240        Type                 N/A
                             Wind             060/06               Ceiling         N/A
                             Gusts            None                 Lighting        Daylight


                             Experience                            Hours
                             Certificate      Private              Total           337              Last 90 Days         20
                             Instrument       Yes                  Make            31               Last 30 Days         11
                             Curr. Medical Yes                     Instmt          31


                            SUMMARY                                                troller advised radar contact, to proceed on
                            A Cirrus SR22 was destroyed when it impacted           course, and to climb to 5,500 feet, which the pilot
                            terrain in Parish, New York, in VMC. The two cer-      acknowledged.
                            tificated private pilots were fatally injured. The
                            two pilots were co-owners of the airplane, which,      At 1836, the controller asked if they were still
                            according to the manufacturer’s records, was           going to make a VFR practice approach into
                            delivered on April 18, 2002. A brother of one of       Oswego County. The pilot answered to the affir-
                            the pilots reported that they had intended on fly-     mative, that they were going to do a practice GPS
                            ing to Rochester to show the airplane to a friend.     Runway 24 approach. The pilot and the controller
                                                                                   then discussed whether or not to cancel VFR
                            During an initial radio call to Syracuse Clearance     flight following. The flight terminated radar serv-
                            Delivery at 1821, one of the pilots stated that they   ice and there were no additional transmissions
                            would depart VFR for Oswego County Airport             recorded from the accident airplane.
                            (FZY), Fulton, New York, at 5,500 feet. The crew
                            was given an altitude restriction of 2,000 feet        A radar track confirmed that the airplane pro-
                            within 5 miles of Syracuse Hancock International       ceeded to Oswego County Airport.
                            Airport (SYR), the departure frequency, and a
                            transponder code of 4626.                              A flight instructor, who was on the ground at
                                                                                   Oswego County, reported seeing a Cirrus,
                            At 1829, the flight was cleared for takeoff.           “Charlie Delta” touch down on Runway 6 about
                                                                                   1840. He recognized the airplane as being a new
                            The flight contacted Syracuse Departure Control,       hangar tenant at the FBO where he worked.
                            passing through 1,200 feet. The departure con-         The airplane touched down in the first 1,000 feet

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AOPA Air Safety Foundation                                                                                                AppendixA



of runway. The flight instructor observed all three     sure which direction the airplane may have
wheels on the ground, then heard a sudden               turned.
application of power. Rotation occurred quickly,
and the airplane made a steep climb. The climb          After the airplane completed its last pull-up, the
was “well underway” by the time the airplane            witness noticed that it entered another dive. The
reached the intersection of Runway 15/33, (about        airplane “suddenly went into a spiral and he went
2,000 feet from the approach end of the runway).        straight down. He seemed to keep a constant
The airplane reached pattern altitude by the end        speed on his descent and it looked like he was in
of Runway 6, and pitched forward “abruptly” to          slow motion spinning. He continued nose down
arrest the climb, while simultaneously entering         to the tree line and continued straight down to
the left crosswind. Power appeared to be reduced        the ground. I did not hear his engine on at all
as the pitch angle was decreased.                       once he went into the spiral. I did not think he
                                                        had an engine problem and was intentionally
The flight instructor lost sight of the Cirrus in the   cutting the power of his plane and then giving it
crosswind. He turned his attention to the final         full power on the climbout.”
approach area, and shortly thereafter observed
his student making a full stop landing. As the stu-     A second witness was also outside his home,
dent was taxiing the airplane to the ramp, the          about 1 mile west-northwest of the airplane.
flight instructor saw the Cirrus on final. “The         When he saw the airplane, it was traveling in an
plane made another well-stabilized approach             easterly direction. The airplane was “pretty small”
and smooth touchdown. Again there was a sharp           and had “plenty of altitude.” The airplane “peeled
application of power, another steep climbout, a         off to the left,” and the witness “remembered see-
quick transition to level flight at pattern altitude,   ing the bottom of the aircraft.” The airplane
and a simultaneous left crosswind turn.”                passed through about 180 degrees of turn, then
                                                        leveled off, “and right after it came back to level
The flight instructor did not see the airplane          flight it stalled.” The airplane “went into a nose
return to the airport.                                  dive spin and then a flat spin into the ground.” It
                                                        “tumbled in a downward spiral, which turned
Radar data indicated that a target departed             into a flat spin because it was basically flat, spin-
Oswego Airport, and climbed to 5,500 feet, then         ning on its own axis, slightly nose down, like a
headed southeast, toward the accident area,             turning top.” The witness believed the engine was
maintaining between 5,200 feet and 5,700 feet.          running the entire time, and expected the pilot to
En route, it made a left 90-degree turn, followed       add power to pull up. He did not hear any sput-
by a right 90-degree turn. It then continued            tering from the engine.
southeast, and made a right, approximately 360-
degree turn, followed by a left 360-degree turn.        A third witness, who observed the airplane with
The target then continued the left turn, until it       the second witness, noted that the airplane “rolled
was transiting east-southeast, and making small-        over once and then twisted, which looked to be
er left and right turns, until it reached the air-      intentional. Suddenly, the plane began doing a
space over the accident site.                           nose spin, which turned into a flat spin. It ap-
                                                        peared as though the pilot lost control of the plane.”
Target altitude readouts in the vicinity of the
accident site included: 5,600 feet at 1906:14; 5,700    Personal information
feet at 1906:23; 5,300 feet at 1906:28; 4,400 feet at   One of the pilots held a private pilot certificate,
1906:32; 3,800 feet at 1906:37; and 3,200 feet at       with ratings for single engine and multiengine
1906:42.                                                land airplanes, and instrument airplane. He
                                                        was also an Aviation Medical Examiner. His lat-
A witness to the accident was outside his home,         est FAA second-class medical certificate was
about 1/2 mile to the north. The witness was            dated December 12, 2000.
accustomed to airplanes performing maneuvers
in the area because of its sparse population. He        According to logbook excerpts provided by a
saw the airplane, and noticed that the pilot            family member, as of April 20, 2002, the pilot
would “cut the engine,” then descend the air-           had recorded 337 hours of total flight time, of
plane, and pull up, recovering with full power.         which, 250 hours were in single-engine air-
The airplane performed the maneuvers for about          planes, 87 hours were in multiengine airplanes,
5 minutes, and the witness saw the maneuver             and 31 hours were in make and model. The
repeated “three or four times.” The witness stated      excerpts documented four training flights in
that he was fairly sure the airplane “probably did      another SR22 prior to the acquisition of the
a turn” at the end of the pull-ups, but he wasn’t       accident airplane, and three training flights in

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AppendixA                                                                                                    AOPA Air Safety Foundation




                            the accident airplane. There was no evidence            sequence. The deployment bag creates an orderly
                            of the pilot previously flying with the other acci-     deployment process by allowing the canopy to
                            dent pilot.                                             inflate only after the rocket motor has pulled the
                                                                                    parachute lines taut. The parachute itself is a
                            Post-mortem medical examination confirmed               2400-square-foot round canopy equipped with a
                            that the pilot had been sitting in the airplane’s       slider, an annular-shaped fabric panel with a
                            left front seat at the time of the accident.            diameter significantly less than the open diame-
                                                                                    ter of the canopy. A three-point harness connects
                            The other pilot also held a private pilot certifi-      the airplane fuselage structure to the parachute.
                            cate, with ratings for single engine land airplanes
                            and instrument airplane. His latest FAA third-          CAPS is initiated by pulling the activation T-
                            class medical certificate was dated June 8, 2001. A     handle installed in the cabin ceiling on the air-
                            contract flight instructor, who conducted SR22          plane centerline just above the pilot’s right
                            flight training with him, estimated that the pilot      shoulder. A placarded cover, held in place with
                            had about 20 hours in make and model, and               hook and loop fasteners, covers the T-handle
                            believed the accident flight was the first one in       and prevents tampering with the control. The
                            which he had flown with the other accident pilot.       cover is removed by pulling the black tab at the
                                                                                    forward edge of the cover. Pulling the activation
                            The pilot’s logbook was not recovered; however,         T-handle removes it from the 0-ring seal that
                            on his Cirrus client profile sheet, dated April 22,     holds it in place and takes out the approximate-
                            2002, he stated he had 475 hours of flight time, all    ly 6 inches of slack in the cable connecting it to
                            in single-engine airplanes.                             the rocket. Once this slack is removed, further
                                                                                    motion of the handle arms and releases a firing
                            Post-mortem medical examination confirmed               pin, igniting the solid-propellant rocket in the
                            that the other pilot had been sitting in the air-       parachute canister.”
                            plane’s right front seat at the time of the accident.
                                                                                    The CAPS parachute was found outside the air-
                            There was no evidence as to which pilot was             frame, in its deployment bag, in front of the right
                            “pilot in command,” or which pilot was at the           wing. The composite CAPS cover was found
                            controls leading up to, or during the accident          about 20 feet in front of the airplane, with no
                            sequence.                                               damage to its interior (kick plate) face. The solid
                                                                                    propellant rocket was located on the ground, aft
                            Aircraft information                                    of the right wing, with cables leading to the
                            The airplane was equipped with a Cirrus Airplane        wreckage. The propellant was expended. The
                            Parachute System (CAPS).                                “maintenance safety pin,” which, when installed,
                                                                                    ensured that the CAPS activation T-handle could
                            According to the SR22 Pilot’s Operating                 not be pulled, was not located.
                            Handbook:
                                                                                    Meteorological information
                            “CAPS [is] designed to bring the aircraft and its       Weather, recorded at Oswego County Airport at
                            occupants to the ground in the event of a life-         1854, included winds from 060 degrees true at 6
                            threatening emergency. The system is intended           knots, visibility 10 statute miles, clear skies, a
                            to save the lives of the occupants but will most        temperature of 54 degrees F, and a barometric
                            likely destroy the aircraft and may, in adverse cir-    pressure of 30.10 inches of mercury.
                            cumstances, cause serious injury or death to the
                            occupants.                                              Weather, recorded at Syracuse-Hancock
                                                                                    International Airport at 1854, included winds
                            The CAPS consists of a parachute, a solid-propel-       from 070 degrees true at 8 knots, visibility 10
                            lant rocket to deploy the parachute, a [manually-       statute miles, a few clouds at 24,000 feet, a tem-
                            activated] rocket activation handle, and a harness      perature of 56 degrees F, and a barometric pres-
                            imbedded within the fuselage structure. A compos-       sure of 30.12 inches of mercury.
                            ite box containing the parachute and solid-propel-
                            lant rocket is mounted to the airplane structure        Additional information
                            immediately aft of the baggage compartment bulk-        SR22 Spins—According to the SR22 Pilot’s
                            head. The box is covered and protected from the         Operating Handbook:
                            elements by a thin composite cover.
                                                                                    “The SR22 is not approved for spins, and has not
                            The parachute is enclosed within a deployment           been tested or certified for spin recovery charac-
                            bag that stages the deployment and inflation            teristics. The only approved and demonstrated

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AOPA Air Safety Foundation                                                                                               AppendixA



method of spin recovery is activation of the            The service bulletin also described means of
Cirrus Airframe Parachute System (See “CAPS             compliance, which included: “install a cable
Deployment,” this section). Because of this, if the     clamp to positively restrain the cable housing at
aircraft ‘departs controlled flight,’ the CAPS must     the CAPS Handle Adapter, loosen and straighten
be deployed.                                            the activation cable above the headliner, and
                                                        remove [an] Adel clamp securing the activation
While the stall characteristics of the SR22 make        cable adjacent to the rocket cone adapter.”
accidental entry into a spin extremely unlikely,
it is possible. Spin entry can be avoided by            According to the manufacturer’s production
using good airmanship: coordinated use of con-          records, the accident airplane was in compliance
trols in turns, proper airspeed control following       with SB 20-95-02.
the recommendations of this handbook, and
never abusing the flight controls with accelerat-       Probable cause
ed inputs when close to the stall. If, at the stall,    The pilots’ failure to maintain airspeed, which
the controls are misapplied and abused acceler-         resulted in an inadvertent stall/spin.
ated inputs are made to the elevator, rudder
and/or ailerons, an abrupt wing drop may be             Factors
felt and a spiral or spin may be entered. In            The continued spin to the ground was a result of
some cases it may be difficult to determine if          the pilots’ failure to deploy the onboard para-
the aircraft has entered a spiral or the begin-         chute recovery system, for undetermined rea-
ning of a spin.                                         sons.

If time and altitude permit, determine whether          ASF comments
the aircraft is in a recoverable spiral/incipient       In certification, aircraft are tested to their limits
spin or is unrecoverable and, therefore, has            in accordance with the FARs. Intentionally push-
departed controlled flight.”                            ing an airplane beyond published limits is a
                                                        deadly choice.
Warning
In all cases, if the aircraft enters an unusual atti-   The SR22 Pilot’s Operating Handbook is very
tude from which recovery is not expected before         specific about spins. Not only are they not
ground impact, immediate deployment of the              approved but recovery may be impossible using
CAPS is required. The minimum demonstrated              conventional spin recovery methods. The only
altitude loss for a CAPS deployment from a one-         approved recovery method is deployment of
turn spin is 920 feet. Activation at higher alti-       CAPS. The two pilots, who had taken delivery of
tudes provides enhanced safety margins for              the airplane only six days prior to the accident,
parachute recoveries. Do not waste time and             were flying together for the first time. While we
altitude trying to recover from a spiral/spin           don’t have information regarding their experi-
before activating CAPS.                                 ence in spins or aggressive maneuvering, it is
                                                        reasonable to assume that they did not have
CAPS enhancements                                       much background or training in this area.
On February 28, 2002, Cirrus Design issued              According to eyewitness reports during the
Service Bulletin (SB) 20-95-02, which became            flight leading up to the accident, they were
effective on March 19, 2002. According the serv-        attempting several high-performance maneu-
ice bulletin, “some production airplanes may            vers. This Normal Category certified airplane is
exhibit a condition where the pull force required       designed for “point A to point B” flying rather
to activate the CAPS may be greater than                than for limited aerobatic maneuvers.
desired.”




                                                                          Technically Advanced Aircraft | www.aopa.org/safetycenter A-11
AppendixA                                                                                                  AOPA Air Safety Foundation




                            FTW02FA162
                            Date/Time        Aircraft            N Number         Operation       Accident             Aircraft
                                                                                                  Phase                Damage
                            05/28/2002 Cirrus SR20               N901CD           Personal        Climb                Destroyed
                            1630 MDT         IO-360-ES


                            Injuries         Fatal               Serious          Minor           None
                            Crew             1                   0                0               0
                            Passengers       0                   0                0               0
                            Ground           0                   0                0               0


                            Location         Angel Fire, NM                       Flight Plan     None
                            Itinerary        Angel Fire, NM—Sioux Falls, SD       Runway          N/A
                            Airport


                            Weather          VFR                 Precipitation    None            Wx Briefing          UNK
                            Visibility       20 sm               Clouds           UNK             Type                 N/A
                            Wind             110/10              Ceiling          UNK
                            Gusts            None                Lighting         Daylight


                            Experience                           Hours
                            Certificate      Commercial          Total            1,350           Last 90 Days         UNK
                            Instrument       Yes                 Make             100             Last 30 Days         UNK
                            Curr. Medical Yes                    Instmt           UNK




                            SUMMARY                                               low at a relatively slow airspeed.” The witness
                            A Cirrus SR20, was destroyed upon impact with         stated that he observed the airplane as it was
                            mountainous terrain while climbing near Angel         “trying to climb the mountain.” As the airplane
                            Fire, New Mexico. The commercial pilot, who was       was flying parallel to the ground, “the [air]plane
                            the sole occupant, was fatally injured. Visual        seemed to sound like any other [air]plane would,
                            meteorological conditions prevailed and a flight      but as it got closer to the mountain and trees, it
                            plan was not filed for the Part 91 personal flight.   tried to elevate higher than where it was when it
                            The cross-country flight departed from Angel Fire     flew overhead. At that point, the [air]plane got
                            Airport (AXX), near Angel Fire, New Mexico, at        lower with every second, then started to sputter
                            1627, and was destined for Joe Foss Field (FSD) in    as it was trying to elevate higher.” As the witness
                            Sioux Falls, South Dakota.                            observed the airplane, he further stated, “it
                                                                                  seemed the airplane was not gaining any eleva-
                            Prior to departing Runway 35, the pilot made a        tion and was flying about the same height as it
                            radio call requesting the temperature. An             was when it passed overhead.” The witness heard
                            employee of the Pierce Air, Inc., fixed-base opera-   an explosion followed by a billowing cloud of
                            tor (FBO) answered the pilot’s request with the       smoke.
                            current weather conditions. The employee
                            observed the airplane takeoff without incident.       Another witness observed the airplane during
                                                                                  run-up in preparation of a takeoff from the south
                            A witness, located northeast of AXX, reported to      end of the runway. The witness proceeded north
                            have observed the airplane fly overhead “really       on Highway 434 to Highway 64 then northeast.

A-12 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                              AppendixA



The witness observed the airplane “fly over so         knots, temperature of approximately 60 degrees
low, it got my attention,” and stated that the         F. The witness informed the pilot that the tem-
“[air]plane seemed to be having trouble gaining        perature reading was “from an instrument
altitude.”                                             under a carport and therefore was in the shade.”
                                                       A witness provided a map of the aircraft’s
A third witness located northeast of AXX was           approximate flight path, and estimated it to be
indoors and heard the airplane fly overhead. He        7.1 nautical miles from takeoff to the place of
thought the airplane sounded “funny.” The wit-         impact.
ness stepped outside and observed the airplane
fly overhead and it “seemed to be missing or run-      Tests and research
ning erratically, maybe like sputtering while on a     No anomalies were found that “would suggest
southerly heading.” The witness went back inside       any engine problem prior to the accident.”
and said he thought, “the plane needed a tune-
up or something.”                                      The density altitude at the accident site was cal-
                                                       culated to be 11,807 feet msl.
A demonstration pilot for the manufacturer, who
had flown the accident aircraft on several occa-       Cirrus Design calculated the following perform-
sions, stated that he departed from Denver on a        ance figures:
hot day with full fuel and ski equipment in the
back, earlier that year. According to the pilot, the   Takeoff Climb Gradient: 262 feet per nautical
aircraft performed “as advertised.” On departure       mile
from Denver, he was asked if he could expedite         Takeoff Rate of Climb: 406 feet per minute
the climb through 8,000 or 9,000 feet for traffic.     Best Angle of Climb Airspeed (VX): 80 KIAS=93
The pilot responded “negative” as he was climb-        KTAS=1.55 nautical miles per minute
ing at about 300 feet per minute with the temper-      Best Rate of Climb (VY): 88 KIAS
ature gauge starting to peak.
                                                       With this data, the manufacturer calculated that
Personal information                                   if the airplane maintained a constant airspeed of
The pilot was issued a commercial pilot certifi-       80 KIAS (VX) after departure, it would have taken
cate on July 30, 1971. On September 26, 2000, the      4 minutes, 11 seconds to climb 1,700 feet.
pilot was issued a second-class medical certifi-       Further calculations revealed that at VX, the air-
cate with a restriction to wear corrective lenses      plane’s approximate flight path would be 6.49
while operating an aircraft. The pilot had accu-       nautical miles.
mulated 1,350 hours total time, of which 100
hours were in the same make and model of the           Probable cause
accident aircraft. The most recent flight review       The pilot’s decision to continue the flight into the
was on June 1, 2001, in a Cirrus SR20.                 rising mountainous terrain, and subsequent fail-
                                                       ure to maintain clearance with the trees.
Meteorological information
At 1153, the weather facility at Las Vegas, New        Factors
Mexico, located 47 nautical miles southeast of         Contributing factors were the rising mountainous
AXX reported the winds calm, visibility 10 statute     terrain, and the high density altitude.
miles, scattered clouds at 1,100 feet, temperature
13 degrees C, dewpoint 1 degree C, and an              ASF comments
altimeter setting of 30.19 inches of Mercury. The      Density altitude is a critical step in preflight
NTSB calculated the density altitude (DA) to           planning that is often overlooked. If the pilot
be 11,807 feet msl.                                    had respected the high-density altitude in the
                                                       mountains, he may have chosen to delay his
An employee of the FBO reported the current            flight until the temperature dropped or shed
weather conditions to the pilot at the time of         some weight from the aircraft, preventing the
departure to be winds from 110 degrees at 10           accident.




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AppendixA                                                                                                   AOPA Air Safety Foundation




                             FTW03LA005

                             Date/Time        Aircraft           N Number        Operation         Accident Phase Aircraft
                                                                                                                  Damage
                             10/03/2002 Cirrus SR22              N1223S          Personal          Cruise                Substantial
                             1440 CDT         IO-550-N


                             Injuries         Fatal              Serious         Minor             None
                             Crew             0                  0               0                 1
                             Passengers       0                  0               0                 0
                             Ground           0                  0               0                 0


                             Location         Lewisville, TX                     Flight Plan              No
                             Itinerary        Addison, TX—Dallas, TX             Runway                   N/A
                             Airport          N/A


                             Weather          VFR                Precipitation   None              Wx Briefing           UNK
                             Visibility       10 sm              Clouds          FEW 4,500 feetType                      N/A
                             Wind             110/09             Ceiling         N/A
                             Gusts            15                 Lighting        Daylight


                             Experience                          Hours
                             Certificate      Private            Total           366               Last 90 Days          29
                             Instrument       Yes                Make            125               Last 30 Days          12
                             Curr. Medical Yes                   Instmt          61



                            SUMMARY                                              then proceeded to preflight the airplane for a
                            A Cirrus SR22 sustained substantial damage           flight to RBD, where the airplane was based. The
                            when it impacted trees and terrain during a          service center informed the pilot that the log-
                            forced landing following an in-flight separation     book entry for completed maintenance was not
                            of the left aileron during cruise flight near        included in the logbooks at that time. During the
                            Lewisville, Texas. The private pilot, who was the    preflight and pre-takeoff checks, the pilot noted a
                            sole occupant of the airplane, was not injured.      “failed” message when testing the autopilot in
                            Visual meteorological conditions prevailed. The      “navigation” mode.
                            flight departed Addison Airport (ADS), in
                            Addison, Texas, approximately 1430, and was          The airplane departed from Runway 13, and the
                            destined for Dallas Executive Airport (RBD),         pilot executed a left turn to the east. After the air-
                            Dallas, Texas.                                       plane was level at 2,000 feet mean sea level (msl)
                                                                                 for approximately 1 minute, the pilot noticed that
                            In an interview with the NTSB, the pilot reported    the airplane began “pulling” to the left. The pilot
                            that on October 2, 2002, a Cirrus authorized serv-   attempted to troubleshoot the problem and con-
                            ice center at ADS completed service bulletin (SB)    centrated on the autopilot system due to the fail-
                            22-95-05. Replacement of CAPS (Cirrus Airframe       ure noted during the pre-flight check. After sever-
                            Parachute System) Activation Cable, and SB A22-      al unsuccessful attempts to disengage the auto-
                            27-03, Trim Cartridge Self-Locking Nut               pilot with the control yoke switch, the pilot
                            Replacement, on the airplane. The pilot con-         attempted to pull the autopilot circuit breaker. As
                            firmed with the service center personnel that the    the pilot bent over to pull the circuit breaker, he
                            maintenance on the airplane was completed and        noticed that the left aileron was separated at one

A-14 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                               AppendixA



hinge attach point. While attempting to maintain        ification of proper hinge bolt installation and
level flight with two hands on the control stick,       torque on the outboard hinge.
the pilot declared an emergency to the ADS air
traffic control tower controller.                       A review of SB A22-27-03 revealed that during
                                                        compliance, the left aileron would have been
The pilot proceeded toward an unpopulated area          removed and reinstalled. The SB instructions for
and climbed to an altitude of 2,500 feet msl. With      the reinstallation of the aileron are the following:
the nose of the airplane heading into the wind, at      “Install LH aileron. (Refer to AMM 57-50).” “AMM
120 knots indicated airspeed, the pilot shutdown        57-50” is the following: Airplane Maintenance
the engine and deployed the CAPS. During the            Manual, Chapter 57 (Wings), -50 (Flight
deployment sequence of the CAPS, the left               Surfaces).
aileron separated from the airplane.
Subsequently, the airplane descended to the             Wreckage and impact information
ground with the aid of the parachute canopy and         The airplane impacted mesquite trees and the
came to rest upright in a field of mesquite trees.      terrain, and came to rest upright. The accident
According to an FAA inspector who responded to          site was located approximately 33 degrees 02
the accident, the left aileron was located approxi-     minutes north latitude, and 096 degrees 57 min-
mately 250 yards from the airplane.                     utes west longitude, at an estimated elevation of
                                                        475 feet. The airplane came to rest intact with the
Personal information                                    exception of the left aileron separation. The para-
The pilot held a private pilot certificate, with air-   chute canopy, suspension lines, and fuselage har-
plane single-engine land and instrument air-            ness of the CAPS remained attached to the fuse-
plane ratings. The private pilot was issued a           lage and came to rest in the mesquite trees.
third-class medical certificate on December 13,
2000, with the limitation “Holder shall wear cor-       Survival aspects
rective lenses.” According to the Pilot/Operator        The CAPS consists of a parachute, a solid-propel-
Aircraft Accident Report (NTSB Form 6120.1/2),          lent rocket, a rocket activation handle, and a har-
the pilot reported he had accumulated a total of        ness imbedded within the fuselage structure. A
366 flight hours, of which 125 hours were accu-         composite box, which is attached to the airframe,
mulated in the same make and model as the               houses the parachute and rocket assembly, and
accident airplane. The pilot’s most recent flight       the parachute is contained in a deployment bag.
review was accomplished on October 21, 2001, in         The deployment bag creates an orderly deploy-
a Cirrus SR22.                                          ment process by allowing the canopy to inflate
                                                        after the rocket has pulled the suspension lines
A review of the pilot training records revealed the     and harness. A three-point harness connects the
pilot completed the Cirrus Pilot Transition             airplane to the parachute. The aft harness strap is
Training course, sponsored by Cirrus Design, on         stowed in the parachute canister, and the forward
October 19, 2001, in Dallas, Texas. According to        harness straps are routed from the parachute
the course syllabus, the pilot underwent training       canister to the firewall attach points and stowed
for the CAPS system in the following areas: com-        under the fuselage skin. The parachute is a 2,400
ponents of the CAPS system, activation of system        square foot round canopy connected to the har-
and stages of deployment, decision making               ness straps by suspension lines.
process involved in activation of system, hazards
of deployment and risk benefit in various situa-        The CAPS is activated by pulling the T-handle
tions, and how to deploy the system.                    installed in the cabin ceiling above the pilot’s
                                                        right shoulder. A maintenance safety pin is pro-
Aircraft information                                    vided to ensure that the activation handle is not
According to the FAA-approved Cirrus Design             pulled during maintenance. A “Remove Before
maintenance manual 13773-001 revision, dated            Flight” streamer is attached to the pin.
November 20, 2000, the aileron is attached to the
wing at an outboard and inboard fixed-hinge             When CAPS is activated, the rocket is launched,
bracket. The outboard hinge point attach hard-          the parachute assembly is pulled outward, and in
ware included: one outer aileron hinge bolt, three      approximately 2 seconds, the canopy begins
thick washers, one thin washer, one self-locking        inflation. As the canopy inflates, the airplane’s
nut, and a safety wire. According to maintenance        forward speed will be slowed. This deceleration
manual procedures, the bolt and washer hard-            should be less than 3 Gs. Eight seconds after acti-
ware were to be torqued to a measured 20 to 25          vation, the aircraft will configure into an approxi-
inch pounds, then safety wired to a actuation fit-      mate level attitude. The vertical descent rate is
ting. After installation, the manual required a ver-    expected to be between 1,600 and 1,800 feet per

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AppendixA                                                                                                    AOPA Air Safety Foundation




                            minute, and a ground impact equivalent to               attached to the aileron, and the outer bearing
                            touchdown from a height of approximately                race remained attached to the hinge structure
                            13 feet. The horizontal velocity and direction is       attached to the wing. The safety wire remained
                            based on the current wind conditions.                   attached to the bolt and the safety wire tab on
                                                                                    the aileron. No other anomalies were noted with
                            The pilot and each passenger seat is equipped           the airplane or the CAPS.
                            with a seatbelt and shoulder harness assembly
                            with inertia reels.                                     In a written statement, a mechanic, who did not
                                                                                    sign off the maintenance that was completed,
                            Cirrus Design recommends that the CAPS                  stated, “Upon completion of work performed on
                            deployment occur at an altitude of 2,000 feet agl       N1223S the replacement of the trim drum screw
                            or higher, wings level attitude, fuel, mixture,         the work was inspected for proper completion as
                            throttle and magnetos in the OFF position, seat-        per the SB. No defects in the completion of the
                            belts tight, battery and alternator master switch-      work were noted. Safeties were inspected and
                            es in the OFF position.                                 found to be intact upon completion of the work.”

                            The POH recommends the CAPS may be appro-               Probable cause
                            priate in the following possible scenarios: mid-air     The improper reinstallation of the left aileron by
                            collision; structural failure; loss of control; land-   maintenance personnel.
                            ing required in terrain not permitting a safe land-
                            ing; and pilot incapacitation. The CAPS deploy-         Factors
                            ment is expected to result in the destruction of        A contributing factor was the nonsuitable terrain
                            the airframe, and possible severe injury or death       for the forced landing.
                            to the occupants.
                                                                                    ASF comments
                            Testing and research                                    When the idea of a BRS was first circulated in
                            On October 4, 2002, the airplane was examined           general aviation circles it was not universally
                            by the NTSB IIC, FAA inspectors, representatives        greeted with enthusiasm. Critics complained
                            of Cirrus Design, and a representative of Ballastic     that it would cause pilots to develop a cavalier
                            Recovery Systems, the manufacturer of the para-         attitude toward inflight safety and decision
                            chute system, at the Air Salvage of Dallas facility.    making, knowing that they could always “hit the
                            Examination of the left aileron and the airframe        silk” in the event that something went wrong.
                            aileron hinges revealed that the outboard aileron       Cirrus pioneered the first production aircraft to
                            hinge bolt was missing, and no evidence of safety       incorporate the BRS into the design. This pilot’s
                            wire was noted. No damage was noted on the              proper training, cool head, and adherence to
                            outboard hinge assembly, and the threads on the         procedure paid off.
                            self-locking nut were intact. The inboard aileron
                            hinge bolt was found pulled from the airframe
                            aileron hinge bearing. The inboard aileron hinge
                            bolt and inboard aileron bearing race remained




A-16 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                              AppendixA




FTW03FA029
Date/Time        Aircraft             N Number         Operation         Accident Phase Aircraft
                                                                                        Damage
11/03/2003 Cirrus SR20                N566T            Personal          Maneuvering          Destroyed
1225 MST         IO-360-ES-6


Injuries         Fatal                Serious          Minor             None
Crew             1                    0                0                 0
Passengers       0                    0                0                 0
Ground           0                    0                0                 0


Location         Las Vegas, NM                         Flight Plan       None
Itinerary        Goodland, KS—Albuquerque, NM Runway                     N/A
Airport          N/A


Weather          IFR                  Precipitation    None              Wx Briefing          Yes
Visibility       10 sm                Clouds           OVC               Type                 DUATs
Wind             090/11               Ceiling          300-500 feet
Gusts            None                 Lighting         Daylight


Experience                            Hours
Certificate      Private              Total            1884              Last 90 Days         UNK
Instrument       None                 Make             82                Last 30 Days         UNK
Curr. Medical Yes                     Instmt           UNK



SUMMARY                                                planned route]. On the morning of the accident, at
A Cirrus SR20 was destroyed after impacting ter-       1115 MST, the pilot contacted the relative and
rain while maneuvering near Las Vegas Municpal         reported he was 136 miles from AEG and the
Airport (LVS) in New Mexico . The noninstru-           weather was beautiful. The relative stated the pilot
ment-rated private pilot, sole occupant of the air-    would typically fly the airplane at a cruise speed of
plane, sustained fatal injuries. Instrument mete-      150 knots and at an altitude of 1,000 feet agl.
orological conditions prevailed and no flight plan
was filed for the flight.                              The flight stopped in GLD and refueled.
                                                       According to the refueler, the pilot did not check
During a telephone interview with a relative of        the computer weather provided at the FBO.
the pilot, the relative stated the pilot would typi-
cally depart from his private airstrip at sunrise.     An employee at the Las Vegas National Wildlife
On the night prior to the accident, the pilot and      Refuge, reported that on the morning of the acci-
relative checked the weather on the computer           dent, between 0820 and 0840, the weather was
using Direct User Access Terminal (DUATs), and         clear, however, a front was coming in from the
the pilot also contacted flight service for any tem-   east. From 0900 until 1045, the employee noted
porary flight restrictions along the planned route     that the weather was not good. Between 1100 and
of flight. The pilot’s planned route of flight:        1115, the volunteer drove on the loop road, and
depart North Dakota, fuel stop in Pierre, South        at this time, the “fog was heavy.” At approximate-
Dakota, fuel stop in Goodland, Kansas (GLD),           ly 1330, the employee reported the “fog was very
and then to Albuquerque (AEG) [the accident            heavy and visibility was very poor, probably no
flight was the second time the pilot had flown the     more than 30 [meters]. West of the loop road near

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AppendixA                                                                                                     AOPA Air Safety Foundation




                            the exit the employee discovered a portion of the       an altitude of 9,500 feet msl. According to the
                            airplane wreckage on the side of the road.              pilot, as he approached LVS from the south-
                                                                                    west, he began to see what appeared to be a
                            Personal information                                    fairly thin layer of clouds. To maintain clear-
                            The pilot held a private pilot certificate with a       ance over the top of the cloud layer, the pilot
                            third-class medical certificate issued on               initiated a climb. At one point during the
                            November 13, 2000, with the limitation, “Holder         climb, the airplane entered a cloud and rime
                            must wear corrective lenses for distant vision and      ice accumulated on the windscreen, landing
                            possess for near vision while exercising the privi-     gear struts, and [wing] leading edges. He stated
                            leges of his airman certificate.” The most recent       he was in the cloud for approximately 10 sec-
                            flight review was completed on January 8, 2001.         onds, and the accumulation of ice was “quite
                            According to the logbook, the pilot was originally      fast.”
                            issued his private pilot certificate in 1950.
                                                                                    According to an FAA inspector who responded to
                            A review of the private pilot’s logbook revealed        the accident site, the pilot did not receive a for-
                            the private pilot had accumulated approximately         mal weather briefing from an FAA flight service
                            1,884 hours total flight time, of which 82 hours        station on the day of the accident.
                            were in the accident airplane. The date of the last
                            recorded entry in the logbook was May 18, 2002,         Pathological information
                            which was a flight recorded as “Albuquerque—            The pilot’s toxicological tests were negative for
                            Home, stops at Kansas and Pierre South Dakota.”         alcohol, and an unspecified amount of
                            On January 8, 2001, the pilot completed the New-        Diphenhydramine was detected in the kidney
                            Owner Training for the Cirrus SR20                      and liver. The FAA Regional Flight Surgeon stat-
                                                                                    ed, “Diphenhydramine is an antihistamine used
                            Meterorological information                             in the treatment of allergic symptoms. It can
                            At 1153, the LVS Automated Surface Observation          cause significant drowsiness and is not recom-
                            System (ASOS) station, located 8.1 miles north of       mended for use while performing safety-sensi-
                            the accident site, reported the wind from 070           tive activities.”
                            degrees at 11 knots, visibility 10 statute miles,
                            ceiling overcast at 300 feet agl, temperature 32        Testing and research
                            degrees F, dewpoint 29 degrees F, and an altime-        On March 3, 2003, a Garmin GNS 430 GPS, which
                            ter setting of 30.19 inches of mercury.                 was installed in the airplane, was examined by
                                                                                    the manufacturer for data extraction. According
                            At 1253, the LVS ASOS station reported the wind         to Garmin, no data was available from the unit;
                            from 090 degrees at 11 knots, visibility 10 statute     “all Garmin-panel mounted avionics do not store
                            miles, ceiling overcast at 500 feet agl, tempera-       data once power is disconnected from the unit.”
                            ture 34 degrees F, dew point 29 degrees F, and an       In addition, the unit sustained damaged during
                            altimeter setting of 30.19 inches of mercury.           the accident.

                            At 1239, a pirep was submitted by a Piper PA–28         Probable cause
                            aircraft on a flight from Dalhart Municipal             The pilot’s inadvertent flight into instrument
                            Airport (DHT) in Texas, to Sante Fe Municipal           meteorological conditions and failure to main-
                            Airport (SAF) in New Mexico, operating at an            tain clearance with the terrain.
                            altitude of 10,500 feet. The location of the
                            aircraft at the time of the submission was              Factors
                            unknown. The pirep reported the sky was over-           A contributing factor was the pilot’s failure to
                            cast with the layer tops at 10,000 feet msl, the        obtain an updated preflight weather briefing.
                            overcast layer began 20 nautical miles west of
                            DHT to 25 nautical miles southeast of SAF, and          ASF comments
                            no turbulence.                                          VFR into IMC is a bad idea. While forecasts are
                                                                                    sometimes in error, once the pilot actually sees
                            The National Weather Service issued an Airmet at        the clouds ahead, it’s time to divert. A key to the
                            1020, which was valid until 1400 for, “occasional       possibility of clouds is the temperature dew-
                            ceiling below 1,000 feet, visibility below 3 miles in   point spreads. In the Metars there was only a
                            mist, fog. Conditions ending [1200 to 1300].            few degrees spread, which should have alerted
                            Mountains occasionally obscured clouds, mist,           the pilot to the danger. After penetrating the
                            fog. Conditions ending [1300 to 1400].” A written       clouds, a 180-degree turn on autopilot would
                            statement was provided by a pilot who was oper-         have saved a life.
                            ating a Cirrus SR22 airplane over LVS at 1500, at

A-18 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                               AppendixA




CHI03FA057
Date/Time        Aircraft              N Number         Operation         Accident Phase Aircraft
                                                                                         Damage
01/18/2003 Cirrus SR22                 N9523P           Personal          Climb                Destroyed
1838 CST         IO-550-N-7


Injuries         Fatal                 Serious          Minor             None
Crew             1                     0                0                 0
Passengers       1                     0                0                 0
Ground           0                     0                0                 0


Location         Hill City, MN                          Flight Plan       None
Itinerary        Grand Rapids, MN—St. Cloud, MN Runway                    N/A
Airport


Weather          MVFR                  Precipitation    None              Wx Briefing          Yes
Visibility       7                     Clouds           FEW 300 feet Type                      FSS
                                                        BKN 1,400 feet
                                                        OVC 2,700
Wind             320/17                Ceiling          1,400 feet
Gusts            22 kts                Lighting         Night


Experience                             Hours
Certificate      Private               Total            248               Last 90 Days         53
Instrument       None                  Make             19                Last 30 Days         16
Curr. Medical Yes                      Instmt           57



SUMMARY                                                 tions at STC and any pilot reports. There were
Night marginal visual meteorological Conditions         none.
prevailed at the time of the accident.
                                                        Several witnesses reported seeing and/or hearing
The pilot contacted Flight Service at 0455 on the       the aircraft shortly before the accident. An individ-
morning of the accident and requested a VFR             ual who resided 4.5 miles south of Grand Rapids
weather briefing from Grand Rapids Airport (GPZ)        reported seeing an aircraft flying southbound past
to St. Cloud Regional Airport (STC), departing at       his residence. The aircraft appeared to be following
0600. The caller was advised of the current and fore-   the road. He estimated the altitude as 100 feet
cast conditions along the proposed route of flight,     above the trees, and the speed as 150 miles per
as well as of the Airmet in effect at the time.         hour. The engine sound was smooth, it “wasn’t
                                                        laboring” and “that thing was moving.” The weather
The pilot later requested an abbreviated weather        conditions at his location were reported as clear
briefing at 0541. Proposed departure time was           and moon lit.
stated as 0600. During his initial statement to the
briefer, the caller noted that conditions at GPZ        A second individual who resided at the north end
were marginal at the time. He noted that current        of Hill Lake stated that he stepped outside and
conditions at GPZ were about 2,800 feet overcast        saw an airplane come over a hill northeast of his
and that he was “hoping to slide underneath it          home. The aircraft’s flight path appeared to be
and then climb out.” He requested current condi         northeast-to-southwest, passing slightly east of

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AppendixA                                                                                                    AOPA Air Safety Foundation




                            his location. He remarked that he thought the           December 12. The endorsement was limited to SR22
                            aircraft was “too low” and the pilot “better pull       aircraft only, according to the training record.
                            that thing up.” He recalled weather conditions at
                            his location as partly to mostly cloudy, with a fair    Meteorological information
                            amount of moonlight.                                    Routine aviation weather reports (Metars) for air-
                                                                                    ports in the area on the morning of the accident
                            A third individual, located in Hill City reported       were as follows:
                            seeing the airplane following the highway. He
                            added, “If he’d been two blocks east, he’d have hit     Location: Grand Rapids (GPZ) — 20 nautical
                            the water tower,” estimating the altitude as 100        miles north of the accident site
                            feet agl. The engine seemed to be at full throttle      Time: 0635
                            and “wasn’t missing.” “He was going fast,” and          Wind: 320 degrees magnetic at 17 knots, gusting
                            the weather conditions were reported as clear           to 22 knots
                            and cold.                                               Visibility: 7 statute miles
                                                                                    Sky condition: Few clouds at 300 feet agl, broken
                            A fourth individual, located about 1 mile south of      clouds at 1,400 feet agl, and overcast clouds at
                            the accident site, heard the aircraft fly over. He      2,700 feet agl
                            stated that it “sounded like the prop wasn’t catch-     Temperature: Minus 16 degrees C
                            ing any air. It was just screaming.” Approximately      Dewpoint: Minus 21 degrees C
                            3 to 4 seconds after the aircraft flew over, he stat-   Altimeter: 29.85 inches of Mercury
                            ed that he heard what he considered to be the
                            impact. He noted that as he was looking out his         Location: Aitkin Municipal (AIT)—21 nm south of
                            window, he saw a “fireball” up over the trees. He       the accident site
                            recalled the weather conditions at his location as      Time: 0635
                            clear, with a full moon.                                Wind: 310 degrees magnetic at 9 knots, gusting to
                                                                                    17 knots
                            Personal information                                    Visibility: 10 statute miles
                            The pilot, age 47, held a private pilot certificate     Sky condition: Scattered clouds at 2,500 feet agl
                            with an airplane single-engine land rating. He          Temperature: Minus 14 degrees C
                            held a third-class medical certificate issued on        Dew point: Minus 17 degrees C
                            October 28, 2002, with the limitation “Must wear        Altimeter: 29.88 inches of Mercury
                            corrective lenses.”
                                                                                    Location: Brainerd Lakes Regional (BRD)—37
                            The pilot’s logbook was recovered at the scene.         nautical miles south-southwest of the accident
                            According to the logbook, he had logged 248             site
                            hours total time. Of these, 18.9 were in an SR22.       Time: 0636
                            Except for 1 hour in a simulator, the remaining         Wind: 310 degrees magnetic at 10 knots, gusting
                            flights logged were in a Cessna 172 aircraft.           to 16 knots
                                                                                    Visibility: 10 statute miles
                            He had logged a total of 57 hours of instrument         Sky condition: Broken clouds at 2,300 feet agl
                            flight time and 19 hours of night flight time.          Temperature: Minus 16 degrees C
                            Instrument and night flight time in the SR22            Dew point: Minus 19 degrees C
                            totaled 0.3 and 2.3 hours, respectively.                Altimeter: 29.91 inches of Mercury

                            According to Cirrus Design/University of North          Airmets for IFR conditions and turbulence were
                            Dakota records, the pilot completed the SR22            in effect at the time of the accident. An Airmet
                            training course on December 12, 2002. The               called for occasional ceilings below 1,000 feet
                            course consisted of four flights for a total of 12.5    agl and/or visibilities below 3 statute miles in
                            hours of dual flight instruction and 5.3 hours of       light snow showers and blowing snow. IFR con-
                            ground instruction.                                     ditions along the GPZ-STC route of flight were
                                                                                    expected to continue beyond 0900, ending
                            The record indicates a ground lesson, which             around 1200.
                            included “Brief on VFR into IMC procedures,”
                            was completed on the last day of the course. The        An Airmet for occasional moderate turbulence
                            flight lesson titled “IFR Flight (nonrated)” was not    below 8,000 feet msl was issued at 0245, and was
                            conducted.                                              forecast to exist through 1500.

                            A VFR-only completion certificate and high-per-         The winds aloft at 3,000 feet were from 325
                            formance aircraft endorsement were awarded on           degrees at 31 knots, and civil twilight on the

A-20 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                              AppendixA



morning of the accident began at 0720. Sunrise
was at 0754. A full moon occurred at 0448 that         Final radar contact was 0.21 nautical miles from
morning.                                               the accident site, as calculated by the plotting
                                                       program. The magnetic course from the last
Medical and pathological information                   radar location to the site was 278 degrees.
A Forensic Toxicology Fatal Accident Report con-
cerning the pilot found :                              The aircraft’s average ground speed, true airspeed
                                                       and climb/descent rate were computed based on
Ephedrine present in the kidney and liver;             the raw radar data and measured winds aloft. The
Phenylpropanolamine detected in the kidney and         aircraft’s true airspeed averaged 191 knots over
liver; Pseudoephedrine detected in the kidney          the final one minute of radar data. The rate of
and liver.                                             climb averaged 2,500 fpm between the final two
                                                       radar data points. This followed an average
Ephedrine is the active ingredient found in over-      descent rate of 2,000 fpm, 36 seconds earlier,
the-counter decongestants, allergy medications,        between 0636:51 and 0637:03.
asthma medications, and diet pills.
                                                       Probable cause
Pseudoephedrine is the active ingredient found in      Spatial disorientation experienced by the pilot,
common over-the-counter decongestants, such as         because of a lack of visual references, and a fail-
Sudafed.                                               ure to maintain altitude.

Phenylpropanolamine is a metabolite of                 Factors
Ephedrine and Pseudoephedrine. It is an over-the-      Contributing factors were the pilot’s decision to
counter decongestant and appetite suppressant.         attempt flight into marginal VFR conditions, his
Phenylpropanolamine is currently not commer-           inadvertent flight into instrument meteorological
cially available in the United States.                 conditions, the low lighting condition (night) and
                                                       the trees.
Testing and research
The initial radar contact was at 0630:16 over GPZ      ASF comments
at 1,700 feet. The aircraft associated with the bea-   VFR at night is always a challenge in MVFR con-
con code proceeded southbound, paralleling             ditions where an instrument rating and flight
Minnesota Highway 169, and reached a maxi-             plan are recommended. The clear areas and
mum of 3,200 feet.                                     bright moon may have lulled the pilot into a false
                                                       sense of security. “It’s like daylight out here.”
At 0636:51, the target began a descending left         Safety in cross-country flight is found by flying
turn, reaching an altitude of 2,400 feet at 0637:27.   higher. Flying only a few hundred feet agl at high
This was an average descent rate of 1,166 feet-        speed at night is asking for big trouble.
per-minute (fpm). From this location, the target
entered a climb while the radius of the continu-       This pilot was outside of his operating envelope
ing left turn decreased.                               with so little flight time and was on the “fast
                                                       track” with almost a fifth of his total time in the
Final radar contact was at 0637:39 at 2,900 feet.      last 90 days.
This was an average climb rate of 2,500 fpm from
2,400 feet at 0637:27




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AppendixA                                                                                                    AOPA Air Safety Foundation




                            LAX03FA072
                            Date/Time        Aircraft              N Number         Operation        Accident Phase Aircraft
                                                                                                                    Damage
                            01/23/2003 Cirrus SR20                 N893MK           Personal         Approach            Destroyed
                            1653 PST         IO-360-ES-6B


                            Injuries         Fatal                 Serious          Minor            None
                            Crew             1                     0                0                0
                            Passengers       0                     0                0                0
                            Ground           0                     0                0                0


                            Location         San Jose, CA                           Flight Plan      IFR
                            Itinerary        Napa, CA—San Jose, CA                  Runway           31R
                            Airport          Reid-Hillview (RHV)


                            Weather          MVFR                  Precipitation                     Wx Briefing         Yes
                            Visibility       4 sm                  Clouds           BKN 1,200        Type                FSS
                            Wind             280/12                Ceiling          OVC 8,000
                            Gusts            None                  Lighting         Daylight
                            Experience                             Hours
                            Certificate      Private               Total            461              Last 90 Days        85
                            Instrument       Yes                   Make             334              Last 30 Days        UNK
                            Curr. Medical Yes                      Instmt           150

                            SUMMARY                                                 pilot questioned the clearance, and in the subse-
                            A Cirrus SR20 collided with power lines near San        quent exchanges the controller acknowledged his
                            Jose, California. The private pilot/owner was           mistaken belief that the pilot was destined to
                            operating the airplane under Part 91. The air-          PAO and that the flight was actually destined to
                            plane was destroyed, and the pilot, the sole occu-      RHV. The controller asked the pilot from which
                            pant, sustained fatal injuries. The personal cross-     fix he would like to initiate the approach, and the
                            country flight departed Napa County Airport             pilot requested vectors to the approach “around
                            (APC), Napa, California, at 1600, en route to Reid-     OZNUM.” OZNUM is the Final Approach Fix
                            Hillview Airport of Santa Clara County (RHV),           (FAF) on the RHV GPS 31R procedure. The con-
                            San Jose, California. Day instrument meteorolog-        troller issued a clearance direct to OZNUM. After
                            ical conditions prevailed, and an instrument            this exchange, radar indicated the airplane
                            flight rules (IFR) flight plan had been filed.          turned almost 90 degrees to the right, and
                                                                                    tracked on a course consistent with proceeding
                            During the initial portions of the flight after take-   direct to PAO. The controller noticed the course
                            off from Napa, ATC issued numerous radar vec-           deviation, and queried the pilot. The controller
                            tors and altitude assignments to the pilot for traf-    provided no specific headings, but told the pilot
                            fic avoidance purposes. Review of the radar data        to make a right turn to avoid traffic associated
                            disclosed that the pilot complied with all instruc-     with Norman Y. Mineta San Jose International
                            tions. At 1627, when the airplane was approxi-          Airport (SJC), and to proceed to OZNUM, which
                            mately abeam Metropolitan Oakland Inter-                he said was “on the east side of RHV.” The pilot
                            national Airport (OAK), the NCT Saratoga sector         acknowledged and made a right turn of approxi-
                            controller instructed the pilot to proceed to navi-     mately 270 degrees, briefly tracking on an
                            gational fixes near Palo Alto Airport (PAO). The        approximately southbound course, which did not

A-22 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                                AppendixA



appear to be aligned with any relevant naviga-          issued if required to intercept the final approach
tional fix. After approximately 3 miles on that         course. ECYON was not an IAF. Review of the
course, the pilot turned left to a track consistent     radar derived ground track revealed that the
with proceeding direct to OZNUM. The radar              intercept angle was about 40 degrees.
data showed that this ground track resulted in
the airplane flying overhead RHV, on approxi-           While the flight was progressing between ECYON
mately the reciprocal of the final approach             and OZNUM, a controller change occurred at
course, i.e., aligned with RHV, and the fixes           LICKE sector. L1 advised the second controller
OZNUM, then ECYON.                                      (L2) that N893MK was on the approach and the
                                                        only remaining task was to issue a frequency
In his interview, the first NCT LICKE sector con-       change to RHV tower. As the airplane passed just
troller (L1) said he became aware of N893MK             northwest of OZNUM, L2 instructed the pilot to
when he overheard the Saratoga sector controller        contact the tower on frequency “118.6.” This fre-
correcting the pilot’s course to OZNUM. The L1          quency is actually assigned to PAO tower. The
controller said he believed the pilot required          pilot queried the controller if that was actually
extra attention and intended to provide what            correct. The controller insisted, “Yes sir, it is.” The
assistance he could.                                    pilot complied and contacted PAO tower. The
                                                        pilot and the PAO controller discussed that he
Comparing the voice transcripts to the recorded         was on the wrong frequency and the pilot said he
radar data showed that upon the pilot’s initial         would switch to the RHV frequency of 119.8.
contact with the LICKE sector, the airplane had         During this conversation, radar indicated the air-
passed OZNUM, and begun a slight left turn to           plane began a turn to the right, with the first tar-
the east. At this point the pilot had no further        get visibly displaced from the final approach
clearance to follow, since the Saratoga controller      course at 1652:33, approximately over JOPAN
had cleared him direct to OZNUM with the                waypoint. At 1652:50, the pilot reported to RHV
expectation that L1 would provide vector service.       tower “descending from JOPAN two thousand
L1’s initial instruction was for the pilot to pro-      feet five point four miles from missed approach
ceed direct to ECYON; the pilot’s response was to       point.” Radar data agreed with the pilot’s report;
question the fix. According to L1’s statements, he      however, the course had diverged almost 90
recalled that the airplane was in a position coin-      degrees from the final approach course.
cident with a downwind leg, and the turn toward
ECYON would work out to be the same as a vec-           Within 2 seconds of the pilot making initial con-
tor to final. Recorded radar data indicates the air-    tact with RHV tower, the minimum safe altitude
plane was flying a course approximately aligned         warning system (MSAW) provided a visual and
with the initial approach fix ZUXOX. Shortly after      audible alert at the RHV tower and NCT. In
this exchange, L1 noted the airplane appeared to        response to the pilot’s call, the RHV tower con-
begin a left turn towards OZNUM, but he                 troller cleared the pilot to land then said “low
instructed the pilot to turn right toward ECYON         altitude alert, check your altitude immediately.”
in order to remain clear of a higher terrain area.      The MSAW system activates whenever the targets
At this time, OZNUM was directly behind the air-        projected track will encounter higher terrain or
plane, and ECYON at about the four o’clock posi-        when the Mode-C reported altitude is below the
tion. The pilot completed a right turn, briefly fly-    minimum safe altitude for the navigational seg-
ing a course consistent with tracking towards           ment being flown. Based on the radar data, the
OZNUM, then made a slight left turn and flew a          airplane’s projected track was diverging away
course consistent with the published segment            from the centerline of the approach, and toward
between ZUXOX and ECYON. L1 said he                     higher terrain. At the time of the alert the air-
observed the pilot on this course and issued a          plane was at about 1,900 feet; the minimum alti-
clearance for the approach.                             tude for the final segment is 1,440 feet. About 30
                                                        seconds later, the tower controller notified the
FAA Order 7110.65 specifies that Standard               pilot that he appeared off course. The pilot made
Instrument Approach Procedures “shall com-              a brief unintelligible transmission and no further
mence at an Initial Approach Fix or an                  radio or transponder signals were received.
Intermediate Approach Fix if there is not an
Initial Approach Fix. Where adequate radar cov-         The radar track of the airplane was lost in the area
erage exists, radar facilities may vector aircraft to   of high-tension power lines, located 6.7 miles
the final approach course [by assigning] headings       south east of RHV at an altitude of 1,600 feet msl.
that will permit final approach course intercep-        The last radar data with an altitude return was at
tion on a track that does not exceed 30 degrees.”       16:53:40, and showed the airplane at a Mode-C
The order further states that vectors should be         reported altitude of 1,700 feet.

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AppendixA                                                                                                  AOPA Air Safety Foundation




                            Personal information                                  operation prior the impact.
                            A review of FAA airman records revealed that the
                            pilot held a private pilot certificate with an air-   Probable cause
                            plane single-engine land and instrument air-          None issued as of date of publication.
                            plane rating. The pilot was issued a third-class
                            medical on June 8, 2001; with the limitations that    ASF comments
                            the pilot must wear lenses for distant vision, and    While this report is only factual (meaning the
                            possess glasses for near vision.                      NTSB hasn’t issued its final ruling on the case) it
                                                                                  appears to be a case of spatial disorientation
                            An examination of the pilot’s logbook indicated       leading to the impact with power lines and a
                            a total flight time of 460.7 hours of which 362.4     mountain. It is clear that, on this flight, the
                            hours were dual. The pilot had logged his total       pilot’s instrument flying skills were deficient and
                            IFR time as 150.3 hours of which 10.7 hours           that will likely be one of the major causes of the
                            were actual IFR. He had 334 hours in this make        accident.
                            and model; 84.8 hours were logged in the last
                            90 days.                                              However, there may be some clues that indicate
                                                                                  the pilot was having trouble with the technology.
                            The pilot had completed and passed an instru-         The first indication comes from radar data. “The
                            ment airplane checkride on January 6, 2003.           controller issued a clearance direct to OZNUM.
                            The designated examiner (DE) was interviewed          After this exchange, radar indicated the airplane
                            and related the pilot was very detail oriented,       turned almost 90 degrees to the right, and
                            and also very knowledgeable about the Cirrus          tracked on a course consistent with proceeding
                            SR20.                                                 direct to PAO.” The pilot could have programmed
                                                                                  PAO into the GPS before the clearance changed
                            Meteorological conditions                             to OZNUM, and with the autopilot on the aircraft
                            The closest official weather observation station      would have turned to PAO.
                            was Reid-Hillview Airport (RHV), San Jose, locat-
                            ed 6.7 nm northwest of the accident site. A spe-      The second may have happened during the last
                            cial aviation weather report (Metar) for RVH was      moments of the flight. “As the airplane passed
                            issued at 1653. It stated: skies 1,200 feet broken,   just northwest of OZNUM, the controller
                            8,000 feet overcast; visibility 4 miles; winds from   instructed the pilot to contact the tower on fre-
                            280 degrees at 12 knots; temperature 60 degrees       quency 118.6.” This frequency is actually
                            F; dewpoint 59 degrees F; and altimeter 30.24 of      assigned to PAO tower. The pilot queried the con-
                            Mercury.                                              troller if that was actually correct. The controller
                                                                                  insisted, “Yes sir, it is.” The pilot complied and
                            Medical and pathological information                  contacted PAO tower. The pilot and the PAO con-
                            Results for tested drugs were; 0.015 (ug/ml, ug/g)    troller discussed that he was on the wrong fre-
                            Dextromethorphan (cough medicine) detected            quency and the pilot said he would switch to the
                            in blood; Dextromethorphan present in urine;          RHV frequency of 119.8. During this conversa-
                            Dextrorphan detected in blood; Dextrorphan            tion, radar indicated the airplane began a turn to
                            present in urine; Ephedrin detected in urine;         the right, with the first target visibly displaced
                            Phenylpropanolamine detected in blood;                from the final approach course at 1652:33,
                            Phenylpropanolamine present in urine;                 approximately over JOPAN waypoint.” The Cirrus’
                            Pseudoephedrine present in blood;                     control stick is located on the left side of the
                            Pseudoephedrine present in urine; and                 pilot, while the GPS is located on the lower right
                            29.5 (ug/ml, ug/g) Acetaminophen detected             of the pilot. Assuming he was hand-flying the air-
                            in urine.                                             craft, as the pilot interfaced with the GPS on his
                                                                                  right, he could have inadvertently started a right
                            Miscellaneous                                         turn by “leaning” to the right and moving the
                            The airplane was equipped with an emergency           control stick to the right. This is, again, purely
                            ballistic parachute system. The ballistic para-       speculative and the exact cause of the righthand
                            chute system had not been deployed. The safety        turn into the power lines will probably never be
                            pin, which is used to prevent inadvertent deploy-     known. Of all the accidents looked at, this is the
                            ment, was still in place. The safety pin had a tag    only one that might involve the technology.
                            attached to it that is red in color with white let-
                            tering and read, “Safety pin. Remove before           Single-pilot IFR in a busy terminal area, at night,
                            flight.”                                              in IMC is a most demanding task for any pilot—
                                                                                  more so for a pilot with an instrument rating just
                            No abnormalities were found to preclude engine        a few weeks old. Repeated confusion on the part

A-24 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                           AppendixA



of the controller as to the pilot’s intended desti-
nation airport could only serve to increase the
cockpit workload. Navigating with advanced
avionics in a terminal area requires far more
“heads down” work than navigation with the IFR
avionics of a few decades ago. True, more situa-
tional awareness is presented to the pilot with
new-generation moving maps but programming
these devices also contribute to the pilot workload
proportionally. A request to the controller to pro-
vide “vectors to the final approach course” is usu-
ally honored, and might have been the best course
of action in this scenario, if the pilot had any
doubt as to the conduct of his own navigation.




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AppendixA                                                                                                   AOPA Air Safety Foundation




                             MIA04LA070

                             Date/Time        Aircraft             N Number        Operation        Accident            Aircraft
                                                                                                    Phase               Damage
                             04/10/2004 Cirrus SR22                N916LJ          Personal         Climb               Substantial
                             0956 EDT         IO-550


                             Injuries         Fatal                Serious         Minor            None
                             Crew             0                    0               0                1
                             Passengers       0                    0               0                0
                             Ground           0                    0               0                0


                             Location         North Ft. Lauderdale, FL                              Flight Plan         IFR
                             Itinerary        Ft. Lauderdale, FL                   Runway           N/A
                                              West Palm Beach, FL
                             Airport          Ft. Lauderdale Executive (FXE)


                             Weather          IFR                  Precipitation   UNK              Wx Briefing         UNK
                             Visibility       2.5 sm               Clouds          OVC              Type                N/A
                             Wind             270/04               Ceiling         600 feet
                             Gusts            None                 Lighting        Daylight


                             Experience                            Hours
                             Certificate      Private              Total           UNK              Last 90 Days        UNK
                             Instrument       Yes                  Make            UNK              Last 30 Days        UNK
                             Curr. Medical Yes                     Instmt          UNK


                            SUMMARY                                                Control Center and climbing at 800 fpm, the
                            A Cirrus SR22 collided with trees during descent       vertical speed indicator suddenly decreased to
                            near North Lauderdale, Florida, after the pilot        0, then increased to 2,000 fpm, then went back
                            intentionally activated the Cirrus Airframe            to 0. He also reported there was no turbulence
                            Parachute System (CAPS). IMC prevailed at the          encountered during this time. He advised ATC
                            time and an IFR flight plan was filed for the per-     that the flight needed to return, and was vec-
                            sonal flight from Fort Lauderdale Executive            tored heading 270 degrees, and cleared to climb
                            Airport (FXE), Fort Lauderdale, Florida, to Palm       to 2,000 feet. At that point, the altimeter began
                            Beach International Airport (LNA), West Palm           bouncing with very large deflections, then the
                            Beach, Florida. The airplane was substantially         attitude indicator did not agree with the turn
                            damaged and the private-rated pilot, the sole          coordinator. He did not activate the alternate
                            occupant, was not injured. The flight originated       static source, and advised the controller that he
                            about 6 minutes earlier from Fort Lauderdale           was “losing gauges” and he would be unable to
                            Executive Airport.                                     execute an instrument landing system approach
                                                                                   to the departure airport. He then advised the
                            The pilot reported no discrepancies either dur-        controller that he was going to activate the
                            ing the preflight inspection or during the engine      CAPS, and he did. He noted that following the
                            run-up before takeoff. He obtained his IFR             deployment of the CAPS, the emergency locator
                            clearance, and shortly after takeoff the flight        transmitter activated, and his door separated.
                            encountered IMC at 400 feet msl. While commu-          The airplane descended reasonably flat into
                            nicating with the Miami Air Route Traffic              trees, with most of the damage to the airplane

A-26 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                            AppendixA



occurring because of the tree contact and not         ASF comments
the ground contact. He further reported he did        Preliminary. After several years with no proof that
not feel the point of ground contact.                 the BRS would work as advertised, the general
                                                      aviation news media was abuzz with reports that
Preliminary examination of the static system of       successful deployments had occurred under
the airplane revealed the lines contained water       “real-life” circumstances with successful results.
between the static port openings and the alter-       Pitot/static system blockages can easily result in
nate static air valve; the water was retained for     disastrous results. A failed instrument is one
analysis. Additionally, testing of the pitot static   emergency that is difficult to contend with. An
system from the alternate air source to the           instrument that continues to operate yet pro-
altimeter and vertical speed indicator revealed       vides erroneous indications and information is a
no discrepancies with the instruments. Bench          horse of a different color. The pilot in this case
testing of the attitude indicator and turn coor-      admits to not activating the alternate static sys-
dinator revealed no evidence of failure or mal-       tem. This might or might not have alleviated the
function.                                             erroneous indications depending on the amount
                                                      of water in the static system and the location of
Probable cause                                        the water. Did this emergency situation warrant
Not available at time of publication.                 deployment of the BRS? That decision alone was
                                                      for the pilot-in-command to make. He elected to
                                                      activate it and successfully walked away from the
                                                      experience. That is the intent of the BRS.




                                                                       Technically Advanced Aircraft | www.aopa.org/safetycenter A-27
AppendixA                                                                                                   AOPA Air Safety Foundation




                             ATL04FA096

                             Date/Time        Aircraft             N Number        Operation        Accident               Aircraft
                                                                                                    Phase                  Damage
                             04/19/2004 Cirrus SR20                N8157J          Business         Climb                  Destroyed
                             1400 EDT         IO-360


                             Injuries         Fatal                Serious         Minor            None
                             Crew             1                    0               0                0
                             Passengers       3                    0               0                0
                             Ground           0                    0               0                0


                             Location         Greenwood, SC                                         Flight Plan            None
                             Itinerary        UNK                                                   Runway                 27
                             Airport


                             Weather          VFR                  Precipitation   None             Wx Briefing            UNK
                             Visibility       10 sm                Clouds          None             Type                   N/A
                             Wind             240/10               Ceiling         Clear
                             Gusts            21                   Lighting        Daylight


                             Experience                            Hours
                             Certificate      Private              Total           UNK              Last 90 Days           UNK
                             Instrument       UNK                  Make            UNK              Last 30 Days           UNK
                             Curr. Medical UNK                     Instmt          UNK



                            SUMMARY                                                Another witness playing golf at a local golf course
                            A private pilot on a cross-country flight observed     located off the departure end of Runway 27 heard
                            the accident airplane taxi and depart from             the sound of an airplane engine sputtering and
                            Runway 27. The takeoff roll was long and the air-      observed the airplane spinning to the ground in a
                            plane lifted off the ground in “ground effect.” The    nose-down attitude to the left. The airplane made
                            observer believed that the pilot was “showing off,”    about two to three turns to the left before it col-
                            and thought the airplane was going to collide with     lided with trees and the ground and burst into
                            the trees off the departure end of the runway. The     flames.
                            nose of the airplane was observed to “pitch
                            straight up and the airplane stalled.” The left wing   Probable cause
                            dropped and the airplane spiraled down to the left     Not available at time of publication.
                            in a nose-down attitude until it disappeared from
                            view. He heard an impact sound and then                ASF comments
                            observed black smoke come up above the trees.          Preliminary—departure stall for unknown rea-
                                                                                   sons.
                            An airframe and power plant mechanic at the air-
                            port observed the accident airplane taxi to
                            Runway 27 with both doors open and the flaps in
                            the retract position. The airplane was observed to
                            depart without conducting an engine run-up.



A-28 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                           AppendixA




CHI04FA255

Date/Time        Aircraft            N Number        Operation        Accident Phase Aircraft
                                                                                     Damage
9/10/2004        Cirrus SR22         N1223S          Personal         Approach               Destroyed
1200 CDT         IO-550


Injuries         Fatal               Serious         Minor            None
Crew             1                   1               0                0
Passengers       0                   0               0                0
Ground           0                   0               0                0


Location         Park Falls, WI                      Flight Plan      None
Itinerary        Sheboygan, WI—Duluth, MN            Runway           18
Airport          Park Falls, WI (PKF)


Weather          VFR                 Precipitation   None             Wx Briefing            UNK
Visibility       10                  Clouds          Clear            Type                   UNK
Wind             170/15              Ceiling         N/A
Gusts            18                  Lighting        Daylight


Experience                           Hours
Certificate      UNK                 Total           UNK              Last 90 Days           UNK
Instrument       UNK                 Make            UNK              Last 30 Days           UNK
Curr. Medical UNK                    Instmt          UNK



SUMMARY                                              Probable cause
A Cirrus SR22, piloted by a private pilot and a      Not available at time of publication.
certified flight instructor, was destroyed when it
impacted a river near Park Falls, Wisconsin. The     ASF comments
airplane came to rest in the Flambeau River          Preliminary.
about 1,000 feet from the approach end of
Runway 18 at Park Falls Municipal Airport (PKF).
The pilot was fatally injured and the flight
instructor received serious injuries. The airplane
departed Sheboygan County Memorial Airport
(SBM), Sheboygan, Wisconsin, at an unconfirmed
time. The airplane’s final intended destination
was Duluth International Airport (DLH), Duluth,
Minnesota.




                                                                      Technically Advanced Aircraft | www.aopa.org/safetycenter A-29
AppendixA                                                                                                 AOPA Air Safety Foundation



                             LAX04LA324

                             Date/Time        Aircraft           N Number        Operation       Accident             Aircraft
                                                                                                 Phase                Damage
                             09/19/2004 Cirrus SR22              N931CD          Personal        Cruise               Substantial
                             1550 PDT         I0-550


                             Injuries         Fatal              Serious         Minor           None
                             Crew             0                  0               0               1
                             Passengers       0                  0               0               1
                             Ground           0                  0               0               0


                             Location         Peters, CA                         Flight Plan     IFR (not activated)
                             Itinerary        Redding, CA—El Cajon, CA           Runway          N/A
                             Airport          N/A


                             Weather          VFR                Precipitation   None            Wx Briefing          UNK
                             Visibility       8                  Clouds          BKN 3,200       Type                 N/A
                             Wind             050/12             Ceiling         BKN 3,200
                             Gusts            18                 Lighting        Daylight


                             Experience                          Hours
                             Certificate      Commercial         Total           UNK             Last 90 Days         UNK
                             Instrument       Yes                Make            UNK             Last 30 Days         UNK
                             Curr. Medical UNK                   Instmt          UNK



                            SUMMARY                                              plane appeared to enter a spin. The pilot deter-
                            A Cirrus SR22 contacted trees in a walnut orchard    mined that the airplane would be in the overcast
                            during an emergency descent near Peters,             cloud layer before he could recover and decided
                            California. Following an encounter with weather      to activate the CAPS. The CAPS deployment was
                            and a loss of control, the pilot deployed the        successful; the airplane broke out of the clouds
                            Cirrus Airframe Parachute System (CAPS) about        about 2,500 feet above ground level (agl), and
                            16,000 feet mean sea level (msl), and the airplane   landed in a walnut grove.
                            made a parachute landing into the orchard. The
                            instrument-rated commercial pilot and single         Convective Sigmet 49W was active in the vicinity
                            passenger were not injured; the airplane was sub-    where the airplane landed. Convective Sigmet
                            stantially damaged. Instrument meteorological        49W stated that there was a line of severe thun-
                            conditions prevailed and an instrument flight        derstorms 30 nm wide moving from 300 degrees
                            plan had been filed but not activated. The flight    magnetic at 15 knots with cloud tops to 27,000
                            originated at Redding, California, at 1500.          feet; hail up to 1 inch in diameter; and wind
                                                                                 gusts up to 50 knots were possible. At 2305 UTC,
                            The pilot reported to the NTSB that he was           weather radar showed intense (Level 5) thun-
                            passing through 14,000 feet msl with the autopi-     derstorms in the vicinity of the accident with
                            lot set at 100 fpm rate of climb. He and his pas-    the severity increasing to extreme (Level 6) by
                            senger were using supplemental oxygen. There         2320 UTC.
                            was a broken cloud layer 1,500 feet below the
                            airplane and he was in visual meteorological         Examination of Los Angeles Center radar records
                            conditions steering east to avoid some weather.      revealed that N931CD, up to 2304:47 UTC, was at
                            He heard a “whirring” sound in his headset and       16,300 feet and climbing steadily at 100 fpm.
                            the nose pitched up. He disconnected the             From 2305:15 to 2305:38 UTC, the airplane
                            autopilot; the left wing dropped and the air-        descended from 16,300 feet to 15,200 feet. From

A-30 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                          AppendixA



2305:43 to 2305:57 UTC, the airplane ascended        of thunderstorms while taking off and landing
from 15,400 feet to 16,700 feet. After the time of   but giving them a wide berth en route is equally
2305:57 UTC, the airplane descended steadily at      important. Many commercial operators provide
ground speeds between 75 and 18 knots, down to       specific guidance as to how close to a thunder-
7,700 feet, at which point the radar data file       storm a pilot may operate. (Usually not closer
stopped (2309:43 UTC).                               than 5 miles at altitudes between 10,000 and
                                                     20,000.) Merely staying clear of the building
Probable cause                                       cumulonimbus isn’t enough. Turbulence and
Not available at time of publication.                hail often exist in clear air in the vicinity of
                                                     thunderstorms. Hail in clear air is particularly
ASF comments                                         prevalent downwind of the direction of travel
Preliminary. Operating near maximum altitude         of the cell or beneath the anvil shaped overhang
capability for this airplane, the pilot had few      of a large cumulonimbus. The pilot’s decision
options when he lost control and entered a           to not attempt stall/spin recovery IMC was wise.
stall/spin. Level 5 thunderstorms lurked nearby.     He was fortunate to have the BRS on board,
At the time of the accident, they were increasing    but unfortunate to have gotten himself into a
in severity to Level 6. (Extreme!) Much educa-       situation where it was the only way out!
tion is directed at not operating in the vicinity




                                                                     Technically Advanced Aircraft | www.aopa.org/safetycenter A-31
AppendixA                                                                                                   AOPA Air Safety Foundation




                             SEA05FA023

                             Date/Time        Aircraft            N Number        Operation         Accident Phase Aircraft
                                                                                                                   Damage
                             12/04/2004 Cirrus SR22               N1159C          Personal          Maneuvering          Destroyed
                             1530 MST         IO-550


                             Injuries         Fatal               Serious         Minor             None
                             Crew             1                   0               0                 0
                             Passengers       2                   0               0                 0
                             Ground           0                   1               0                 0


                             Location         Bozeman, MT         Flight Plan     None
                             Itinerary        Bozeman, MT (local)                 Runway            N/A
                             Airport          N/A


                             Weather          VFR                 Precipitation   None              Wx Briefing          UNK
                             Visibility       10 sm               Clouds          BKN               Type                 N/A
                             Wind             210/03              Ceiling         12,000
                             Gusts            None                Lighting        Daylight


                             Experience                           Hours
                             Certificate      Commercial          Total           None              Last 90 Days         None
                             Instrument       UNK                 Make            UNK               Last 30 Days         UNK
                             Curr. Medical UNK                    Instmt          UNK


                            SUMMARY                                               remained on the tower frequency and heard the
                            A Cirrus SR22 impacted mountainous terrain            airplane depart. The pilots of both aircraft then
                            while maneuvering about 12 miles northeast of         tuned their radios to an air-to-air frequency and
                            Bozeman, Montana. The commercial pilot and            established communications.
                            two of the three passengers were killed. The other
                            passenger received serious injuries. The airplane,    The motorglider had shut down and stowed his
                            which was registered to Flightline Fractionals Inc.   engine and was soaring north along the western
                            and operated by the pilot, was destroyed. VMC         edge of the Bridger mountain range nearing
                            prevailed, and no flight plan was filed for the       Sacagawea Peak. The airplane made one pass
                            local flight. The airplane departed from Gallatin     above the glider, circled, and made a second pass
                            Field (BZN), Bozeman, Montana, at 1518.               above and to the left of the glider. When the air-
                                                                                  plane passed over the glider, it was “in coordinat-
                            At the time of the accident, a motorglider was fly-   ed flight,” with the flaps up, and it was either fly-
                            ing near the area where the accident occurred.        ing level or descending slightly. The glider pilot
                            The pilot of the motorglider was interviewed by       watched the airplane continue heading north
                            the NTSB investigator and reported that he was        “straight out in front of him” for about 5 to 10
                            giving a ride to a friend of the pilot of the acci-   seconds. Since the glider was losing lift, the glider
                            dent airplane. Prior to departing from Gallatin       pilot then made a turn to the south.
                            Field, the motorglider pilot spoke with the pilot
                            of the accident airplane, who told him that he        At the time the glider pilot last saw the airplane,
                            would get the airplane out, takeoff, catch up with    it was heading towards a transverse “foothills
                            the glider and make some “flybys” of the glider.      ridge” that runs downward from the summit of
                            The motorglider pilot said that after takeoff, he     Sacagawea Peak (elevation about 9,600 feet)

A-32 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                              AppendixA



towards the west and then hooks toward the             The surviving passenger was interviewed in the
south. There is a peak (elevation about 8,800          hospital by FAA inspectors and reported that the
feet) on the transverse ridge at the point where       airplane came up on the left side of the motor-
it hooks south. According to the glider pilot, this    glider. According to the passenger, the pilot of
ridge is unique compared to the rest of the            the airplane started a turn and tried to slow the
transverse ridges coming off the crest of the          airplane down. The pilot attempted to lower the
Bridgers in that it “does not fall away like the       flaps and said the flaps were “not working.” At
rest of the foothills.” The combination of the         this point, the passenger heard the airplane’s
crest of the Bridger range and this transverse         stall warning horn, which he described as “very
ridge form a cirque or bowl that is open to the        loud.” The pilot added full power and told the
south and has high terrrain to the west, north,        passengers to “hold on.” The airplane then went
and east.                                              into the trees.

After gaining altitude, the glider pilot turned back   Probable cause
to the north. He then saw a column of black            Not available at time of publication.
smoke, which was later identified as being from
the crash site. The column of smoke was located        ASF comments
just south of the 8,800-foot-peak on the trans-        Preliminary. This, in all probability, will be cate-
verse ridge. The glider pilot estimated it was 5 to    gorized as the pilot failing to avoid terrain while
10 minutes between the time he last saw the air-       distracted. These accidents, while not common,
plane and the time he turned back north and            are relatively predictable when pilots who are not
spotted the smoke. The glider pilot reported that      used to flying formation or on photo flights, do
the weather was clear blue sky, no turbulence,         not take appropriate precautions. There appears
“no sucking downdrafts,” but some “down air” in        to be nothing relative to TAA that would be con-
the area where he last saw the airplane.               sidered a cause or factor in this accident.




                                                                         Technically Advanced Aircraft | www.aopa.org/safetycenter A-33
AppendixA                                                                                                   AOPA Air Safety Foundation




                            IAD05FA032

                            Date/Time        Aircraft            N Number         Operation        Accident             Aircraft
                                                                                                   Phase                Damage
                            01/15/2005 Cirrus SR22               N889JB           Personal         Climb                Destroyed
                            1223 EST         IO-550N


                            Injuries         Fatal               Serious          Minor            None
                            Crew             1                   0                0                0
                            Passengers       0                   0                0                0
                            Ground           0                   0                0                0


                            Location         Coconut Creek, FL                    Flight Plan      IFR
                            Itinerary        Ft. Lauderdale, FL—Naples, FL        Runway           N/A
                            Airport


                            Weather          IMC                 Precipitation    None             Wx Briefing          UNK
                            Visibility       10                  Clouds           OVC              Type                 N/A
                            Wind             340/04              Ceiling          600 feet
                            Gusts            None                Lighting         Daylight


                            Experience                           Hours
                            Certificate      Commercial          Total            483              Last 90 Days         UNK
                            Instrument       Yes                 Make             405              Last 30 Days         UNK
                            Curr. Medical Yes                    Instmt           76



                            SUMMARY                                               subsequently made one more left turn, through
                            A Cirrus SR22 was destroyed when it impacted a        north, to the northwest, and its last altitude
                            house, then terrain, in Coconut Creek, Florida.       readout, at 1223:17, was 1,100 feet. The last
                            The certificated commercial pilot was fatally         radar contact was about 500 feet southeast of
                            injured. Instrument meteorological conditions         the accident site.
                            prevailed, and the airplane was operating on an
                            IFR flight plan from Fort Lauderdale Executive        A review of air traffic control transmissions
                            Airport (FXE) to Naples Municipal Airport (APF)       revealed:
                            and back to Fort Lauderdale Executive.
                                                                                  At 1219:13, the pilot stated, “(blocked), Cirrus
                            Preliminary radar and transponder data                November-Eight-Eight-Nine-Juliet-Bravo is
                            revealed that after the airplane departed FXE,        through a thousand, ah (blocked).”
                            climbed to the northwest to 1,600 feet, then
                            began a right turn toward the northeast. The air-     At 1219:59, the controller responded, “Eight-
                            plane then climbed to 1,800 feet, continued the       Eight-Niner-Juliet-Bravo you’re radar contact,
                            right turn, and once on a southeast heading,          turn left heading Two Seven Zero.” The pilot then
                            descended to 1,000 feet. Subsequently, the air-       responded with: “ah, Two Seven Zero, Nine Zero,
                            plane turned left, and headed northeast, climb-       ah, Nine-Juliet-Bravo.
                            ing to 1,900 feet. It then made a right turn to the
                            south, and descended to 400 feet during a 12-         At 1220:07, the controller stated (to another
                            second period, followed by a climb to 1,400 feet      pilot), “Seven Eight Five, turn right, heading Zero
                            during the next 12-second period. The airplane        Niner Zero.”

A-34 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                              AppendixA



At 1220:11, an unidentified voice, similar to the      pilot responded, “Zero Nine Zero, Seven-Eight-
accident pilot’s, responded, “Ah, did you say a        Kilo.”
right turn to Two Seven Zero?”
                                                       At 1221:32, the controller stated, “Cirrus Niner-
At 1220:15, the controller stated, “Turn right Zero    Juliet-Bravo, climb and maintain two thousand,
Niner Zero Seven Eight Five.”                          over.”

The pilot from that airplane did not respond.          At 1221:36, the pilot responded, “Climbing to two
                                                       thousand (pause), and you happen (transmission
At 1220:21, the controller stated, “Three Six Seven    cut off).”
Eight Five, turn right heading Zero Niner Zero.”
                                                       At 1221:41, the controller stated, “November-
At 1220:27, there was a sound similar to two           Niner-Juliet-Bravo, just continue on a ninety
pilots blocking each other’s transmissions.            heading, heading Zero Niner Zero. I’m trying to
                                                       get you away from a Cessna.”
At 1220:30, the controller stated, “Eight-Juliet,
correction, Niner-Juliet-Bravo, turn left, Two         There was no response from the pilot.
Seven Zero.”
                                                       At 1221:51, the controller stated, “November-Niner-
At 1220:34, the pilot responded, “Two Seven Zero       Juliet-Bravo, fly heading Zero Niner Zero, over.”
for Nine-Juliet-Bravo.”
                                                       There was no response from the pilot.
At 1220:37, the controller stated, “Turn now
please.”                                               At 1222:00, the controller asked, “November-
                                                       Eight-Eight-Niner-Juliet-Bravo, how do you hear,
At 1220:39, the controller stated, “November-Six-      over?”
Niner-Xray, turn left, heading One Five Zero,” and
that pilot responded with: “One Five Zero, Six-        At 1222:05, the pilot responded, “I’m hearin’ ya.
Niner-Xray.”                                           I’m hearin’ ya. I’m, I’m, I gotta get, ah, my act
                                                       together here.”
At 1220:44, the controller stated, “November-
Nine-Juliet-Bravo, turn left, heading Two Seven        At 1222:12, the controller stated, “November-
Zero, two seventy the heading Niner-Juliet-Bravo.      Niner-Juliet-Bravo, fly heading Zero Niner Zero. I
you’ve turned the wrong way.”                          have aircraft off your left, will be on the approach
                                                       at Pompano. Just fly a ninety heading, climb, and
At 1220:51, the pilot responded, “You told me to       maintain two thousand.”
turn ninety; I’m turning back to two seventy
now.”                                                  There was no answer from the pilot.

At 1220:54, the controller stated, “Negative sir,      At 1222:30, the controller stated, “Seven-Eight-
that was for a Seven Eight Five. November-Niner-       Kilo, turn left, Three Six Zero, it’s going to be a
Juliet-Bravo, continue in the turn heading of Zero     short vector, I’ve got a Cirrus disorientated out to
Niner Zero. Traffic alert. Traffic eleven o’clock,     the of, ah, east of you. I have to get him under
one mile, indicates two thousand, he’s south-          control again.” That pilot responded, “Three Six
bound.”                                                Zero, Seven-Eight-Kilo.”

At 1221:08, the pilot responded, “Zero Nine Zero       At 0222:39, the controller stated, “Thank you.
on the heading, Nine-Juliet-Bravo.”                    November-Seven-Eight-Five, turn right, heading
                                                       One Eight Zero. This will be vectors across the
At 1221:15, the controller stated, “November-          localizer for aircraft that’s just going to be coming
Niner-Juliet-Bravo, just continue on a ninety          across Pompano at two thousand feet.” There
heading. November-Six-Niner-Xray, turn right,          was no response from that pilot.
heading of Zero, correction, turn right, heading
Two Seven Zero.” That pilot responded, “Two            At 1222:53, the controller asked, “Cirrus Eight-
Seven Zero, Six Niner X.”                              Eight-Niner-Juliet-Bravo, Miami, how do you
                                                       hear?”
At 1221:25, the controller stated, “November-
Seven-Eight-Kilo, turn left, turn left, heading Zero   At 1222:57, the pilot responded, “I hear you, but I’ve
Niner Zero, maintain three thousand,” and the          got, I’ve got problems, I’ve got avionics problems.”

                                                                         Technically Advanced Aircraft | www.aopa.org/safetycenter A-35
AppendixA                                                                                                         AOPA Air Safety Foundation




                            At 1223:03, the controller stated, “Cirrus Niner-          According to certificates found in his logbook, the
                            Juliet-Bravo, Roger. Do you have a gyro?”                  pilot obtained his private pilot certificate on June 1,
                                                                                       2003, his instrument rating on October 6, 2003, and
                            At 1223:09, the pilot responded, “I’m trying to get        his commercial certificate on March 25, 2004.
                            the plane, ah, level, Nine-Juliet-Bravo.”
                                                                                       The pilot had logged 483 hours of flight time,
                            At 1223:13, the controller asked, “OK, November-           with 405 hours between two SR22s. He began fly-
                            Niner-Juliet-Bravo, do you see the ground?”                ing the first SR22, N97CT, on June 5, 2003, and
                                                                                       logged 304 hours in it. He began flying the acci-
                            At 1223:18, the pilot responded, “Negative, I do           dent SR22 on June 2, 2004.
                            not see the ground, Nine-Juliet-Bravo.”
                                                                                       The pilot had also logged a total of 15 hours of
                            At 1223:21, the controller asked, “All right, you          actual instrument time, and 61 hours of simulat-
                            have your wings level?”                                    ed instrument time. His last flight before the acci-
                                                                                       dent flight was 1.6 hours on January 7, 2005, in
                            At 1223:23, the pilot responded, “The wings are            which he also logged one instrument approach
                            level, Nine-Juliet-Bravo.”                                 and 0.2 hours of actual instrument time.

                            At 1223:26, the controller asked, “November-               On December 30, 2004, the pilot logged a flight in
                            Niner-Juliet-Bravo, Roger, do you have a direc-            which he flew two ILS, one VOR, and one GPS
                            tional gyro?”                                              approach. According to the flight instructor on
                                                                                       that flight, one of the approaches was flown par-
                            At 1223:30, the pilot stated, “I’m losin’, I’m losin’ it   tial panel, without the PFD. The flight instructor
                            again here.”                                               also noted that it wasn’t the first time they had
                                                                                       practiced partial panel; they had done it a num-
                            There were no further transmissions from the pilot.        ber of times previously.

                            A witness, an airline transport pilot who was at a         The pilot’s latest FAA first-class medical certifi-
                            park near the accident site, reported that he heard        cate was issued on April 16, 2004.
                            the airplane flying southeast at a very low altitude.
                            He looked up, but couldn’t see it through the low          Aircraft information
                            overcast and mist. The airplane didn’t sound like it       The airplane was manufactured in 2004, and was
                            had any engine problems, but as it flew farther            the second Cirrus SR22 that the pilot’s company
                            away, it sounded as if it was maneuvering.                 had owned. The airplane was equipped with an
                                                                                       Avidyne FlightMax Entrega-Series Primary Flight
                            A second witness, who was outside his home                 Display (PFD). Information provided by the PFD
                            near the accident site, stated that he heard an air-       included airplane attitude, airspeed, heading and
                            plane above the clouds that sounded like it was            altitude, a horizontal situation indicator, and a
                            conducting acrobatics, climbing and descending.            vertical speed indicator.
                            Suddenly, it descended out of the clouds, then
                            banked and headed back up into the clouds in               According to maintenance records, the PFD had
                            northeasterly direction. As it ascended, the wit-          been replaced on June 4, 2004, at 12.2 hours, on
                            ness heard “an rpm change, like it was climbing.”          September 14, 2004, at 55.2 hours, and on
                            The witness then heard the engine get louder, fol-         December 20, 2004, at 80.6 hours.
                            lowed by the sound of an explosion. The witness
                            did not see the airplane exit the clouds a second          Below the PFD, on a “bolster panel” in front of
                            time due to trees in his line of sight.                    the pilot, were backup altimeter, airspeed, and
                                                                                       attitude indicators, to be used “in case of total or
                            Another witness, who did see the airplane                  partial PFD failure.”
                            descend from the clouds the second time, stated
                            that when it did so, the airplane was perpendicu-          The airplane was also equipped with a Cirrus
                            lar to the ground, “but on a slant.”                       Airplane Parachute System (CAPS).

                            The accident occurred during daylight hours, in            According to the Cirrus SR22 Pilot’s Operating
                            the vicinity of 26 degrees, 15.5 minutes north lati-       Handbook: “CAPS [is] designed to bring the air-
                            tude, 080 degrees, 10.4 minutes west longitude.            craft and its occupants to the ground in the event
                                                                                       of a life-threatening emergency. The system is
                            Personal information                                       intended to save the lives of the occupants but will
                            The pilot held a commercial pilot certificate.             most likely destroy the aircraft and may, in adverse

A-36 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                              AppendixA



circumstances, cause serious injury or death to the    The engine sustained impact damage. The three-
occupants.                                             bladed propeller, and the front of the engine,
                                                       including the crankshaft to just aft the number-6
CAPS is initiated by pulling the activation T-         connecting rod, were separated from the rest of
handle installed in the cabin ceiling on the air-      the engine and buried in the ground. One of the
plane centerline just above the pilot’s right          propeller blades was broken off about 5 inches
shoulder. A placarded cover, held in place with        from the hub, another blade exhibited deep
hook and loop fasteners, covers the T-handle           chordwise scratching, and the third was bent aft.
and prevents tampering with the control. The
cover is removed by pulling the black tab at the       There was no evidence of any pre-impact anom-
forward edge of the cover. Pulling the activation      aly to either the engine or airframe. All flight
T-handle removes it from the O-ring seal that          instruments were destroyed in either the ground
holds it in place and takes out the approximate-       impact or the post-impact fire.
ly 6 inches of slack in the cable connecting it to
the rocket. Once this slack is removed, further        The CAPS parachute bag extended, by attached
motion of the handle arms and releases a firing        risers, about 40 feet from the wreckage, and came
pin, igniting the solid-propellant rocket in the       to rest in front of a fence. The parachute was still
parachute canister.”                                   in the parachute bag. The CAPS cover was locat-
                                                       ed near the airplane, and exhibited a circular
There were no flight data or cockpit voice record-     impact mark on the inside, consistent with rocket
ing devices installed on the airplane.                 activation. The squib had also been fired. The
                                                       rocket motor and lanyard were found near the
Meteorological information                             parachute bag.
Fort Lauderdale Executive Airport was located
about 4 miles to the south of the accident site.       The CAPS T-handle safety pin was found in the
Weather, recorded there at 1153, included winds        wreckage, away from the T-handle, with its red
from 340 degrees true at 4 knots, surface visibility   safety flag wrapped around it. The T-handle was
10 statute miles, and an overcast cloud layer at       found pulled out of its housing by about 2 1/2
600 feet.                                              inches; however, it could not be determined if the
                                                       pilot had pulled it, or if it had been displaced by
Weather, recorded at 1253, included winds from         impact forces.
310 degrees true, at 5 knots, surface visibility 5
statute miles, light rain and mist, and an overcast    Probable cause
cloud layer at 600 feet.                               Not available at the time of publication.

Wreckage and impact information                        ASF comments
The airplane’s wreckage was located in a back-         Preliminary. It appears that the pilot was disori-
yard of one house, next to another house. The          ented and having difficulty in maintaining con-
right wing tip was broken off in the roof of the       trol. The failure of either a PFD or backup instru-
second house. The wreckage, which displayed no         mentation is always a possibility. The odds of
ground impact marks consistent with forward            having both fail simultaneously are very small.
motion, was consumed in a post-impact fire.            Additionally, assuming the autopilot is still func-
                                                       tioning, this would be an excellent alternative to
All flight control surfaces were accounted for at      hand flying until the problem is resolved. It’s
the scene, and control cable continuity was con-       worth noting that the PFD had been replaced
firmed from the cockpit, to where all flight sur-      three times on this aircraft in the preceeding
face attach points would have been.                    months.




                                                                         Technically Advanced Aircraft | www.aopa.org/safetycenter A-37
AppendixA                                                                                                   AOPA Air Safety Foundation




                             SEA05FA038

                             Date/Time        Aircraft           N Number        Operation         Accident              Aircraft
                                                                                                   Phase                 Damage
                             01/20/2005 Cirrus SR22              N6057M          Personal          Cruise                Destroyed
                             2020 PST         IO-550N


                             Injuries         Fatal              Serious         Minor             None
                             Crew             1                  0               0                 0
                             Passengers       2                  0               0                 0
                             Ground           0                  0               0                 0


                             Location         Hood River, OR                     Flight Plan       Yes (Not activated)
                             Itinerary        Salem, OR—Hood River, OR           Runway            N/A
                             Airport          N/A


                             Weather          IMC                Precipitation   UNK               Wx Briefing           UNK
                             Visibility       5 sm               Clouds          UNK               Type                  N/A
                             Wind             UNK                Ceiling         UNK
                             Gusts            UNK                Lighting


                             Experience                          Hours
                             Certificate      UNK                Total           UNK               Last 90 Days          UNK
                             Instrument       UNK                Make            UNK               Last 30 Days          UNK
                             Curr. Medical UNK                   Instmt          UNK




                            SUMMARY                                              Probable cause
                            A Cirrus SR22 was destroyed following impact         Not available at time of publication.
                            with terrain near Hood River, Oregon. The com-
                            mercial pilot and his two passengers were fatally    ASF comments
                            injured. The airplane departed McNary Field          Preliminary. The crash site is on a ridge about 6
                            (SLE) Salem, Oregon, at 1951, and was flying         miles west at about the 2,000 feet level. The
                            VFR to Ken Jernstedt Airfield (4S2) Hood River,      ridges along the Columbia River gorge in this
                            Oregon. Several pilots at Ken Jernstedt Airfield,    area are typically shrouded in stratus this time of
                            Hood River, Oregon, said the weather was             year. This is a common area for VFR into IMC
                            instrument meteorological conditions at the          accidents. In fact, a similar accident occurred
                            time of the accident.                                about 15 years previous, just 500 feet higher up
                                                                                 the ridgeline.
                            Air Traffic Control at Salem, Oregon, said that
                            the airplane departed at 1951. Seattle Air Route
                            Traffic Control Center said that its last radar
                            return from the airplane was over Cascade
                            Locks, Oregon, at 2014; the airplane was at 2,000
                            feet. Search and rescue personnel located the
                            airplane on January 21, at approximately 1700.


A-38 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                              AppendixA




LAX05FA088
Date/Time         Aircraft              N Number        Operation        Accident            Aircraft
                                                                         Phase               Damage
02/06/2005 Cirrus SR22                  N286CD          Personal         Cruise              Destroyed
1820 PST          IO-550N


Injuries          Fatal                 Serious         Minor            None
Crew              1                     0               0                0
Passengers        0                     0               0                0
Ground            0                     0               0                0


Location          Truckee, CA                           Flight Plan      IFR
Itinerary         Reno, NV—Novato, CA                   Runway           N/A
Airport           N/A


Weather           IMC                   Precipitation   Snow/Ice         Wx Briefing         UNK
Visibility        UNK                   Clouds          BKN              Type                UNK
Wind              240/06                Ceiling         OVC
Gusts             None                  Lighting        Night


Experience                              Hours
Certificate       Private               Total           473              Last 90 Days        100
Instrument        Yes                   Make            69               Last 30 Days        39
Curr. Medical Yes                       Instmt




SUMMARY                                                 ASF comments
Not available. Initial reports indicate that the air-   Preliminary. At 16,000 feet there will not be much
craft was in cruise flight at 16,000 feet msl when      climb performance left. Engine power output will
the pilot reported that he was taking on ice and        be significantly reduced and any residual ice on
going down. The aircraft had departed Reno,             unprotected parts of the airframe will decrease
Nevada, for Novato, California. This Cirrus was         airspeed and possibly increase stall speed. The
equipped with a TKS “weeping-wings” deicing             TKS system on the Cirrus is not approved for
system. It appears that the parachute was               flight into icing conditions.
deployed, but was found separately from the
main wreckage.

Probable cause
Not available at time of publication.




                                                                         Technically Advanced Aircraft | www.aopa.org/safetycenter A-39
AppendixA                                                                                                    AOPA Air Safety Foundation




                             Cessna 182 Accidents
                             LAX01FA003

                             Date/Time        Aircraft              N Number         Operation        Accident            Aircraft
                                                                                                      Phase               Damage
                             10/04/2000 Cessna 182S                 N2373D           Business         Initial Climb       Destroyed
                             0931 PDT         IO-540-AB1A5


                             Injuries         Fatal                 Serious          Minor            None
                             Crew             1                     0                0                0
                             Passengers       0                     0                0                0
                             Ground           0                     0                0                0


                             Location         Santa Rosa, CA                         Flight Plan      IFR
                             Itinerary        Santa Rosa, CA—Concord, CA             Runway           19
                             Airport          Sonoma County (STS)


                             Weather          IFR                   Precipitation                     Wx Briefing         None
                             Visibility       6 sm                  Clouds           OVC              Type                N/A
                             Wind             Calm                  Ceiling          600 feet
                             Gusts            N/A                   Lighting         Day


                             Experience                             Hours
                             Certificate      Private               Total            600              Last 90 Days        UNK
                             Instrument       Yes                   Make             UNK              Last 30 Days        UNK
                             Curr. Medical Yes                      Instmt           UNK



                                                                                     At 0929:29, radio contact was established as the
                            SUMMARY                                                  pilot reported he was climbing through 1,100
                            A Cessna 182S descended into a pond about 2.3            feet msl.
                            nautical miles west of Charles M. Schulz-Sonoma
                            County Airport (STS), Santa Rosa, California. The        Then, at 0930:15, the controller informed the
                            pilot owned and operated a Cessna 206. The 206           pilot that he was not receiving the airplane’s
                            was receiving maintenance, and the pilot rented          transponder signal. The controller advised the
                            the accident airplane from a local fixed base            pilot to “verify squawking Three Three Two One
                            operator to fly to a business meeting. Instrument        and say Altitude Leaving.”
                            meteorological conditions prevailed and the pri-
                            vate pilot filed an IFR flight plan. The flight origi-   The pilot responded at 0930:23, and stated,
                            nated from STS about 0927.                               “Sixteen Hundred Seven Three Delta.” This
                                                                                     was the last transmission recorded from the
                            The pilot received an IFR departure clearance for        accident pilot. The controller subsequently
                            the Santa Rosa Five Departure and was cleared to         indicated that, after he advised the pilot to
                            takeoff from Runway 19 and climb to 5,000 feet,          verify his transponder code, “It came up and
                            or until reaching visual conditions and canceling        I got one hit” before the airplane disappeared
                            the IFR clearance. The prescribed departure pro-         from his radar a couple miles west of the
                            cedure required the pilot to execute a right turn        airport.
                            upon takeoff.

A-40 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                              AppendixA



Personal information                                   to ATC, the top of the stratus cloud layer was
The pilot’s personal flight record logbook was not     reported 1,800 feet msl.
provided for examination. Based upon informa-
tion provided by acquaintances of the pilot from       Radar track data
their examination of records associated with the       The FAA reviewed all radar data from the Sonoma
operation of the pilot’s own airplane (a Cessna        County Airport area around the time of the acci-
206), during the period between March 15, 2000,        dent. The FAA indicated that in this location it
and September 10, 2000, the pilot had flown his        has only one long-range radar site that covers the
Cessna 206 for 42 hours. During the preceding 12       area below 5,000 feet. When the recorded radar
months, from March 8, 1999, to March 8, 2000,          data was filtered to search for targets within a 10
the pilot had flown his airplane for 81.4 hours.       nm radius around the airport and up to 5,000
                                                       feet, the subject airplane was only observed one
The operator reported that the accident pilot had      time on a transponder code of 3311. The target
successfully completed a flight review on              had an invalid Mode-C code at that time, with no
September 1, 2000. The certified flight instructor,    radar reinforcement.
who administered the review, did not recall hav-
ing flown any instrument approaches during the         The approximate distance and bearing from the
flight, nor was this required.                         end of Runway 19 at STS, to this first radar hit, is
                                                       2.3 nm and 261 degrees, magnetic. The approxi-
Regarding the pilot’s familiarity with the accident    mate distance and bearing from the radar hit to
Cessna 182S, the operator reported it has no evi-      the crash site is 0.6 nm and 042 degrees, magnet-
dence that the accident pilot had previously           ic.
flown or been checked out in this model of air-
plane.                                                 Probable cause
                                                       The pilot’s failure to maintain aircraft control
The pilot was issued an instrument rating in           because of spatial disorientation.
September 1996. The pilot’s recent instrument
flying experience was not determined.                  Factors
                                                       A related factor was the low ceiling.
On October 1, 1998, when the pilot was issued his
most recent third-class aviation medical certifi-      ASF comments
cate, he indicated that his total flight time was      It’s possible that this pilot became spatially dis-
about 600 hours.                                       oriented when trying to use avionics that he was
                                                       unfamiliar with. Flying single pilot in actual con-
Meteorological information                             ditions is no the time to learn how to program
At 0853 and 0953, Sonoma County Airport report-        the GPS. Even the most experienced pilots can be
ed the following weather conditions: wind calm,        affected by spatial disorientation.
visibility 7 and 6 miles, respectively, and an over-
cast ceiling at 600 feet agl. The temperature/dew-
point was reported at 12/10 degrees C. According




                                                                         Technically Advanced Aircraft | www.aopa.org/safetycenter A-41
AppendixA                                                                                                   AOPA Air Safety Foundation




                            CHI02FA120

                            Date/Time        Aircraft             N Number         Operation        Accident            Aircraft
                                                                                                    Phase               Damage
                            05/03/2002 Cessna 182S                N293MA           Personal         Go-around           Destroyed
                            1350 CDT         IO-540-AB1A5


                            Injuries         Fatal                Serious          Minor            None
                            Crew             1                    0                0                0
                            Passengers       0                    0                0                0
                            Ground           0                    0                0                0


                            Location         Sheboygan, WI                         Flight Plan      None
                            Itinerary        Local                                 Runway           21
                            Airport          Sheboygan County Memorial (SBM)


                            Weather          VFR                  Precipitation    None             Wx Briefing         None
                            Visibility       10 sm                Clouds           NOWE             Type                N/A
                            Wind             150/09               Ceiling          Clear
                            Gusts            N/A                  Lighting         Daylight


                            Experience                            Hours
                            Certificate      Private              Total            406              Last 90 Days        UNK
                            Instrument       Yes                  Make             UNK              Last 30 Days        UNK
                            Curr. Medical Yes                     Instmt           UNK




                            SUMMARY                                                Another pilot witness, reported that at an altitude
                            A Cessna 182S collided with terrain following a loss   of about 50 feet, the airplane began to bank to
                            of control during a go-around on Runway 21 (5,399      the right and it got progressively steeper. This
                            feet by 100 feet wide) at Sheboygan County             witness reported, “The plane was too low to be
                            Memorial Airport (SBM), in Sheboygan, Wisconsin.       banking this quickly.” The airplane was near 90
                                                                                   degrees of bank when the witness lost sight of it
                            One witness, who was a pilot, reported the C182        behind the trees. He reported the airplane was
                            appeared a little fast, but on a proper glide path     developing “good power” and there was no sput-
                            for landing. The airplane then began drifting to       tering of the engine.
                            the right side of the runway. The pilot initiated a
                            go-around and the airplane maintained an alti-         In a telephone interview, another pilot reported
                            tude of 10 to 20 feet above the ground for a brief     seeing the airplane at about 100 feet above the
                            period after which it gained altitude and entered      ground. He said the airplane continued down the
                            a shallow bank to a heading of about 240 degrees.      runway then it made a right turn near the inter-
                            The airplane continued to climb to an altitude of      section of Runway 21. The turn continued until
                            “no more than 200 feet” then it entered a 40 to 60     the airplane paralleled the south side of Runway
                            degree right bank. It continued in the steep bank,     21. It continued to parallel the runway until it
                            turning to a heading of about 020 degrees and          reached the end and made another right turn
                            then started to “lose altitude rapidly.” The witness   and descended into the terrain. All the turns
                            did not see any attempt to level the wings or stop     appeared coordinated. The witness reported that
                            the descent.                                           he did not see the flaps extended, nor did he

A-42 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                              AppendixA



notice any major aileron deflections. He stated        Probable cause
that he did not become concerned with the angle        The pilot’s inability to maintain control of the air-
of bank until the last turn.                           craft while executing a go-around landing.

Personal information                                   Factors
The pilot, age 61, held a private pilot certificate    The crosswind conditions on Runway 21 likely
with an instrument rating. His private pilot cer-      contributed to the aircraft drifting to the right
tificate was issued on July 4, 1968, and the instru-   while overcorrecting for the wind. These condi-
ment rating was added on May 20, 2000. The             tions likely lead the pilot to determine a go-
pilot held a third-class medical certificate dated     around landing was necessary. Steep-banked
September 25, 2001. This certificate contained         turns at extremely low altitudes were likely to be
the restriction, “Holder shall wear lenses that cor-   a factor to the pilot’s inability to maintain control
rect for distant vision and posses glasses that cor-   during the go-around.
rect for near vision.”
                                                       ASF comments
The pilot reported having 360 hours of flight time     A low-time pilot with hours spread over three
at the time of his last airmen medical examina-        decades most likely did not compensate for the
tion on September 25, 2001. Other records indi-        left turning tendency of a high-performance air-
cated that the pilot’s total time was approximate-     craft. This is a physical aircraft skill and can be
ly 406 hours. The pilot completed his last flight      addressed by practice with an instructor. An
review on May 20, 2000.                                ample amount of right rudder and a little right
                                                       aileron would probably have prevented this acci-
FBO employees reported that the pilot would fre-       dent.
quently come to the airport during the day to fly
the airplane if someone else didn’t schedule it. An
employee, who saw the pilot just prior to the
flight, stated that he appeared in good health,
was in good spirits and, was happy to be going
flying.




                                                                         Technically Advanced Aircraft | www.aopa.org/safetycenter A-43
AppendixA                                                                                                    AOPA Air Safety Foundation




                            IAD03FA004

                            Date/Time        Aircraft             N Number         Operation        Accident             Aircraft
                                                                                                    Phase                Damage
                            10/11/2002 Cessna 182S                N100TY           Personal         Cruise               Destroyed
                            2038 EDT         IO-540


                            Injuries         Fatal                Serious          Minor            None
                            Crew             1                    0                0                0
                            Passengers       0                    0                0                0
                            Ground           0                    0                0                0


                            Location         Brownville Junction, ME               Flight Plan      None
                            Itinerary        Caribou, ME—Norridgewock, ME          Runway           N/A
                            Airport


                            Weather          IMC                  Precipitation    None             Wx Briefing          None
                            Visibility       10 sm                Clouds           SCT 3,200’       Type                 N/A
                            Wind             Calm                 Ceiling          OVC 4,300’
                            Gusts            None                 Lighting         Night


                            Experience                            Hours
                            Certificate      ATP                  Total            3,288            Last 90 Days         UNK
                            Instrument       Yes                  Make             UNK              Last 30 Days         UNK
                            Curr. Medical Yes                     Instmt           UNK


                            SUMMARY                                                conducted a preflight examination of the air-
                            A Cessna 182S was destroyed when it collided           plane, and filled the tanks with fuel. They depart-
                            with mountainous terrain near Brownville               ed EEN about 1630.
                            Junction, Maine. No flight plan was filed for the
                            night VFR cross-country flight that originated at      The student pilot said the autopilot was engaged
                            Caribou Municipal Airport (CAR), Caribou,              for the majority of the flight, and they used the
                            Maine, about 1957, destined for Central Maine          panel mounted global positioning system (GPS)
                            Airport of Norridgewock (OWK), Norridgewock,           to navigate. The pilot requested, and was cleared
                            Maine. According to the pilot’s wife, her husband      for the non-precision GPS-A approach at CAR.
                            was returning to their home in Norridgewock
                            when the accident occurred. The pilot, who was         According to the student pilot, the runway lights
                            also a certificated flight instructor, had complet-    at CAR were reported inoperative, but the pilot
                            ed an instrument cross country training flight         elected to land there anyway. After two attempts,
                            from Dillant-Hopkins Airport (EEN), Keene, New         the pilot landed the airplane about 1930, taxied
                            Hampshire, to Caribou, with one of his flight stu-     to the terminal, and parked the airplane. The stu-
                            dents, a private pilot applicant. The pilot had just   dent pilot described the environmental condi-
                            flown the airplane back from Portland, Maine,          tions at Caribou as dark, with some residual light,
                            where it had undergone an annual inspection.           clear skies, and about 10 miles visibility to the
                            The weather conditions at EEN were IMC.                north.

                            In preparation for the flight to Caribou, the pilot    The student pilot then conducted a “quick walk-
                            obtained weather information, and filed an IFR         around” of the airplane, during which, he saw the
                            flight plan with flight service. The student pilot     pilot in the terminal building on his cell phone.

A-44 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                             AppendixA



When the pilot returned to the airplane, the stu-     Weather at Caribou Municipal Airport, at 1954,
dent pilot asked him if he was tired and if he        included winds from 140 degrees at 3 knots, visi-
wanted to spend the night, and then get an early      bility 10 statute miles, overcast clouds at 1,900
start in the morning. The pilot declined the offer,   feet, temperature 43 degrees F, dewpoint 42
and said that he was not tired.                       degrees F, and a barometric pressure of 30.40
                                                      inches Mercury.
The student pilot was concerned about the mar-
ginal weather conditions, and told the pilot to       Weather at Millinocket Municipal Airport (MLT),
watch out for Mt. Katahdin, a 5,268-foot moun-        Millinocket, Maine, about 20 nautical miles
tain located along the route of flight. The student   northeast of the accident site, at 2058, included
pilot was also concerned because he knew the          calm winds, visibility 10 statute miles, scattered
pilot liked to fly at “lower” altitudes, between      clouds 3,200 feet, overcast clouds at 4,300 feet,
2,000 and 3,000 feet. The pilot then departed         temperature 54 degrees F, dewpoint 46 degrees F,
about 2000, and the student pilot last observed       and a barometric pressure of 30.49 inches of
the airplane at an altitude of about 2,000 feet,      Mercury.
headed south.
                                                      Medical and pathological information
A review of ATC communications revealed that          Paroxetine, an antidepressant commonly known
the pilot contacted the Bangor AFSS after he          as Paxil, was detected in the pilot’s heart and
departed Caribou, and requested the radio fre-        liver.
quency for Boston Air Route Traffic Control
Center (ARTEC). However, the pilot never con-         Probable cause
tacted Boston ARTCC.                                  The pilot’s failure to maintain sufficient altitude
                                                      while flying in mountainous terrain at night
An examination of radar showed a target that
climbed and maintained an altitude of 3,100           Factors
feet. The target proceeded on a southwesterly         A factor was the night lighting conditions.
track until the data ended at 2029, about 15
nautical miles northeast of the accident site. At     ASF comments
2036:37, the target reappeared at an altitude of      Before departing for Norridgewock (OWK), the
3,100 feet, which it maintained for just more         pilot did not heed multiple warnings from his
than 1 minute. During the next 1 minute and 12        student regarding the mountainous terrain,
seconds, the target momentarily climbed to            marginal weather and fatigue. It appears that
3,200 feet, then descended to 2,700 feet before       the pilot did not get a weather briefing on the
the data ended. The last radar target was record-     ground in Caribou (CAR). It should have caused
ed at 2038:49, about 1.6 miles from the accident      concern that the Area Forecast’s outlook section
site.                                                 included a VFR ceiling deteriorating to an IFR
                                                      ceiling by early morning. Airmet Sierra had been
Meteorological information                            updated, adding the pilot’s route to the IFR
The area forecast included scattered to broken        areas, shortly before his departure. Aeronautical
clouds from 1,500 to 2,500 feet, broken clouds at     charts were found on board the airplane, but it
4,000 feet, and tops at 10,000 feet. By 1600, over-   appears that the pilot did not use them to refer-
cast clouds were expected at 4,000 feet. The out-     ence maximum elevation figures (MEFs) or min-
look included a VFR ceiling, becoming an IFR          imum en route altitudes (MEAs) in the area.
ceiling with mist by 0600.                            Filing a flight plan may have prompted the pilot
                                                      to select a more appropriate cruise altitude for
A review of possible in-flight weather advisories     the route. The decision to continue may have
along the route of flight revealed that Airmet        been affected by personal pressures; the pilot’s
Sierra, which reported IFR conditions and             wife was expecting him back home in
mountain obscuration in the state of Maine, was       Norridgewock that evening. The pilot’s
issued, and updated at 1915. The amendment            advanced ratings (ATP, CFI, and CFII) might
updated the areas associated with the IFR por-        have contributed to a sense of complacency.
tion of the Airmet, and included the pilot’s route    Ultimately, the pilot should not have been flying
of flight. It was valid until 2200.                   at all because his medical was rendered invalid
                                                      by unapproved medication usage.




                                                                        Technically Advanced Aircraft | www.aopa.org/safetycenter A-45
AppendixA                                                                                                      AOPA Air Safety Foundation




                            NYC03FA015

                            Date/Time        Aircraft             N Number         Operation          Accident Phase Aircraft
                                                                                                                     Damage
                            10/31/2002 Cessna 182S                N7099L           Personal           Cruise                Substantial
                            1105 EST         IO-540


                            Injuries         Fatal                Serious          Minor              None
                            Crew             1                    0                0                  0
                            Passengers       0                    0                0                  0
                            Ground           0                    0                0                  0


                            Location         Accident, MD                          Flight Plan        None
                            Itinerary        Batavia, OH—Meriden, CT               Runway             N/A
                            Airport          N/A


                            Weather          IFR                  Precipitation    None               Wx Briefing           Yes
                            Visibility       10 sm                Clouds           BKN                Type                  FSS
                            Wind             Var/03               Ceiling          1,000 feet
                            Gusts                                 Lighting         Daylight


                            Experience                            Hours
                            Certificate      Private              Total            837                Last 90 Days          UNK
                            Instrument       No                   Make             82                 Last 30 Days          25
                            Curr. Medical Yes                     Instmt           UNK


                            SUMMARY                                                100 LL fuel prior to departure.
                            A Cessna 182S was substantially damaged during
                            a forced landing near Accident, Maryland. The          A review of ATC communications revealed that
                            certificated private pilot was fatally injured.        while en route, the pilot contacted Clarksburg
                            Instrument meteorological conditions prevailed         Approach Control at 1040, for flight following advi-
                            and no flight plan was filed for the cross-country     sories and information about the cloud ceiling
                            flight from Clermont County Airport (I69),             ahead of him. The pilot was advised of the
                            Batavia, Ohio, to Meriden Markham Municipal            Clarksburg weather, and instructed to contact the
                            Airport (MMK), Meriden, Connecticut. The per-          Elkins AFSS, for further weather advisories.
                            sonal flight was conducted under Part 91.
                                                                                   On initial contact with Elkins FSS, the pilot stated
                            According to a FAA inspector, the pilot was            that he was in level flight at 3,300 feet, flying in and
                            attending initial instrument flight training at I69    out of the clouds, and encountering light icing con-
                            during the previous two weeks. Unable to com-          ditions. The FSS specialist advised the pilot of
                            plete the training, the pilot elected to return        instrument meteorological conditions along the
                            home.                                                  route of flight, mountain obscuration, and icing
                                                                                   conditions. He then recommended that the pilot
                            The pilot obtained a weather briefing from AFSS        climb to 6,000 feet, where he could expect visual
                            on October 29, 30, and 31, 2002.                       meteorological conditions. The pilot responded
                                                                                   that his flight conditions were “not that bad,” and
                            Witnesses observed the airplane depart I69 about       he would remain at 3,300 feet. The weather adviso-
                            0900 on October 31, 2002. The witnesses also           ry was terminated, and the pilot re-contacted the
                            stated that the airplane was filled to capacity with   radar controller.

A-46 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                            AppendixA



The pilot reported back on the approach fre-         knots, visibility 10 statute miles, a broken cloud
quency, and at 1056, he told the controller that     layer at 1,000 feet, overcast clouds at 1,400 feet, a
he needed to climb because he was accumulating       temperature of 37 degrees F, dewpoint 35 degrees
rime ice. The controller replied that another air-   F, and an altimeter setting of 30.15 inches of
craft had reported ice at 7,000 feet, and cloud      Mercury.
tops at 7,400 feet. The pilot then stated that he
could not maintain VFR, and had “been in it” for     According to a witness at 2G4, the weather condi-
10 to 15 minutes. He further stated that he was      tions at 2G4, about the time of the accident, were
getting some ice build up, but was “OK” with it.     IMC, and at times “zero-zero.” The witness also
                                                     recalled that an airplane flew overhead the air-
The controller advised the pilot that Garrett        port between 1000 and 1100, and departed the
County Airport (2G4), Oakland, Maryland, was 6       area. He did not observe the airplane and did not
miles northeast, and suggested a heading of 056      hear anyone transmit on the local traffic advisory
degrees to the airport.                              frequency.

About 1059, the approach controller observed the     Probable cause
accident airplane’s target disappear from the        The pilot’s decision to continue flight into known
radar screen. No further transmissions were          adverse weather conditions.
received from the pilot.
                                                     Factors
A witness who lived less than a 1/4 mile from the    A factor related to the accident was the icing con-
accident site stated he was in his driveway when     ditions.
he heard the sound of an airplane engine. When
he looked up, he saw an airplane descend out of      ASF comments
the clouds, heading south. The airplane’s engine     This pilot was not responding to the warning sig-
was “sputtering,” at a very low power setting;       nals being sent to him. Not only was ice begin-
however, the propeller was still turning. As the     ning to collect on his aircraft, FSS and other
airplane passed overhead, just over the treetops,    pilots (through pireps) issued warnings of icing
it made a 180-degree turn to the right, before       conditions in the area.
descending into a field. The witness also stated
the weather at the time included a low cloud         Although the pilot had been attempting to obtain
layer, and mixed precipitation of ice and snow.      his instrument rating in the two weeks prior to
                                                     the accident, his training was not complete. His
The airplane came to rest in a soft, plowed, field   decision to continue VFR flight into IMC during
about 4 miles east of 2G4.                           daylight hours was apparently deliberate.

Pilot information                                    Although by the pilot’s own admission he was “in
The pilot held a private pilot certificate with a    and out of clouds” during cruise flight at 3,300
rating for airplane single engine land. His most     feet msl, he also admitted to accumulating “light
recent FAA third-class medical was issued on         icing.” Other than rare occasions involving freez-
April 16, 2002.                                      ing rain, few pilots who are flying “legal VFR” will
                                                     ever pick up ice accumulations. Furthermore, at
According to the pilot’s logbook, he had about       1056, only nine minutes before the crash, he
837 hours of total flight experience.                requested a climb “because he had rime ice.” The
                                                     controller responded that there were ice reports
Meteorological information                           at higher altitudes as well. The 180-degree turn
The recorded weather at Morgantown Municipal         works for inadvertent icing encounters just as
Airport-Walter L. Bill Hart Field (MGW), in West     well as it works for inadvertent IMC encounters
Virginia, which was located about 13 miles west      for VFR-only pilots.
of 2G4, at 1954, included variable winds at 3




                                                                       Technically Advanced Aircraft | www.aopa.org/safetycenter A-47
AppendixA                                                                                                  AOPA Air Safety Foundation




                             NYC03FA205

                             Date/Time        Aircraft            N Number        Operation         Accident            Aircraft
                                                                                                    Phase               Damage
                             09/27/2003 Cessna 182T               N936LP          Personal          Approach (ILS)      Destroyed
                             1103 EDT         IO-540-AB1A5


                             Injuries         Fatal               Serious         Minor             None
                             Crew             1                   0               0                 0
                             Passengers       1                   0               0                 0
                             Ground           0                   0               0                 0


                             Location         Concord, MA                         Flight Plan       IFR
                             Itinerary        Fulton, NY—Bedford, MA              Runway            11
                             Airport


                             Weather          IFR                 Precipitation   None              Wx Briefing         Yes
                             Visibility       .75 sm              Clouds          OVC               Type                DUATs
                             Wind             090/08              Ceiling         400 feet
                             Gusts            None                Lighting        Daylight


                             Experience                           Hours
                             Certificate      Private             Total           2,600             Last 90 Days        30
                             Instrument       Yes                 Make            210               Last 30 Days        10
                             Curr. Medical Yes                    Instmt          120




                            SUMMARY                                               reported with the departure or en route phases of
                            A Cessna 182T was destroyed when it struck trees      the flight.
                            in Concord, Massachusetts, while on approach to
                            Laurence G. Hanscom Field (BED), Bedford,             As the airplane neared its destination, the pilot
                            Massachusetts. The certificated private pilot and     was instructed to contact Boston Approach
                            passenger were fatally injured. Instrument mete-      Control. The pilot initiated a descent and was
                            orological conditions prevailed for the personal      radar vectored for the ILS (instrument landing
                            flight, which departed from Oswego County             system) Runway 11 approach.
                            Airport (FZY), Fulton, New York. The flight was
                            operated on an IFR flight plan.                       According to a transcript of air/ground commu-
                                                                                  nications from the FAA control tower at BED:
                            The pilot filed an instrument flight rules (IFR)
                            flight plan to BED, via DUATs. The proposed           At 1058:22, the pilot established radio contact
                            departure time was 0830 on September 27, 2003.        with the control tower. The local controller asked
                                                                                  the pilot to report the outer marker, and also told
                            No documents were found to indicate what              him that the Runway 11 runway-visual-range
                            weather the pilot had viewed prior to departure.      (RVR), was greater than 6,000 feet. The pilot
                                                                                  asked for the data to be repeated and the local
                            The flight departed FZY about 0910. The initial en    controller complied.
                            route altitude was 7,000 feet, with the pilot later
                            being assigned 9,000 feet. No problems were           At 1059:31, the pilot reported that he was at the

A-48 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                              AppendixA



outer marker. The local controller acknowledged        which he described as a Cessna, operating just
the transmission, cleared the airplane to land,        above the tops of the trees, heading away from
and advised the pilot that the last two airplanes      the airport. He did not hear the accident. He said
broke out at minimums. The pilot did not reply.        there was fog near the tops of the trees.

At 1100:45, the pilot transmitted, “Nine-Six-          A second witness, who lived near the outer mark-
Three-Lima-Pop....”                                    er, reported hearing an airplane and an applica-
                                                       tion of power, which she described as a, “real
At 1100:50, the local controller stated, “Calling      roar.” She said the weather was, “murky.”
tower, say again.”
                                                       A third witness reported he could hear an air-
At 1100:57, the local controller stated, “Nine-Six-    plane turning where airplanes don’t normally
Three-Lima-Pop, check your altitude, altimeter is      turn. He never had visual contact with the air-
30.12, minimum descent altitude 383 feet, check        plane. However, he did say he heard the airplane
your altitude immediately. The pilot did not ini-      until impact, and that the engine was not sput-
tially reply. However, at 1101:24, the pilot trans-    tering or missing. He then walked into the woods
mitted “and Six-Lima-Pop....”                          and found the wreckage. He reported that there
                                                       was a strong smell of fuel at the accident site.
At 1101:30, the local controller told the pilot that
he was on a two-mile final and asked him his           Additional interviews of pilots operating in the
heading.                                               area at the time of the accident revealed no prob-
                                                       lems with either the localizer and/or glideslope.
At 1101:41, the local controller again asked the
pilot his heading.                                     Personal information
                                                       The pilot held a private pilot certificate with rat-
At 1101:53, the pilot reported he was on a head-       ings for airplane single-engine land and instru-
ing of 330 degrees.                                    ment airplane. He was last issued a second-class
                                                       FAA airman medical certificate on March 20,
At 1102:02, the local controller transmitted,          2003. The pilot received his private pilot rating on
“Cessna Three-Lima-Pop, climb and maintain             September 14, 1978. He received his instrument
2,000, execute a missed approach now, frequency        rating with a total flight experience of 238 hours
124.4.”                                                on August 27, 1981. According to the pilot’s appli-
                                                       cation for the instrument rating, his total instru-
At 1102:06, the pilot replied, “Missed approach,       ment flight time was 120 hours.
can you give me the heading?”
                                                       According to the pilot’s last FAA airman medical
At 1102:09, the local controller stated, “What         application, he had a total flight experience of
heading are you on now sir.”                           2,600 hours, and had flown 70 hours in the pre-
                                                       ceding 6 months. In the preceding 90 days, the
At 1102:13, the pilot replied, “Heading 180            pilot was estimated to have flown about 30 hours,
[degrees].”                                            and in the preceding 30 days, he was estimated to
                                                       have flown about 10 hours. Since his last FAA air-
At 1102:16, the local controller transmitted, “All     man physical, the pilot was estimated to have
right, just climb to 2,000, contact Boston             flown about 60 hours, for a total flight experience
Approach now 124.4.”                                   of 2,660 hours. The pilot was estimated to have
                                                       210 hours in the accident airplane.
The pilot replied, “124.0,” and the local controller
corrected the pilot by repeating the frequency,        The pilot’s last flight review was conducted in the
“124.4.”                                               accident airplane on August 29, 2002. This was
                                                       also the last entry in the pilot’s logbook. It includ-
No further transmissions were received from the        ed a flight review and an instrument competency
pilot.                                                 check. The review was administered by an FAA
                                                       operations inspector who reported the flight was
One witness was fishing from his boat in the           satisfactory and that the pilot flew commensu-
Concord River. He reported that he was used to         rate for his ratings and level of experience, and
hearing airplanes on approach, and heard an air-       was familiar with the airplane.
plane on approach that sounded normal. He
then heard an application of power, and a few          Meteorological information
seconds later, saw a white, high-wing airplane,        The 1056 recorded weather from BED, included

                                                                         Technically Advanced Aircraft | www.aopa.org/safetycenter A-49
AppendixA                                                                                                      AOPA Air Safety Foundation




                            visibility of 3/4 mile, ceiling 400 feet overcast, and   standby frequency was found to be 110.9 Mhz. The
                            winds from 090 degrees at 8 knots. Interviews            other radio had impact damage that precluded a
                            with pilots operating in the area disclosed the          frequency check.
                            clouds extended west to the Hudson River, and
                            the tops of the overcast were about 7,000 feet.          The database in the GPS was found to be expired.
                            The base of the clouds was about 450 feet. Local
                            area witnesses reported that clouds were at the          Attitude indicator and directional gyro
                            tops of the trees.                                       The attitude indicator and directional gyro were
                                                                                     forwarded to the NTSB materials laboratory in
                            Radar and other remotely recorded data                   Washington, D.C., for examination. Rotational
                            According to the instrument approach procedure           scoring was found with the gyro from the attitude
                            for the ILS Runway 11 approach to Bedford, the           indicator. The directional gyro was found to be a
                            minimum en route altitude to intercept the glide         slaved unit with no internal gyro.
                            slope was 1,700 feet. The inbound heading on the
                            localizer was 113 degrees. The glideslope crossed        GPS/Nav switch flight test
                            the outer marker at 1,456 feet. The published            On October 30, 2003, a flight test was conducted
                            minimums for a straight-in approach were 383             in an exemplar Cessna 182, which was equipped
                            feet, and 5,000 feet of RVR. The published missed        with radios similar to the accident airplane. The
                            approach was to climb to 2,000 feet, and proceed         purpose of the flight test was to check the func-
                            to Shaker Hills non-directional radio beacon,            tion of the GPS/Nav switch. According to the
                            which was located about 6 nautical miles east of         report from Cessna:
                            the airport.
                                                                                     “The glideslope pointer on the HSI remained out
                            Radar data from Boston Approach Control re-              of view unless a glideslope signal was being
                            vealed the airplane was above the glide slope and        received and the GPS/Nav switch was in the Nav
                            descending as it approached the outer marker.            position. An ILS frequency in the active window
                            The airplane crossed the outer marker at 2,000           of the # 1 navigation radio did not override the
                            feet, and then performed a descent to 700 feet in        GPS/Nav switch. Therefore, localizer and glide-
                            about 40 seconds, during which time it passed            slope information was not displayed on the HSI
                            through and descended below the glideslope. The          until the GPS/Nav Switch was selected to Nav....”
                            airplane then initiated a turn to the left and start-
                            ed climbing. The airplane proceeded northwest,           Probable cause
                            and then while climbing initiated another turn to        The pilot’s failure to maintain aircraft control
                            the left. In the turn the altitude was inconsistent,     because of spatial disorientation.
                            and the radius of turn decreased. The airplane
                            completed more than 360 degrees of turn.                 Factors
                            However, as the radius of turn decreased, the            Low ceilings.
                            radar contacts became closer together, and it was
                            not possible to discern the actual movements of          ASF comments
                            the airplane in the last few seconds of the flight.      Although the instrument-rated private pilot was
                            The last radar contact occurred at 1102:51.56,           estimated to have flown 60 total hours in the last
                            with an indicated altitude of 500 feet. At that          six months, there is no record of the amount of
                            time, the airplane was about 245 feet northwest          instrument time. Based on the pilot’s inability to
                            of the accident site.                                    overcome spatial disorientation, the pilot may
                                                                                     not have been instrument proficient.
                            While maneuvering, the local controller had twice
                            asked the pilot his heading. When the information        Considering that the last logbook entry was of a
                            received from the pilot was compared with the            satisfactory flight review and a satisfactory
                            radar tracks, they were found to be similar.             instrument competency check on August 29,
                                                                                     2002, it is also possible that the pilot was not
                            Testing and research                                     instrument current.
                            Navigation radios
                            The navigation radios were examined at Honeywell,
                            in Olathe, Kansas, under the supervision of an air-
                            worthiness inspector from the FAA. The examina-
                            tion revealed the radios had received impact dam-
                            age. On one navigation radio, the navigation fre-
                            quency was found to be 111.15 Mhz, which corre-
                            sponded to the ILS frequency at Bedford. The

A-50 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                           AppendixA




FTW03FA114

Date/Time        Aircraft            N Number        Operation        Accident               Aircraft
                                                                      Phase                  Damage
03/20/2003 Cessna 182S               N97TD           Personal         Approach               Destroyed
1910 CST         I0-540


Injuries         Fatal               Serious         Minor            None
Crew             0                   0               1                0
Passengers       1                   1               0                0
Ground           0                   0               0                0


Location         Fayetteville, AR                    Flight Plan      IFR
Itinerary        Wichita, KS—Fayetteville, AR        Runway           UNK
Airport


Weather          IFR                 Precipitation                    Wx Briefing            UNK
Visibility       4 sm                Clouds          OVC              Type                   N/A
Wind             310/11              Ceiling         500 feet
Gusts            14                  Lighting        Night


Experience                           Hours
Certificate      Private             Total           UNK              Last 90 Days           UNK
Instrument       Yes                 Make            UNK              Last 30 Days           UNK
Curr. Medical UNK                    Instmt          UNK


SUMMARY                                              Probable cause
A Cessna 182S was destroyed when it impacted         Not available at time of publication.
trees and terrain during an instrument approach
into Drake Field Airport (FYV), Fayetteville,        ASF comments
Arkansas. The instrument-rated private pilot sus-    Preliminary.
tained minor injuries, one passenger was seri-
ously injured, and the other passenger was fatally
injured. Night instrument meteorological condi-
tions prevailed, and an instrument flight rules
(IFR) flight plan was filed and activated.

Preliminary information indicates that the pilot
was cleared to land, and radio communications
and radar contact was lost 5 miles south of the
airport.




                                                                      Technically Advanced Aircraft | www.aopa.org/safetycenter A-51
AppendixA                                                                                                  AOPA Air Safety Foundation




                            ATL04FA093

                            Date/Time        Aircraft            N Number         Operation       Accident               Aircraft
                                                                                                  Phase                  Damage
                            04/12/2004 Cessna 182S               N364ME           Personal        Cruise                 Destroyed
                            1007 EDT         I0-540


                            Injuries         Fatal               Serious          Minor           None
                            Crew             1                   0                0               0
                            Passengers       2                   0                0               0
                            Ground           0                   0                0               0


                            Location         North Augusta, SC                    Flight Plan     IFR
                            Itinerary        Aiken, SC—Greenville, MS             Runway          N/A
                            Airport


                            Weather          IMC                 Precipitation    None            Wx Briefing            UNK
                            Visibility       8 sm                Clouds           OVC             Type                   N/A
                            Wind             140/08              Ceiling          700 feet
                            Gusts            None                Lighting         Daylight


                            Experience                           Hours
                            Certificate      Private             Total            UNK             Last 90 Days           UNK
                            Instrument       Yes                 Make             UNK             Last 30 Days           UNK
                            Curr. Medical UNK                    Instmt           UNK


                            SUMMARY                                               As the flight neared Augusta Regional Airport. At
                            A Cessna 182S collided with trees and the ground      Bush Field (AGS) in Augusta, Georgia, the pilot
                            in North Augusta, South Carolina.                     asked to divert for landing. ATC provided a head-
                                                                                  ing and altitude for a Surveillance Approach, and
                            According to ATC records, the IFR flight was en       the pilot acknowledged. Heading, altitude, and
                            route to Greenville, Mississippi. Shortly after       ground speed continued to fluctuate, and the
                            departing Aiken Municipal Airport (AIK), Aiken,       flight was lost from radar at 1007. Witnesses a few
                            South Carolina, the pilot contacted air traffic       hundred yards from the accident site reported
                            control. The controller called radar contact, and     seeing the airplane flying low and erratic over the
                            the flight proceeded on course. A preliminary         trees, and then it banked left and nosed straight
                            review of radar data revealed constantly fluctuat-    down through the trees and to the ground.
                            ing altitude, heading, and ground speed, and not
                            following its filed course. ATC contacted the pilot   Probable cause
                            and asked if he was experiencing equipment            Not available at time of publication
                            problems; the pilot reported none. The flight pro-
                            ceeded, but did not intercept its course. Altitude,   ASF comments
                            heading, and ground speed continued to fluctu-        Preliminary. Basic aircraft control appears to be
                            ate. ATC asked the pilot to level the airplane and    in question.
                            to contact him when in straight and level flight.




A-52 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                             AppendixA




CHI04FA257

Date/Time        Aircraft             N Number         Operation        Accident               Aircraft
                                                                        Phase                  Damage
09/12/2004 Cessna 182T                N843MC           Personal         Go-Around              Destroyed
2116 CDT         IO-540


Injuries         Fatal                Serious          Minor            None
Crew             1                    0                0                0
Passengers       3                    0                0                0
Ground           0                    0                0                0


Location         Chesterfield, MO                      Flight Plan      None
Itinerary        Sikeston, MO—Chesterfield, MO Runway                   26R
Airport          Spirit of St. Louis (SUS)


Weather          VFR                  Precipitation    None             Wx Briefing            UNK
Visibility       5 sm                 Clouds           FEW              Type                   UNK
Wind             Calm                 Ceiling          7,500 feet
Gusts            N/A                  Lighting         Night


Experience                            Hours
Certificate      Private              Total            UNK              Last 90 Days           UNK
Instrument       UNK                  Make             UNK              Last 30 Days           UNK
Curr. Medical UNK                     Instmt           UNK


SUMMARY                                                Automated Terminal Information Service weather
A Cessna 182T was destroyed on impact with             at 2054 indicated that wind was calm, visibility
trees and terrain, during a go-around from run-        was five miles with mist, few clouds at 7,500 feet,
way 26R at Spirit of St. Louis Airport (SUS), St.      temperature 19 degrees C, dewpoint 17 degrees
Louis, Missouri. A post-impact fire occurred and       C, and the altimeter was 30.06 of Mercury.
night visual meteorological conditions prevailed
at the time of the accident. The flight originated
from Sikeston Memorial Municipal Airport (SIK),        Probable cause
Sikeston, Missouri, and was in the pattern at SUS      Not available at time of publication.
performing a go-around maneuver at the time of
the accident.                                          ASF comments
                                                       Preliminary.
The pilot informed the tower at SUS that he was
11 miles south of the airport inbound for landing
on the north runway. The flight was cleared to
land on Runway 26R. On the first approach, the
pilot informed the tower that he was going
around. The flight was subsequently cleared to
make right traffic for Runway 26R. At about 2116,
the pilot confirmed the clearance for right traffic.
That was the last transmission received from the
pilot.


                                                                        Technically Advanced Aircraft | www.aopa.org/safetycenter A-53
AppendixA                                                                                                    AOPA Air Safety Foundation




                             LAX02FA019

                             Date/Time        Aircraft             N Number        Operation         Accident             Aircraft
                                                                                                     Phase                Damage
                             10/31/2001 Cessna 182S                N7270E          Personal          Approach             Destroyed
                             1830 PST         IO-540


                             Injuries         Fatal                Serious         Minor             None
                             Crew             1                    0               0                 0
                             Passengers       0                    0               0                 0
                             Ground           0                    0               0                 0


                             Location                                              Flight Plan       None
                             Itinerary        Palo Alto, CA—Little River, CA       Runway            N/A
                             Airport          Little River, CA (048)


                             Weather          IFR                  Precipitation                     Wx Briefing          UNK
                             Visibility       1 sm                 Clouds          OVC               Type                 N/A
                             Wind             Calm                 Ceiling         300 feet
                             Gusts            None                 Lighting        Night


                             Experience                            Hours
                             Certificate      Commercial           Total           UNK               Last 90 Days         UNK
                             Instrument       Yes                  Make            UNK               Last 30 Days         UNK
                             Curr. Medical UNK                     Instmt          UNK



                            SUMMARY                                                es of Mercury. At 1856, UKI was reporting calm
                            A Cessna 182S crashed when it impacted trees           wind; visibility 10 statute miles; sky clear; tem-
                            and the ground about 2.5 miles from Little River       perature 57 degrees F; dewpoint 52 degrees F;
                            Airport, (O48) Little River, California. The pilot,    and altimeter 30.06 inches of Mercury.
                            the sole occupant, was fatally injured.
                                                                                   According to a witness at the airport, he heard an
                            Weather conditions at O48 at the time of the acci-     airplane about 1745, and didn’t think much of it
                            dent reported a fog layer at 300 feet msl with 1-      because it sounded normal. He went into his
                            mile visibility. Ground witnesses reported that it     office to go over some receipts. About 10 minutes
                            had been clear for most of the day. About 1700, a      later he came out of the office and heard an
                            stratus layer drifted in from the north. The           engine throttle back. He stated that he couldn’t
                            ground witnesses further indicated that by 1800        see the airplane because of the fog, but could
                            the fog layer was a couple of hundred feet thick,      hear it. He went inside to get his handheld radio
                            and the light condition was about 80-percent           to find out what the pilot’s intentions were. He
                            dark.                                                  contacted the pilot and the pilot asked him what
                                                                                   the conditions were. The witness drove out on to
                            Weather reported at Ukiah Municipal Airport            the taxiway and said that he could see both ends
                            (UKI), Ukiah, California, located about 26 miles       of the runway, but because it was dark could not
                            west-southwest of the accident site at 1756 was:       tell how high the overcast layer was.
                            wind from 280-degrees at 4 knots; visibility 10
                            statute miles; sky clear; temperature 61 degrees F;    The witness saw the airplane on the downwind/
                            dewpoint 52 degrees F; and altimeter 30.05 inch-       base portion of the flight; however, about a 1/2

A-54 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                               AppendixA



mile out he lost sight of the airplane. He also         Probable cause
indicated that the pilot stated that he lost sight of   Not available at time of publication.
the airport. The witness heard the airplane make
a turn to the right and fade away into the fog at a     ASF comments
low power setting. He waited for the pilot to con-      Preliminary. The Northern California Coast is
tact him, but did not get an answer. The witness        legendary for late afternoon fog formation dur-
stated that he thought the pilot had gone onto          ing the autumn months. Clear skies had been
Ukiah because of the weather. The witness fur-          reported at the airport of intended landing up
ther stated that the engine sounded normal, it          until a half hour prior to the pilot’s arrival over-
was just at a low power setting.                        head. A ground witness reported seeing the
                                                        accident aircraft on a downwind/base leg. It is
The airport manager was sitting in his living           not clear at this point, however, if the pilot had
room and heard an airplane fly overhead. He             established visual contact with the airport.
then received a page from the fire department of        Although the layer of fog was reportedly a “cou-
a possible airplane down. He attempted to make          ple of hundred feet thick” it was forming slowly.
contact with the airplane, checked both ends of         Likely, the pilot had occasional visual contact
the runway, but didn’t receive a response or see        with the ground arriving in the vicinity of the
the airplane. He stated that the runway lights          airport. The temptation to continue a flight VFR
were illuminated. The airport manager called the        under these conditions can be compelling.
Ukiah airport, but the airplane was not there. He       Near-dark conditions, visibility down to 1 mile
then called air traffic control (ATC) to see if they    in fog combined with low altitude maneuvering
had talked to the pilot but received a negative         can tax even the most experienced of aviators.
response. He reported that the Coast Guard              Clear skies and good visibility were reported just
searched for the airplane until about 2000, but         a few minutes flight inland. This instrument-
left because of weather. He further indicated that      rated pilot had many options available.
about 2130 the ground search was called off
because of weather.




                                                                          Technically Advanced Aircraft | www.aopa.org/safetycenter A-55
AppendixA                                                                                                    AOPA Air Safety Foundation




                             Mooney Accidents

                             NYC99LA129
                             Date/Time        Aircraft             N Number         Operation        Accident            Aircraft
                                                                                                     Phase               Damage
                             05/27/1999 Mooney M20R                N496DE           Personal         Landing             Substantial
                             2100 EDT         IO-550G


                             Injuries         Fatal                Serious          Minor            None
                             Crew             0                    0                0                2
                             Passengers       0                    0                0                0
                             Ground           0                    0                0                0


                             Location         Ravenna, OH                           Flight Plan      None
                             Itinerary        Mansfield, OH—Ravenna, OH             Runway           27
                             Airport          Portage County (29G)


                             Weather          VFR                  Precipitation    None             Wx Briefing         UNK
                             Visibility       10 sm                Clouds           None             Type                N/A
                             Wind             240/04               Ceiling          Clear
                             Gusts            None                 Lighting         Night


                             Experience                            Hours
                             Certificate      Private              Total            1750             Last 90 Days        60
                             Instrument       None                 Make             200              Last 30 Days        30
                             Curr. Medical Yes                     Instmt


                            SUMMARY                                                 way, down a grass embankment, across a
                            A Mooney M20R was substantially damaged                 drainage ditch, and struck a large cement box.
                            while landing at the Portage County Airport
                            (29G), in Ravenna, Ohio. The certificated private       Probable cause
                            pilot and passenger were not injured. VMC pre-          The pilot’s improper flare, which resulted in a
                            vailed and no flight plan had been filed.               hard landing, and his failure to maintain direc-
                                                                                    tional control after touchdown.
                            In a written statement, the pilot said, “I landed
                            hard and bounced. The approach was good and             ASF comments
                            normal. Winds were light and from the west.             This pilot’s decision to go-around can’t be fault-
                            After bouncing I added power to go around               ed, however his subsequent decision to terminate
                            because I couldn’t see the runway or lights. After      the go-around and attempt to land is puzzling.
                            power was added I did not feel that I was getting       Short of any mechanical problems with the air-
                            a positive rate of climb. The airplane just seemed      plane (subsequent examination by an FAA
                            to just hang there. At this time I was just trying to   inspector revealed none) remaining airborne
                            see the runway lights. I could not make them out.       would have been a better course of action. The
                            After feeling that I wasn’t climbing I cut the          go-around is a seldom-practiced maneuver, par-
                            power and landed.”                                      ticularly by pilots who have left the training
                                                                                    regime. It requires strict adherence to the manu-
                            The airplane landed on the right side of the run-       facture’s recommended procedure.
                            way, it then veered off the right side of the run-

A-56 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                            AppendixA




MIA99LA211
Date/Time        Aircraft            N Number        Operation        Accident             Aircraft
                                                                      Phase                Damage
08/01/1999 Mooney M20R               N9169E          Personal         Go-around            Substantial
1026 EDT         IO-550G


Injuries         Fatal               Serious         Minor            None
Crew             0                   0               0                1
Passengers       0                   0               0                0
Ground           0                   0               0                0


Location         Reidville, NC                       Flight Plan      None
Itinerary        Moneta, VA—Greensboro, NC           Runway           UNK
Airport          Rockingham County Shiloh (78N)


Weather          VFR                 Precipitation   None             Wx Briefing          Yes
Visibility       9 sm                Clouds          SCT 13,000       Type                 Wx service
Wind             300/08              Ceiling         BKN 25,000
Gusts            None                Lighting        Daylight


Experience                           Hours
Certificate      Private             Total           426              Last 90 Days         18
Instrument       None                Make            18               Last 30 Days         5
Curr. Medical Yes                    Instmt          51




SUMMARY                                              Probable cause
A Mooney M20R crashed on landing at Rocking-         The pilot’s failure to maintain airspeed and ade-
ham County NC Shiloh Airport (N45), Reidville,       quately compensate for torque and P-factor,
North Carolina. VMC prevailed and no flight plan     resulting in the loss of directional control, colli-
was filed. The airplane was substantially dam-       sion with hangars, and substantial damage to the
aged, but there were no injuries.                    aircraft during the attempted go around/recovery
                                                     from a landing.
The pilot said that he decided to practice land-
ings at Rockingham County Shiloh Airport before      ASF comments
going on to Greensboro, North Carolina. The first    This 280-horsepower Mooney proved to be diffi-
landing was uneventful, but during the second        cult to control for the relatively low-time-in-type
landing, the aircraft bounced twice. When full       private pilot. He is to be commended for recog-
power was applied to initiate the go-around after    nizing his need to practice landings. Perhaps the
the second bounce, the pilot stated that he lost     best course of action would have been to practice
directional control and the aircraft banked to the   under the supervision of a qualified CFI who
left, collided with hangars, and incurred substan-   could provide proper guidance. The learning
tial damage.                                         curve is rather steep at first for a private pilot
                                                     transitioning from low-powered trainers to high-
                                                     er horsepower, retractable-gear singles.



                                                                       Technically Advanced Aircraft | www.aopa.org/safetycenter A-57
AppendixA                                                                                                  AOPA Air Safety Foundation




                            LAX00LA352

                            Date/Time        Aircraft            N Number         Operation        Accident            Aircraft
                                                                                                   Phase               Damage
                            09/27/2000 Mooney M20S               N68FM            Personal         Landing             Substantial
                            1820 PDT         IO-550-G


                            Injuries         Fatal               Serious          Minor            None
                            Crew             0                   0                1                0
                            Passengers       0                   0                0                0
                            Ground           0                   0                0                0


                            Location         San Carlos, CA                       Flight Plan      None
                            Itinerary        Prescott, AZ—San Carlos, CA          Runway           30
                            Airport          San Carlos, CA (SQL)


                            Weather          VFR                 Precipitation    None             Wx Briefing         UNK
                            Visibility       20                  Clouds           SCT 2,000        Type                N/A
                            Wind             270/10              Ceiling          BKN 20,000
                            Gusts            None                Lighting         Daylight


                            Experience                           Hours
                            Certificate      Private             Total            230              Last 90 Days        UNK
                            Instrument       None                Make             30               Last 30 Days        UNK
                            Curr. Medical Yes                    Instmt           1



                            SUMMARY                                               the wing flaps in the 10 [degree] position.” He
                            A Mooney M20S was substantially damaged on            said the airplane began to veer to the left of the
                            impact with a hangar during an aborted land-          runway and, although he applied right rudder
                            ing at San Carlos Airport (SQL), San Carlos,          and right aileron, the drift to the left continued.
                            California. The private pilot, the sole occupant,     The stall warning horn never sounded prior to
                            received minor injuries. VMC prevailed.               the left wingtip hitting the hangar. The pilot
                                                                                  also reported there were no mechanical mal-
                            Witnesses reported that the pilot’s first landing     functions with the airplane, however, during
                            approach to Runway 30 was too high and the            the attempted go-around, it didn’t feel or sound
                            aircraft performed a go-around. The second            as if the engine was producing full power.
                            approach to the same runway was also high
                            and when the aircraft touched down it began to        In a telephone interview with the NTSB investi-
                            porpoise. After two bounces, it appeared that         gator, the pilot stated that the flying day had
                            the pilot attempted another go-around, howev-         started in San Antonio, Texas, with a fuel stop in
                            er, the aircraft drifted off the runway to the left   Prescott, Arizona, and then continued to San
                            and the left wing struck a hangar in the north-       Carlos. The en route flying time was 7.5 hours
                            west corner of the airport. The aircraft came to      at 8,500 feet, without supplemental oxygen, and
                            rest between two rows of hangars.                     the pilot acknowledged that fatigue might have
                                                                                  been a factor in the accident.
                            The pilot reported that he attempted the go-
                            around after several bounces by placing “the          Probable cause
                            power to full, verified mixture rich, and placed      The pilot’s failure to maintain directional con-

A-58 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                            AppendixA



trol of the airplane during an aborted
landing.

ASF comments
This relatively low-time private pilot was wise to
initiate a go-around following his first landing
attempt. A go-around from low altitude, in this
case, after several bounces, is a maneuver that
must be delicately performed. The aircraft is very
close to stall speed when full power is applied. In
this condition, p-factor is at it’s greatest. A
healthy dose of right rudder must be gently
applied as power is applied to maintain direc-
tional control of the airplane. At the same time,
attention must be given to the flaps, spoilers,
landing gear and propeller. Although the go-
around maneuver is a required portion of the pri-
vate pilot curriculum, it is usually practiced in
“clean” conditions. Typically, a CFI will instruct a
student who has arrived over the threshold a little
high and/or fast to “go-around” to test the stu-
dent’s ability to correctly perform the maneuver.
Rarely in the course of flight training do we prac-
tice a go-around halfway down the runway fol-
lowing an improper recovery from a bounced
landing or a pilot induced oscillation. Perhaps
this type of go-around ought to be included in
the flight training curriculum, particularly for
lower time pilots transitioning to higher-per-
formance airplanes.




                                                       Technically Advanced Aircraft | www.aopa.org/safetycenter A-59
AppendixA                                                                                                    AOPA Air Safety Foundation




                             CHI01LA061

                             Date/Time        Aircraft            N Number         Operation         Accident             Aircraft
                                                                                                     Phase                Damage
                             01/01/2001 Mooney M20S               N2184N           Personal          Landing              Substantial
                             1245 EST         IO-550-G6


                             Injuries         Fatal               Serious          Minor             None
                             Crew             0                   0                0                 1
                             Passengers       0                   0                0                 0
                             Ground           0                   0                0                 0


                             Location         Port Huron, MI                       Flight Plan       None
                             Itinerary        Detroit, MI—Port Huron, MI           Runway            04
                             Airport          St. Clair County (PHN)


                             Weather          VFR                 Precipitation    None              Wx Briefing          None
                             Visibility       10                  Clouds           None              Type                 N/A
                             Wind             270/11              Ceiling          Clear
                             Gusts            18                  Lighting         Daylight


                             Experience                           Hours
                             Certificate      Private             Total            168               Last 90 Days         80
                             Instrument       None                Make             92                Last 30 Days         14
                             Curr. Medical Yes                    Instmt           12



                            SUMMARY                                                He reported he applied power to recover, but could
                            A Mooney M20S operated by a private pilot collided     not gain enough airspeed. The airplane veered to
                            with a snow bank while landing on Runway 4 at St.      the right and the right main landing gear hit the
                            Clair County International Airport (PHN) in Port       snow on the side of the runway. According to the
                            Huron, Michigan. The pilot was not injured, but the    pilot, the airplane spun around clockwise into the
                            airplane was substantially damaged. The pilot          snow where it came to rest.
                            reported he flew a practice ILS approach to Runway
                            4 at PHN. The approach was terminated in a go-         The local weather report, taken 5 minutes prior to
                            around followed by a VFR traffic pattern and full      the accident, was winds from 270 degrees at 11
                            stop landing on Runway 4.                              knots, gusting to 18 knots.

                            The pilot reported the winds were out of the           Probable cause
                            northwest at 10 knots. He then departed on, and        The pilot failed to maintain directional control of
                            made a left hand traffic pattern for, another land-    the airplane and the runway selected resulted in a
                            ing. The pilot reported, “Final approach required      tailwind condition.
                            minimal crab to correct for crosswind and then
                            mild slip to maintain the centerline.” He reported     Factors
                            that just prior to touchdown while 2 feet above        Factors associated with the accident were the gusty
                            the runway “…a significant gust ballooned the          crosswind and the snow bank.
                            aircraft 5 to 6 feet above the runway where the
                            aircraft stalled and began to settle abruptly with a   ASF comments
                            nose high attitude.”                                   A quartering tailwind is a difficult component to

A-60 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                           AppendixA



factor into any landing. Selection of a runway more
in line with the winds would have eliminated this
factor. The first sign of trouble on a landing is
the proper time to give consideration to abort-
ing the landing. The pilot reported he “applied
power to recover, but could not gain enough
airspeed.” This was no time for a salvage job.
Go-around power would have been in order,
not to salvage the landing, but to perform a go-
around, regroup, and reattempt.




                                                      Technically Advanced Aircraft | www.aopa.org/safetycenter A-61
AppendixA                                                                                                    AOPA Air Safety Foundation




                            MIA01FA071

                            Date/Time        Aircraft            N Number         Operation          Accident              Aircraft
                                                                                                     Phase                 Damage
                            02/04/2001 Mooney M20R               N88FJ            Personal           Climb                 Destroyed
                            1318 EST         IO-550-G


                            Injuries         Fatal               Serious          Minor              None
                            Crew             1                   0                0                  0
                            Passengers       1                   0                0                  0
                            Ground           0                   0                0                  0


                            Location         Bluffton, SC                         Flight Plan        IFR
                            Itinerary        Savannah, GA—Lumberton, NJ           Runway             N/A
                            Airport          N/A


                            Weather          IFR                 Precipitation    Mist               Wx Briefing           Yes
                            Visibility       4 sm                Clouds           OVC                Type                  FSS
                            Wind             360/08              Ceiling          700 feet
                            Gusts            None                Lighting         Daylight


                            Experience                           Hours
                            Certificate      Private             Total            425                Last 90 Days          UNK
                            Instrument       Yes                 Make             303                Last 30 Days          UNK
                            Curr. Medical Yes                    Instmt           97



                            SUMMARY                                               time of the accident said that he heard the air-
                            A Mooney M20R, operated by a private individual       craft pass overhead, and the engine sounded as if
                            as a Part 91 personal flight, crashed in Bluffton,    it was operating normally, and another witness
                            South Carolina. Instrument meteorological con-        stated that she was outside on the porch and she
                            ditions prevailed and an IFR flight plan was filed.   heard, as well as saw the accident aircraft, at a
                            The private-rated pilot and one passenger             very low altitude prior to its impact. She said that
                            received fatal injuries, and the aircraft was         as the aircraft was descending, one wing was low
                            destroyed. The flight originated from Savannah/       as if it was in a turn, just prior to it impacting,
                            Hilton Head International Airport (SAV) in            and bursting into flames. She also stated that the
                            Savannah, Georgia, the same day, about 1309.          engine sounded as if it was operating normally
                                                                                  prior to the impact.
                            Several witnesses on Highway 170 at the time of
                            the accident saw a wall of fire extending about 40    Information obtained from the FAA showed that
                            feet in the air, along with scattered and burning     the pilot had been in radio communications con-
                            debris. They heard a corresponding “swooshing”        tact with the Savannah North Radar Controller, and
                            sound, as a fireball of burning debris crossed the    had received a clearance to turn the aircraft to a
                            four-lane highway. One witness said that upon         heading of 080 degrees, and to climb to and main-
                            seeing the debris he stopped his vehicle, some-       tain 3,000 feet. At 1312, the pilot verified his alti-
                            how concluding that it could only have been an        tude to be 3,000 feet, and at 1313, the radar con-
                            aircraft that had crashed, and he went in to the      troller coordinated with Marine Beaufort Approach
                            wooded areas to see if he could offer any assis-      Control, the next air traffic control facility along the
                            tance. A witness who was inside his house at the      intended route of flight, to affect a radio communi-

A-62 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                               AppendixA



cations handoff. At 1316:19, the pilot checked into     medical certificate, issued on September 25,
Beaufort’s airspace. At 1316:22, the Marine Beau-       2000, showed that at the time of the application
fort Approach controller responded, “Mooney-            he reported having 425 flight hours, of which 65
Eight-Eight-Foxtrot-Juliet Beaufort Approach.           flight fours were flown in the past six months.
Beaufort altimeter Three Zero One Eight.”               The medical certificate had the limitation that he
                                                        must have available his spectacles for near vision,
At 1316:26, the pilot responded, “Three Zero One        and that his certificate was valid only for 12
Eight Fox-Juliet.”                                      months following the month he had been exam-
                                                        ined. The pilot attended Flight Safety
At 1318:18, the pilot stated, “And Beaufort             International’s Mooney initial flight training
Mooney-Eight-Eight-Foxtrot-Juliet,” to which the        course, from September 9 to September 11, 1999.
Marine Beaufort controller responded two times,
requesting that the pilot “Say intentions,” but a       Meteorological information
reply was never received. Subsequent attempts by        The SAV surface weather observation at 1253 was
both Marine Beaufort Approach and Savannah              winds from 360 degrees at 8 knots, visibility 10
North Radar controllers to reestablish communi-         statute miles, ceiling 700 feet overcast, tempera-
cations with the pilot also yielded negative results.   ture 48 degrees F, dewpoint temperature 45
                                                        degrees F, altimeter setting 30.20 inches of
According to the Marine Beaufort Approach con-          Mercury. Savannah International Airport is located
troller, radar data showed that at 1316:20, the         about 18 nautical miles, southwest of the accident
accident airplane was on a heading of 070, at an        site, at an elevation of 50 feet.
altitude of 2,900 feet, and had a ground speed of
190 knots. At 1318:25, when the controller repeat-      The Beaufort Marine Corps Air Station surface
ed the request that the pilot, “Say intentions,” the    weather observation at 1322 was winds from 360
accident airplane was on a heading of 230, at an        degrees at 7 knots, visibility 4 statute miles, mist,
altitude of 2,400 feet, and a ground speed of 170       ceilings 600 feet broken, 1,000 feet broken, 2,000,
knots. Savannah North radar data also showed            feet overcast, temperature 46 degrees F, dewpoint
the aircraft in a descending right turn, with the       temperature 45 degrees F, altimeter setting 30.17
last radar indication occurring at 1318:36, at an       inches of Mercury.
altitude of 1,700 feet. There was no further com-
munications or radar contact.                           Probable cause
                                                        The pilot’s failure to maintain control because of
The Mooney collided with high-voltage utility           spatial disorientation.
wires, and impacted the ground in the vicinity of
the intersection of highways US278 and SC170,           ASF comments
spreading burning debris over a large area.             Weather for this flight was honest-to-goodness-IFR
                                                        weather. Low ceilings and visibilities below the
Personal information                                    cloud bases existed and precipitation was reported.
FAA records indicate that the pilot held an FAA         The pilot was instrument rated and the Mooney
private pilot certificate, with an airplane single-     was adequately equipped for IFR flight. All we
engine land rating, which had been issued on            know of the last few minutes of flight is from radar
November 4, 1996. On January 15, 2000, the pilot        tracks obtained from ATC as well as Mode C
added an airplane instrument rating. Logbooks           returns. Normal ATC communications were con-
were not obtained by the NTSB, but the pilot’s          ducted for the first 9 minutes of the flight, and the
application for the instrument rating, dated            pilot said nothing that would indicate any onboard
January 15, 2000, showed that at the time of his        problems. The radar returns show the aircraft in a
application for the rating, he reported having had      descending right turn starting at 3,000 feet and
a total of 366 flight hours, of which about 303         continuing until radar contact was lost at 1,700 feet
flight hours were in similar aircraft to the acci-      msl. A descending spiral is often the result of spa-
dent airplane. He also reported having had 97           tial disorientation. If the pilot even saw the ground
hours of instrument flight experience at the time       upon emerging from the clouds, it was too late to
of his application for the instrument rating. The       begin a recovery in VMC. Cloud bases were report-
pilot’s last application for an FAA third-class         ed as low as 600 feet in the vicinity of the wreckage.




                                                                          Technically Advanced Aircraft | www.aopa.org/safetycenter A-63
AppendixA                                                                                                     AOPA Air Safety Foundation




                             NYC02LA022

                             Date/Time        Aircraft             N Number         Operation         Accident              Aircraft
                                                                                                      Phase                 Damage
                             10/31/2001 Mooney M20S                N1008R           Instructional     Landing               Substantial
                             1830 EDT         IO-550-G


                             Injuries         Fatal                Serious          Minor             None
                             Crew             0                    0                0                 2
                             Passengers       0                    0                0                 2
                             Ground           0                    0                0                 0


                             Location         Buckhannon, WV                        Flight Plan       None
                             Itinerary        Lewisburg, WV—Buckhannon, WV Runway                     29
                             Airport          Upshur County Regional (W22)


                             Weather          VFR                  Precipitation    None              Wx Briefing           UNK
                             Visibility       10 sm                Clouds           None              Type                  N/A
                             Wind             150/03               Ceiling          Clear
                             Gusts            None                 Lighting         Daylight


                             Experience                            Hours
                             Certificate      Commercial           Total            787               Last 90 Days          137
                             Instrument       Yes                  Make             24                Last 30 Days          30
                             Curr. Medical Yes                     Instmt           392



                            SUMMARY                                                 the CFI to take the flight controls for the landing.
                            A Mooney M20S was substantially damaged while           The airplane arrived without incident.
                            landing at Upshur County Regional Airport (W22),
                            in Buckhannon, West Virginia. The CFI, private          The flight departed LWB, with the private pilot at
                            pilot, and two passengers were not injured. Night       the controls, and proceeded to W22.
                            VMC prevailed and an IFR flight plan was filed for
                            the instructional portion of flight.                    Arriving at W22, the private pilot entered a stan-
                                                                                    dard left traffic pattern for Runway 29. As the air-
                            According to the CFI, he had been giving the pri-       plane was on left base, the private pilot again
                            vate pilot dual instruction towards an instrument       asked the CFI to take the flight controls for the
                            rating since October 1, 2001 in a Cessna 172; how-      final approach and landing.
                            ever, the private pilot also wanted to receive some
                            dual training in the Mooney.                            During the final approach, the descent angle, air-
                                                                                    speed, and altitude all appeared normal. The CFI
                            The flight plan was to fly from Clarksburg (CKB),       verified that the before-landing checklist was com-
                            West Virginia, to Lewisburg (LWB), West Virginia,       pleted and that all the occupants had their safety
                            pick up two passengers, fly to W22, drop off the        belts on and secured. Upon reaching what the CFI
                            passengers, and proceed back to CKB as a final          perceived as the flare position, he pulled back on
                            destination. The flight to LWB was conducted with       the yoke in preparation for landing. He realized
                            the private pilot at the controls from the left seat,   that the airplane had not touched down on the
                            while the CFI gave dual instruction from the right      runway, and became concerned that a safe land-
                            seat. Upon arriving at LWB, the private pilot asked     ing could not be made. At that point, the CFI “felt

A-64 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                             AppendixA



a heavy sink rate...along with a flared pitch atti-
tude.” As he applied full throttle to abort the land-
ing, the airplane touched down hard on the run-
way, collapsing the landing gear.

Probable cause
The CFI’s improper flare, which resulted in a hard
landing.

ASF comments
The private pilot in the left seat was wise to recog-
nize his limitations and relinquish the controls to
his instructor. The instructor’s actions, however,
might indicate that his limited experience in type
prevented him from carrying out his duties as a
CFI properly. The duties of a CFI are twofold. First
and foremost, he or she must be able to carry out
the full duties of pilot in command from either the
right or left front seat. Second, a CFI must be able
to convey the principle being taught effectively to
the student trainee.




                                                        Technically Advanced Aircraft | www.aopa.org/safetycenter A-65
AppendixA                                                                                                   AOPA Air Safety Foundation




                             MIA02LA125

                             Date/Time        Aircraft            N Number         Operation        Accident             Aircraft
                                                                                                    Phase                Damage
                             07/02/2002 Mooney M20R               N2043N           Personal         Go-around            Substantial
                             1430 EDT         IO-550G6B


                             Injuries         Fatal               Serious          Minor            None
                             Crew             0                   0                0                1
                             Passengers       0                   0                0                0
                             Ground           0                   0                0                0


                             Location         Mt. Pleasant, SC                     Flight Plan      IFR
                             Itinerary        Marietta, GA—Mt. Pleasant, SC        Runway           UNK
                             Airport          East Cooper (8S5)


                             Weather          VFR                 Precipitation    None             Wx Briefing          UNK
                             Visibility       10 sm               Clouds           SCT 3,600        Type                 UNK
                             Wind             070/05              Ceiling          None
                             Gusts            None                Lighting         Daylight


                             Experience                           Hours
                             Certificate      Private             Total            2185             Last 90 Days         35
                             Instrument       None                Make             875              Last 30 Days         10
                             Curr. Medical Yes                    Instmt           UNK




                            SUMMARY                                               Probable cause
                            A Mooney M20R crashed while the pilot was             The pilot’s failure to maintain airspeed resulting
                            attempting a go-around at East Cooper Airport         in a stall, an uncontrolled descent, and an impact
                            (8S5), Mt. Pleasant, South Carolina . VMC pre-        with the ground during the attempted go-
                            vailed, and an IFR flight plan was filed. The air-    around.
                            plane sustained substantial damage, but the pri-
                            vate pilot received no injuries.                      ASF comments
                                                                                  Training go-arounds is usually conducted in con-
                            The pilot stated that it had been a routine flight    ditions much more sterile than this case. That is,
                            all the way to short final, but the approach speed    an instructor will call “go-around” to a student on
                            was a little fast, and the airplane touched down      short final in order to test the student’s ability to
                            about a third of the way down the runway. He          correctly perform the maneuver. In a training sit-
                            said it bounced once and he pulled back on the        uation, it is usually not feasible to simulate the
                            yoke expecting it to settle to the runway, but it     conditions that led up to this go-around. Multiple
                            bounced again. The nose was high so he added          bounces, inadvertent flap retraction, and possi-
                            power to affect a go-around, but the airplane did     ble improper rudder input at a slow speed proved
                            not climb as he expected. He activated the flap       to be more than this pilot could handle.
                            control, intending to raise the flaps just a notch,
                            but accidentally raised the flaps all the way, and
                            the airplane yawed to the left and descended,
                            impacting the ground.

A-66 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                             AppendixA




IAD03FA039

Date/Time         Aircraft             N Number        Operation        Accident             Aircraft
                                                                        Phase                Damage
03/20/2003 Mooney M20R                 N1005P          Personal         Approach             Destroyed
1945 EST          IO-550


Injuries          Fatal                Serious         Minor            None
Crew              1                    0               0                0
Passengers        0                    0               0                0
Ground            0                    0               0                0


Location          Leesburg, VA                         Flight Plan      IFR
Itinerary         Youngstown, OH—Leesburg, VA          Runway           17 (Localizer approach)
Airport           Leesburg Executive (JYO)


Weather           VFR                  Precipitation   None             Wx Briefing          Yes
Visibility        10 sm                Clouds          BKN 3,400 feet Type                   WX service
                                                       BKN 4,100 feet
                                                       OVC 5,500 feet
Wind              280/03               Ceiling         3,400 feet
Gusts             None`                Lighting        Night


Experience                             Hours
Certificate       Private              Total           786              Last 90 Days         UNK
Instrument        Yes                  Make            42               Last 30 Days         UNK
Curr. Medical Yes                      Instmt          295

SUMMARY                                                onds, then rolled into a 60-degree left bank. The
A Mooney M20R was destroyed when it collided           airplane then rolled wings level, “suddenly”
with terrain while on final approach to Leesburg       pitched over, and the nose of the airplane “went
Executive Airport (JYO), Leesburg, Virginia. The       straight down” toward the ground. It did not
certificated private pilot/owner was fatally           spin.
injured. An IFR flight plan was filed for the flight
that originated at Youngstown-Warren Regional          The student also said it was night, there was a
Airport (YNG), Youngstown-Warren, Ohio, about          light drizzle, and it was not windy. He did not see
1820. Visual meteorological conditions prevailed       the airplane fly through any clouds or fog.
for the personal flight.
                                                       A second witness, who was standing in the back-
Several witnesses observed and heard the air-          yard of a townhouse about a mile from the end of
plane. According to one witness, a student pilot       the runway, said that the airplane passed directly
in his truck stopped at a traffic light, when he       over his head about 25 to 30 feet above the town-
first observed the airplane above and to the left      house. The airplane’s engine was not operating,
of his position.                                       and all he heard was a “swoosh” of wind as it
                                                       passed by. He could not see the airplane, but did
He said the airplane appeared to be turning            observe its lights through the fog. Shortly after
onto a 1-mile final, when it suddenly made a           the witness lost sight of the airplane, he heard a
60-degree right bank and started a right turn.         “loud crashing noise.”
The airplane stayed in the bank for about 5 sec-

                                                                        Technically Advanced Aircraft | www.aopa.org/safetycenter A-67
AppendixA                                                                                                        AOPA Air Safety Foundation




                            He also noted that it was dark and foggy, and that it     plane. His most recent Federal Aviation
                            had stopped raining about 30 minutes prior to the         Administration (FAA) third-class medical certificate
                            accident.                                                 was issued on November 23, 2002.

                            A third witness, who lived across the street from the     Examination of the pilot’s logbook revealed that he
                            accident site, was in his home when he simultane-         had accrued a total of 786 flight hours of which 42
                            ously heard a “strong wind sound” and a loud bang         hours were in make and model.
                            on the south side of his home, followed by a “drag-
                            ging” noise, “similar to ice falling from [his] roof.”    Communications
                            He then heard a loud “crashing noise” outside. The        Review of air traffic control communications
                            witness also noted that he did not hear the air-          revealed that the pilot was instructed to proceed
                            plane’s engine operating prior to the accident.           direct to STILL intersection, and intercept the local-
                                                                                      izer course for the LOC RWY 17 approach. The pilot
                            He responded to the accident site and observed fuel       acknowledged, and also reported that he had the
                            leaking from the airplane. He said it was not rain-       current weather information at the airport.
                            ing, it was not windy, and the sky was clearing.
                            Subsequent examination of his home revealed no            At 1937, when the airplane was about 6 nautical
                            damage.                                                   miles from STILL intersection, the approach con-
                                                                                      troller cleared the pilot for the approach, and
                            A review of radar data revealed that an instrument        instructed him to cross STILL intersection at or
                            flight rules target, with the same transponder code       above 3,000 feet. The pilot acknowledged.
                            assigned to the accident airplane, approached
                            Leesburg Airport from the north. Examination of           About 3 minutes later, the approach controller
                            the last 8 minutes of radar data revealed that the        advised the pilot twice that he was about 1 mile east
                            target was initially 16 nautical miles north from the     of the localizer course. The pilot acknowledged
                            end of Runway 17. It then made five to six turns          both advisories, and stated that he was “correcting”
                            along and across the localizer course, left and right,    his course.
                            as it proceeded toward the airport.
                                                                                      When the airplane was 2 nautical miles north of
                            When the target was about 16 nautical miles north         WARDE intersection, the approach controller
                            of the runway, the Mooney was at an altitude of           informed the pilot that he appeared to be on the
                            5,800 feet msl, at a groundspeed of 186 knots.            localizer course. The pilot acknowledged.

                            Then, abeam STILL intersection, about 10 nautical         At 1942, when the airplane was 1 nautical mile
                            miles north of the runway, it was at an altitude of       north of WARDE intersection, the approach con-
                            4,100 feet msl, at a groundspeed of 142 knots.            troller terminated radar services, approved a
                                                                                      change in advisory frequency, and told the pilot to
                            After crossing over WARDE intersection, the               report when he cancelled IFR services. The pilot
                            Mooney was at an altitude of 2,000 feet msl, at a         acknowledged, and cancelled IFR services with the
                            groundspeed of 127 knots.                                 controller. The controller then advised the pilot that
                                                                                      IFR services were cancelled, and to maintain his
                            Approximately 1 mile from the end of the runway,          current transponder beacon code until he was on
                            the aircraft began a left, 360-degree turn at an alti-    the ground. The pilot acknowledged, and there
                            tude of 1,600 feet msl, at a groundspeed of 98 knots.     were no further communications from him.
                            The turn was completed within a radius of approxi-
                            mately 0.2 nautical miles. Upon completion of the         Probable cause
                            turn, the Mooney was at an altitude of 1,000 feet         Not available at time of publication.
                            msl.
                                                                                      ASF comments
                            The aircraft then continued to track toward the           Preliminary.The pilot was having difficulty with
                            airport. Approximately 20 seconds later, it began         proper instrument procedures. That he even
                            a left turn to the east, just before the data ended       arrived over WARDE intersection (the FAF) at 2,000
                            at 1945. The last radar return showed an altitude         feet msl with a groundspeed of 127 knots is some-
                            of 900 feet msl.                                          what of a feat considering when on a 16-mile final
                                                                                      he was more than 1,000 feet high on the descent
                                                                                      profile with a groundspeed of 186 knots. The
                            Personal information                                      Mooney is famous for its speed. This is a result of an
                            The pilot held a private pilot certificate with ratings   aerodynamically clean wing. Merely pointing the
                            for single-engine land and sea, and instrument air-       nose down and reducing power doesn’t produce

A-68 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                               AppendixA



quite the same result as it might in a slower training
aircraft. While struggling with tracking the localizer,
the pilot was also concentrating on slowing to gear
extension speed, all the while realizing that he
might be too high and fast to conduct a straight-in
landing out of the approach. The decision to com-
mence a 360-degree turn on short final is com-
mendable. His execution of the maneuver for some
reason produced a stall/spin situation from which
recovery was impossible at low altitude. A recently
purchased airplane, low time in type, night IMC,
and possibly an unfamiliar approach put too much
on the plate of this 786-hour private pilot.




                                                          Technically Advanced Aircraft | www.aopa.org/safetycenter A-69
AppendixA                                                                                                   AOPA Air Safety Foundation




                            FTW04LA053

                            Date/Time        Aircraft             N Number        Operation        Accident             Aircraft
                                                                                                   Phase                Damage
                            01/01/2004 Mooney M20R                N5284C          Personal         Cruise               Substantial
                            1515 CST         IO-550G


                            Injuries         Fatal                Serious         Minor            None
                            Crew             0                    0               1                0
                            Passengers       0                    0               1                0
                            Ground           0                    0               0                0


                            Location         Sheridan, AR                         Flight Plan      IFR
                            Itinerary        Walnut Ridge, AR—Brownsville, TX Runway               N/A
                            Airport


                            Weather          VFR                  Precipitation   None             Wx Briefing          Yes
                            Visibility       10 sm                Clouds          SCT 900 feet Type                     FSS
                            Wind             190/13               Ceiling         BKN 2,700 feet
                            Gusts            None                 Lighting        Daylight


                            Experience                            Hours
                            Certificate      Private              Total           4,800            Last 90 Days         65
                            Instrument       Yes                  Make            1825             Last 30 Days         9
                            Curr. Medical Yes                     Instmt          UNK




                            SUMMARY                                               vectored by the air traffic controller toward 9M8;
                            A Mooney M20R was substantially damaged               however, the airplane was unable to make the
                            when it impacted the ground during a forced           runway.
                            landing following a loss of engine power while
                            diverting to Sheridan Municipal Airport (9M8),        Information obtained from the Little Rock Air
                            Sheridan, Arkansas. The instrument-rated private      Route Traffic Control Center (ARTCC) indicated
                            pilot and passenger received minor injuries. IMC      that the pilot reported the airplane’s engine was
                            prevailed and an IFR flight plan was filed for the    “running rough,” and he was diverting to 9M8. In
                            personal flight.                                      addition, the pilot reported that he had the air-
                                                                                  field in sight and was landing. However, the air-
                            The 4,800-hour pilot reported that the fuel tanks     plane landed in a wooded area of “stumps and
                            were topped-off with 82 gallons at Walnut Ridge       branches,” about 2.5 miles northeast of 9M8.
                            Airport (ARG) in Walnut Ridge, Arkansas. One
                            hour into the flight from ARG to Brownsville          Examination of the airplane by an FAA inspector
                            Airport (BRO) in Brownsville, Texas, the pilot        revealed that the right fuel tank contained
                            “switched to the right tank, and about 5 minutes      approximately 25 gallons of fuel, and the left fuel
                            later the engine stopped.” I went back to the left    tank was empty. The fuel selector valve was
                            tank and tried to restart the engine several times.   observed to be in the Left tank position.
                            At one time I got 14 to 15 inches of manifold
                            pressure for a few seconds, and then it stopped       On February 24, 2004, an examination of the
                            again.” The pilot declared an emergency and was       engine was conducted at a maintenance facility

A-70 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                            AppendixA



in Mena, Arkansas, under the supervision of an
FAA inspector. From a test truck, the engine ran
for 10 minutes, with no anomalies.

Probable cause
The loss of engine power due to fuel starvation as
a result of the pilot’s improper positioning of the
fuel tank selector.

Factors
A factor was the lack of suitable terrain for the
forced landing.

ASF comments
Some discrepancy exists between the pilot’s
account of topping off the tanks prior to depar-
ture with 82 gallons and the FAA inspector find-
ing only 25 gallons on board after just 75 minutes
flying time. Careful verification of fuel quantity
prior to departure is of crucial importance for the
successful completion of any flight. The great cir-
cle distance from the departure point of this
flight to the intended destination is nearly 700
nm. Some pilots have been surprised to exhaust
their fuel supply within sight of their destination.
This fuel-starvation-induced landing occurred
approximately 130 miles into the 700-mile flight.




                                                       Technically Advanced Aircraft | www.aopa.org/safetycenter A-71
AppendixA                                                                                                        AOPA Air Safety Foundation




                            NYC04CA135

                            Date/Time         Aircraft             N Number          Operation          Accident               Aircraft
                                                                                                        Phase                  Damage
                            05/29/2004 Mooney M20R                 N53WM             Personal           Landing                Substantial
                            1130 EDT          IO-550-G6B


                            Injuries          Fatal                Serious           Minor              None
                            Crew              0                    0                 0                  1
                            Passengers        0                    0                 0                  0
                            Ground            0                    0                 0                  0


                            Location          Warren, VT                             Flight Plan        None
                            Itinerary         Bedford, MA—Warren, VT                 Runway             04
                            Airport           Warren-Sugarbush (0B7)


                            Weather           VFR                  Precipitation     None               Wx Briefing            Yes
                            Visibility        10 sm                Clouds            OVC                Type                   WX service
                            Wind              310/14               Ceiling           6,000 feet
                            Gusts             21                   Lighting          Daylight


                            Experience                             Hours
                            Certificate       Commercial           Total             913                Last 90 Days           42
                            Instrument        None                 Make              757                Last 30 Days           8
                            Curr. Medical Yes                      Instmt            222


                            SUMMARY                                                  Winds reported at an airport located about 13 miles
                            A Mooney M20R was substantially damaged while            northeast of the accident site, and at an elevation of
                            landing at Warren-Sugarbush Airport (0B8) in             1,165 feet, about the time of the accident, were
                            Warren, Vermont. The commercial pilot was not            from 310 degrees, at 14 knots, with 21-knot gusts.
                            injured. VMC prevailed and no flight plan had been
                            filed for the flight that departed Laurence G.           Probable cause
                            Hanscom Field (BED) in Bedford, Massachusetts.           The pilot’s improper flare, which resulted in a hard
                                                                                     landing.
                            According to the pilot, he over flew the airport and
                            did not observe a windsock, however, he was              Factors
                            informed over the Unicom frequency that Runway           A factor in this accident was the wind shear as
                            4 was in use, and he observed an airplane depart         reported by the pilot.
                            from Runway 4.
                                                                                     ASF comments
                            The pilot entered the traffic pattern for Runway 4 at    Although the steady state wind (310/14) was well
                            BED.The airplane was approximately 10 feet above         within the maximum demonstrated crosswind com-
                            the runway, when it encountered a strong winds-          ponent for this Mooney M20R, the wind gusts of up
                            hear and dropped “fast and hard” onto the runway.        to 21 knots could well have exceeded it. A relatively
                            The pilot aborted the landing and was informed           short and narrow (2,500 feet by 25 feet) runway can
                            over the Unicom, that the airplane’s left main land-     be a handful. It is not unusual for wind of this velocity
                            ing gear had separated. The pilot elected to divert to   in mountainous terrain to produce strong low-level
                            Lebanon, New Hampshire, where he performed a             windshear. While it is nearly impossible to plan for
                            gear up landing, without further incident.               this on final approach, “forewarned is forearmed.”

A-72 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                           AppendixA




FTW04CA177

Date/Time        Aircraft            N Number        Operation        Accident             Aircraft
                                                                      Phase                Damage
06/24/2004 Mooney M20R               N9147H          Personal         Landing              Substantial
1515 CDT         IO-550 G5B


Injuries         Fatal               Serious         Minor            None
Crew             0                   0               0                1
Passengers       0                   0               0                0
Ground           0                   0               0                0


Location         Kerrville, TX                       Flight Plan      None
Itinerary        Castroville, TX—Kerrville, TX       Runway           30
Airport          Kerrville Municipal (ERV)


Weather          VFR                 Precipitation   None             Wx Briefing          UNK
Visibility       10 sm               Clouds          SCT 8,000 feet Type                   UNK
Wind             240/06              Ceiling         BKN 9,000 feet
Gusts            None                Lighting        Daylight


Experience                           Hours
Certificate      Private             Total           272              Last 90 Days         28
Instrument       None                Make            63               Last 30 Days         19
Curr. Medical Yes                    Instmt          4


SUMMARY                                              degrees, and full power was applied with right
A Mooney M20R was substantially damaged fol-         aileron and rudder. The airplane was turning left
lowing a loss of control during a landing at         and sinking as it was accelerating. It touched
Kerrville Municipal Airport/Louis Schreiner Field    down on the left wheel and bounced in the grass
(ERV), Kerrville, Texas. The private pilot was not   left of the runway. The nose of the airplane was
injured. VMC prevailed, and a flight plan was not    lowered in an attempt to gain speed, but recovery
filed for the personal flight.                       from the left turn was not possible with the limit-
                                                     ed altitude.
The pilot reported that following his departure
from Castroville Municipal Airport (T89), San        The pilot added that he appeared to have made
Antonio Approach Control was heard vectoring         the approach “into a localized microburst caused
aircraft landing at San Antonio around weather       by unstable air in the area.”
that was developing in the area. The pilot had
planned a full stop at ERV, and a layover until      Witnesses at the airport reported that “dramatic
the weather conditions improved at San               wind shifts” and gusty winds prevailed at the
Antonio. He stated that the localizer approach       time of the accident.
for Runway 30 at ERV was flown with the VASI
lights indicating slightly high. The airplane was    Probable cause
“established and stable” on the approach. The        The pilot’s failure to compensate for existing
pilot noted that his speed over the threshold        wind conditions.
was 80 knots, and at touchdown his speed was
approximately 75 knots. The airplane “bal-           Factors
looned” with the right wing rising about 30          Contributing factors were the gusty high winds.

                                                                      Technically Advanced Aircraft | www.aopa.org/safetycenter A-73
AppendixA                                                                                                 AOPA Air Safety Foundation




                            ASF comments                                         won’t terminate the flight in a surprise manner!
                            A low-altitude go-around in a relatively lightly     The high-performance single is not an untam-
                            loaded, high-performance aircraft demands            able beast. Like the challenge a conventional-
                            exacting piloting skills from any pilot. It is a     gear aircraft is to tricycle gear pilots though, the
                            healthy sign when a pilot recognizes the need        low-time private pilot needs training, discipline
                            to practice. Perhaps it is equally healthy to rec-   and plenty of practice before he or she is ready
                            ognize the need for the right front seat to be       to handle any situation. Remember, sometimes
                            occupied by a CFI who is competent and quali-        the decision not to go is the very first step in
                            fied in the airplane. That way any “surprises”       good aeronautical decision-making.
                            uncovered in your aeronautical understanding




A-74 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                              AppendixA




SEA04LA124

Date/Time         Aircraft             N Number         Operation        Accident            Aircraft
                                                                         Phase               Damage
07/06/2004 Mooney M20R                 N1054K           Personal         Landing             Substantial
1530 MDT          IO-550


Injuries          Fatal                Serious          Minor            None
Crew              0                    0                0                1
Passengers        0                    0                0                0
Ground            0                    0                0                0


Location          Hailey, ID                            Flight Plan      VFR
Itinerary         Salt Lake City, UT—Hailey, ID         Runway           31
Airport           Friedman Memorial (SUN)


Weather           VFR                  Precipitation    None             Wx Briefing         None
Visibility        30                   Clouds           FEW              Type                N/A
Wind              270/08               Ceiling          None
Gusts             None                 Lighting         Daylight


Experience                             Hours
Certificate       Private              Total            2,200            Last 90 Days        46
Instrument        None                 Make             1,650            Last 30 Days        17
Curr. Medical Yes                      Instmt           129


SUMMARY                                                 then attempted to abort the landing by adding
A Mooney M20R sustained substantial damage              full power, reducing the flaps and raising the
following a loss of control while landing at the        landing gear, but the airplane would not acceler-
Friedman Memorial Airport (SUN), Hailey, Idaho.         ate or climb. The airplane stayed in ground effect
The private pilot, sole occupant of the aircraft,       and weaved back and forth (left to right) before
was not injured. VMC prevailed for the personal         exiting the right side of the runway and impact-
cross-country flight, and a VFR flight plan was         ing a taxiway sign with the left wing. The airplane
filed.                                                  subsequently swung around to the left and came
                                                        to rest in an upright position facing west. The
The pilot reported that when he was approxi-            pilot turned off all the electrical (switches) and
mately 8 miles from the airport he configured the       exited the aircraft uninjured. There was no post-
airplane for landing by lowering the landing gear,      accident fire.
added one notch of flaps, pushed in the propeller
control, and set the mixture control for a normal       At 1555, the weather reporting facility at SUN
landing. While on a 3 1/2 mile final to Runway 31       indicated the wind was 270 degrees at 8 knots,
he was advised by air traffic control that a jet air-   with visibility 30 statute miles.
craft was in front of him. On a 2-mile final he
selected full flaps, trimmed the airplane, and          Probable cause
noticed his approach speed on short final was 75        The pilot’s improper flare, failure to maintain
knots. As he crossed the threshold he pulled the        directional control, and inadequate remedial
power back to idle, but as his landing gear             action, which resulted in the airplane impacting
touched the runway the airplane suddenly                a taxiway sign along the side of the runway.
bounced, and then bounced a second time. He

                                                                         Technically Advanced Aircraft | www.aopa.org/safetycenter A-75
AppendixA                                                                                                    AOPA Air Safety Foundation




                            Factors                                               technically legal, the conditions were ripe for the
                            A factor contributing to the accident was the taxi-   upwind vortex to linger over the touchdown zone
                            way sign.                                             during the Mooney’s landing. (The wind was
                                                                                  from 270 degrees at 8 knots landing on Runway
                            ASF comments                                          31.) The pilot’s description that “the airplane
                            High-density altitude, distractions on final          stayed in ground effect and weaved back and
                            approach, and possible concerns about wake tur-       forth (left to right) before exiting the right side of
                            bulence from the jet aircraft could all have been     the runway” is consistent with a “low and slow”
                            factors in this accident. Although the spacing        encounter with wake turbulence.
                            between the Mooney and the preceding jet was




A-76 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                              AppendixA




DEN04CA102

Date/Time        Aircraft             N Number         Operation        Accident             Aircraft
                                                                        Phase                Damage
07/10/2004 Mooney M20S                N10059           Positioning      Go-around            Substantial
1113 MDT         IO-550-G6B


Injuries         Fatal                Serious          Minor            None
Crew             0                    0                1                0
Passengers       0                    0                0                0
Ground           0                    0                0                0


Location         Farmington, NM                        Flight Plan      Yes
Itinerary        Santa Teresa, NM—Farmington, NMRunway                  UNK
Airport          Four Corners Regional (FMN)


Weather          VFR                  Precipitation    None             Wx Briefing          Yes
Visibility       10 sm                Clouds           None             Type                 FSS
Wind             190/05               Ceiling          Clear
Gusts            None                 Lighting         Daylight


Experience                            Hours
Certificate      ATP                  Total            22,000           Last 90 Days         125
Instrument       Yes                  Make             17               Last 30 Days         40
Curr. Medical Yes                     Instmt           750
SUMMARY                                                Probable cause
A Mooney M20S sustained substantial damage             The pilot’s failure to maintain airspeed resulting
when it impacted terrain during a go-around at         in a stall.
Four Corners Regional Airport (FMN), Farming-
ton, New Mexico. VMC prevailed at the time of          Factors
the accident. The ATP-rated pilot sustained            A contributing factor was the pilot’s diverted
minor injuries.                                        attention.

According to the pilot, he was the second air-         ASF comments
plane in a flight of two and he was number two         This ATP (with more than 20,000 hours) fell prey
for landing. During the base leg of the traffic pat-   to a “gotcha” that more frequently affects less
tern, he became concerned about separation             experienced aviators. Diverted attention on final
between his airplane and the airplane landing in       approach, even in VFR conditions, can be dan-
front of him. As the airplane in front of him start-   gerous at best, fatal at worst. This high-perform-
ed to clear the runway, the pilot noticed that he      ance aircraft should have been capable of a posi-
“had allowed an excessive sink rate to develop”        tive rate of climb on go-around. High-density
and the airplane had drifted to the right of the       altitude conditions existed, but the NTSB narra-
runway. He elected to go around. The pilot             tive leaves some gaps in our knowledge of the
reported that during the go-around, the airplane       configuration of the aircraft. Was the go-around
“was not able to accelerate or climb out of            conducted “by the book?” Flap position? Gear
ground effect” and impacted the ground, collaps-       configuration? Propeller high rpm? At sea level on
ing the landing gear and bending the right wing        a cold day, a go-around is a non-event. Take the
spar. A post-accident examination of the airplane      same airplane into a mountainous region and
systems revealed no anomalies.                         add high-density altitude and the stakes go up.

                                                                         Technically Advanced Aircraft | www.aopa.org/safetycenter A-77
AppendixA                                                                                                    AOPA Air Safety Foundation




                            DEN04LA116

                            Date/Time        Aircraft             N Number         Operation        Accident             Aircraft
                                                                                                    Phase                Damage
                            08/04/2004 Mooney M20R                N4157            Business         Landing              Substantial
                            1430 MDT         IO-550-G                              Sales Demo


                            Injuries         Fatal                Serious          Minor            None
                            Crew             0                    0                0                2
                            Passengers       0                    0                0                0
                            Ground           0                    0                0                0


                            Location         Aspen, CO                             Flight Plan      VFR
                            Itinerary        San Angelo, TX—Aspen, CO              Runway           15
                            Airport          Pitken County/Sardy Field (ASE)


                            Weather          VFR                  Precipitation    None             Wx Briefing          UNK
                            Visibility       10 sm                Clouds           None             Type                 N/A
                            Wind             320/08               Ceiling          Clear
                            Gusts            16                   Lighting         Daylight


                            Experience                            Hours
                            Certificate      Commercial           Total            1,500            Last 90 Days         200
                            Instrument       Yes                  Make             200              Last 30 Days         40
                            Curr. Medical Yes                     Instmt           500



                            SUMMARY                                                When they turned onto the final approach to
                            A Mooney M20R piloted by a commercial pilot,           Runway 15, the PAPI (precision approach path
                            sustained substantial damage during a hard land-       indicator) lights indicated a “normal Mooney
                            ing at Aspen-Pitkin County/Sardy Field (ASE),          approach:” descent rate was 400 feet per minute,
                            Aspen, Colorado. VMC prevailed at the time of the      and indicated airspeed was 90 knots. Because of
                            accident. The pilot and flight instructor on board     the tailwind, they crossed the runway threshold
                            the airplane were not injured.                         “a little high” and fast. About 12 feet above the
                                                                                   runway, the pilot raised the aircraft nose to flare
                            The CFI stated that he was asked to give a sales       for landing. Airspeed dropped rapidly and the
                            demonstration flight to a potential customer. He       instructor told the pilot to relinquish aircraft con-
                            was told the customer was “an experienced pilot”       trol. The pilot continued to raise the nose and the
                            who often flew his Cessna P210 to Aspen, and           stall warning horn sounded. As the pilot held the
                            wanted to fly the Mooney M20R. The instructor          nose-high attitude, the instructor applied full
                            said the customer (hereinafter referred to as the      power “to keep the nose from falling over from the
                            pilot) “was fully aware that I was an instructor and   impending stall.” The airplane then impacted the
                            that he would relinquish control of the aircraft at    runway.
                            any time that I stated that it was my aircraft.” The
                            flight was uneventful. As they approached Aspen,       The pilot’s accident report corroborated that of the
                            they were advised that the wind was from 330           flight instructor’s—only he said the wind was 10 to
                            degrees at 10 knots, gusts to 15 knots, and of low-    15 knots from the southeast. “Over the threshold,
                            level windshear. They extended their downwind          [the instructor] said we were too high and began
                            leg and made a 360-degree turn to lose altitude.       pushing the control yoke forward. I interpreted his

A-78 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                               AppendixA



control inputs as help to [aid] me [in] landing.         recently changed to prevent exactly this type of
Simultaneously I began pulling back on the yoke to       confusion in the cockpit. Both pilots were obvi-
flare the plane for landing.” The tail struck the run-   ously attempting to accomplish a safe, smooth
way and the airplane bounced, then the propeller         arrival and landing. However one was pushing
struck the runway, stopping the engine. The air-         the control yoke forward, the other was pulling
plane coasted off the runway onto a taxiway.             back on the yoke to flare. Given their experience
                                                         levels, it is probable that either one, working
Probable cause                                           alone of course, could have conducted the land-
Not available at time of publication.                    ing uneventfully. Working together, without com-
                                                         plete communication between them was a recipe
ASF comments                                             for disaster. When flying with another pilot in the
Preliminary. By both pilot’s accounts, positive          cockpit, it is imperative that there be complete
transfer of the controls between them never              understanding who is pilot in command and who
occurred. FAA Practical Test Standards were              is manipulating the controls.




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AppendixA                                                                                                     AOPA Air Safety Foundation




                            Cessna 210 Accident

                            LAX02FA049

                            Date/Time        Aircraft             N Number          Operation        Accident             Aircraft
                                                                                                     Phase                Damage
                            12/14/2001 Cessna T210L               N210RE            Personal         Approach             Destroyed
                            1528 PST         IO-520-H


                            Injuries         Fatal                Serious           Minor            None
                            Crew             1                    0                 0                0
                            Passengers       0                    0                 0                0
                            Ground           0                    0                 0                0


                            Location         San Jacinto, CA                        Flight Plan      IFR
                            Itinerary        Santa Monica, CA—Hemet, CA             Runway           UNK
                            Airport


                            Weather          VFR                  Precipitation     None             Wx Briefing          Yes
                            Visibility       5 sm                 Clouds            SCT 1,000 feet Type                   FSS
                                                                                    BKN 1,800 feet
                                                                                    OVC 5,000 feet
                            Wind             200/17               Ceiling           1,800
                            Gusts            24                   Lighting          Daylight


                            Experience                            Hours
                            Certificate      Private              Total             1,215            Last 90 Days         UNK
                            Instrument       Yes                  Make              425              Last 30 Days         UNK
                            Curr. Medical Yes                     Instmt            122

                            SUMMARY                                                 minute the pilot advised the controller that he
                            A Cessna T210L collided with rising mountainous         was descending from 7,000 to 6,000 feet msl.
                            terrain during an instrument approach to the            The controller informed the pilot that the altime-
                            Hemet-Ryan Airport (HMT), about 4 nm northeast          ter was 29.68.
                            of San Jacinto, California. The airplane was
                            destroyed, and the instrument-rated private pilot       The pilot indicated that he desired to start the
                            was fatally injured. Instrument meteorological          instrument approach to HMT at SETER. At
                            conditions prevailed in the vicinity and an instru-     1516:39, the controller stated to the pilot, “Cross
                            ment flight rules (IFR) flight plan was filed. At the   SETER at, ah, five-thousand cleared GPS into
                            time of the accident, the airplane was between the      Hemet.”
                            initial and final approach fixes and was approxi-
                            mately 5.9 nm east of the specified southerly           Several instrument approach procedures exist for
                            approach course.                                        use at HMT. The approach procedure titled “NDB
                                                                                    and GPS-A” has the lowest published landing
                            At 1515, as the airplane was en route to HMT, a         minima. When performing the GPS-A IAP, the
                            March Air Reserve Base (ARB) air traffic con-           minimum descent altitude is 2,600 feet msl (1,088
                            troller (March GCA) established radar contact           feet agl). The listed minimum visibility is 1 1/4
                            with the accident airplane’s pilot. The following       miles.

A-80 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                               AppendixA



The pilot responded by asking, “Cleared direct          The controller replied at 1526:08, and stated,
SETER right now?”                                       “OK, I hear you now its, ah, when you get behind
                                                        those mountain ranges over there it’s, ah, we usu-
The controller replied, “Affirmative, you can go        ally lose radar and radio back there.”
direct at this time.”
                                                        At 1526:16 and 1526:26, the controller again
The pilot then stated “OK, direct SETER and did         transmitted IFR cancellation instructions to the
you say descend to five-thousand?”                      pilot, but no reply was recorded. The controller
                                                        transmitted, “Zero, Romeo-Echo, radar contact
The controller replied at 1516:59, and stated,          lost” at 1526:51.
“Stand by sir, I’m trying to see where the
approach starts at, fifty-five or five, stand by.”      No witness reported observing the accident. The
                                                        pilot’s route of flight between the location where
The pilot responded and said, “I show it fifty-five     radar contact was last recorded and the 6.6 nm
on my, ah, on my chart here.”                           distance to the crash site is unknown. During the
                                                        last minute of radar-recorded flight, the airplane’s
The controller replied, “Yeah, I believe you’re         average track and ground speed were about 092
right, yeah, you can cross SETER at five-thou-          degrees and 160 knots. Based on this ground
sand-five hundred cleared GPS into Hemet.”              speed, and the 107-degree direct course between
                                                        the last recorded radar return (hit) and the crash
Recorded radar data from the LAX ARTCC and the          site, the accident occurred about 1528.
SoCal TRACON indicate that between 1523:27 and
1523:49, the northeast bound accident airplane          Personal information
passed SETER, descended from 5,600 to 5,500 feet        The pilot held a private pilot certificate with sin-
(as indicated by the airplane’s Mode-C-equipped         gle and multiengine land, instrument, and heli-
transponder), and began tracking in an easterly         copter ratings. On February 20, 2001, the pilot
direction toward the KENDE intersection.                was issued a second-class aviation medical cer-
                                                        tificate, with the restriction that he must wear
For several minutes thereafter, there were no           corrective lenses. His reported total flight time
additional recorded communications to or from           was 1,150 hours.
the accident pilot. Then, at 1525:15, the con-
troller attempted to communicate with the pilot.        A relative of the pilot, who completed the NTSB’s
The controller advised the pilot to report cancel-      “Pilot/Operator Aircraft Accident Report” indicat-
ing his IFR flight on the current radio frequency,      ed that the pilot’s experience flying the accident
or after landing via telephone. The controller          model of airplane was 425 hours. Data extracted
heard no response from the pilot.                       from the pilot’s flight record logbook indicates
                                                        that the pilot’s total flight time was in excess of
About this time, the accident airplane was              1,215 hours. Also, the pilot’s total actual and sim-
approximately 0.6 nm south of the KENDE inter-          ulated instrument flying experience was in excess
section and was crossing the 153-degree pre-            of 39 and 83 hours, respectively.
scribed direct course to the San Jacinto final
approach fix. About 12 seconds later, the air-          On October 10, 2001, the pilot successfully com-
plane’s 077-degree track had become 092 degrees.        pleted an instrument proficiency check (IPC) in
                                                        his (accident) airplane. According to the CFI who
At 1525:33, 1525:40, and 1525:47, the controller        administered the IPC, during the flight the pilot
again attempted to contact the pilot. During the        demonstrated steep turns, unusual attitudes,
latter effort, the controller stated, “If you hear me   holding, compass turns, and ILS and VOR instru-
ident.” At 1526:02, the controller stated, “I copy      ment approaches. The CFI did not report that the
the ident.”                                             pilot demonstrated any proficiency performing
                                                        GPS approaches.
The last recorded radar hit occurred 23 seconds
earlier, at 1525:39, at which time the airplane had     GPS installation and revision service
descended to 5,100 feet. The airplane’s location at     data
1526:02 was subsequently recalled by the con-           According to Able Avionics, Van Nuys, California,
troller as being southeast of KENDE.                    about April 23, 2001, its repair station personnel
                                                        installed a Garmin International Inc. GPS receiv-
The pilot’s last recorded radio transmission            er model GNS 530 into the pilot’s airplane. The
occurred at 1526:05, when he said “Ah March, do         airplane was not equipped with a separate auto-
you read me, Zero-Romeo-Echo.”                          matic direction finder (ADF receiver) or a sec-

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AppendixA                                                                                                  AOPA Air Safety Foundation




                            ondary GPS receiver. The GNS 530 unit was cer-        cated that he did not observe the airplane
                            tificated for instrument en route, terminal, and      because there were low clouds in the area. The
                            nonprecision instrument procedures.                   witness’ elevation was about 1,500 feet msl, and
                                                                                  he estimated the cloud base was about 500 feet
                            The GNS 530’s serial number was 78401266. The         above the ground.
                            software version in the unit was unchanged since
                            Able’s acquisition of the unit from the manufac-      Weather briefings
                            turer. The pilot was advised to keep the receiver’s   At 1035, the pilot telephoned the Hawthorne,
                            aviation database current using Jeppesen’s revi-      California, FSS and requested a weather briefing
                            sion service.                                         for an IFR flight from Santa Monica to Hemet.
                                                                                  The FSS briefer informed the pilot of the
                            Personnel at Jeppesen verbally reported to the        issuance of an Airmet for moderate icing and
                            NTSB investigator that in order to maintain a         stated that the freezing level was “just under six
                            current database in the GNS 530, the pilot had        thousand feet.” The forecast condition for 1400
                            subscribed to its Skybound Datawriter revision        in the vicinity of the March ARB (15 nm west-
                            service. This service provides for revisions on a     northwest of HMT) was for broken sky condi-
                            28-day cycle via Internet downloads. Jeppesen         tion with clouds based between 2,000 and 3,000
                            reported that the pilot had subscribed to this        feet above ground level (agl), visibility 3 to 5
                            revision service. However, they were unable to        miles, light rain showers and mist. After 1600,
                            ascertain whether, in fact, the pilot had down-       the March ARB forecast was for scattered to bro-
                            loaded the current data. Jeppesen’s personnel         ken clouds based at 4,000 feet agl, with isolated
                            also noted, however, that there had not been any      light rain showers, and surface wind from 280
                            changes to the Hemet GPS-A approach proce-            degrees at 25 knots.
                            dure between the receiver’s April installation and
                            the December accident date.                           The FSS briefer stated to the pilot that he did not
                                                                                  have any good weather reporting at HMT.
                            Flight limitation, equipment                          However, HMT did have an automatic weather
                            certification, and maintenance                        observing system (AWOS), but its report was not
                            The FAA certified the airplane for flight into        available in the FAA’s computer system. The com-
                            instrument meteorological conditions (IMC). The       mercial landline telephone number for Hemet-
                            airplane was not certified for flight-into-icing      Ryan Airport was listed in the FAA’s Airport/
                            conditions. The airplane was equipped with a          Facility Directory.
                            heated pitot tube and an alternate source for
                            obtaining static atmospheric pressure for emer-       The briefer advised the pilot that there were no
                            gency use if the primary static port became           notams for Hemet-Ryan Airport. Also, all of the
                            blocked. The primary static port was not heated.      navigation aids in the area were operating nor-
                                                                                  mally.
                            The FAA authorized IFR operation of the GNS 530
                            under a field approval process following a func-      The pilot did not inform the FSS briefer that dur-
                            tional evaluation on May 2, 2001. Also, an            ing his planned flight GPS navigation would be
                            (S-TEC-60-2) autopilot having pitch, roll, and        used. During the standard briefing, there was no
                            altitude hold capability was installed in the air-    discussion regarding the status of GPS receiver
                            plane. Its installation was accomplished under        autonomous integrity monitoring (RAIM) out-
                            the provisions of a supplemental type certificate.    ages or GPS notams.

                            An FAA avionics inspector reviewed the installa-      At 1150, the pilot telephoned the FSS and
                            tion documentation for the GPS and the autopi-        obtained an abbreviated briefing for his pro-
                            lot, in addition to data associated with the pitot-   posed round robin flight. The pilot indicated he
                            static system and transponder checks. In summa-       anticipated flying around 1400.
                            ry, the FAA inspector reported that the reviewed
                            documentation included several FAA Form 337s          The briefer advised the pilot that there was an
                            and airplane logbooks. The documents were             Airmet for icing above 8,000 feet. However, some
                            found satisfactory, and no discrepancies were         reports indicated icing existed at 7,000 feet. The
                            reported.                                             weather was forecast to improve first over the Los
                                                                                  Angeles basin area, and then later during the
                            Meteorological information                            afternoon it was forecast to improve over the
                            About 1530, a witness located about 5 miles west      Ontario area. (Ontario is located 35 nm west-
                            of the accident site reported hearing a low-flying    northwest of Hemet.)
                            airplane pass by his location. The witness indi-

A-82 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                                AppendixA



At 1420, the pilot telephoned the FSS again. The         “whiskey” compass was found along with its
pilot advised the bl;riefer that he was “kind of         magnetic deviation card several yards uphill from
familiar with the weather” because he had                the main wreckage. The compass was functional.
received a couple of briefings and updates. The
pilot indicated that he desired to file an IFR flight    Jeppesen chart usage
plan, and he requested a little assistance with the      Information verbally received from the acquain-
routing. The pilot stated that he desired to “stay       tances of the pilot and from Jeppesen Sanderson,
low...out of the freezing level.”                        Inc., indicates that the pilot was a current sub-
                                                         scriber of Jeppesen instrument charts.
The briefer responded by asking the pilot if he
had flown around the Los Angeles basin, or if he         Acquaintances of the pilot reported that the pilot
was from out of town. The pilot responded by             regularly used Jeppesen charts while flying, and
stating, “I know the basin.”                             he carried Jeppesen charts in the airplane. In the
                                                         wreckage, remnants of a Jeppesen-like metal
The briefer advised the pilot that the freezing          binder were located. In the binder were ashes
level was 7,000 feet or higher. He then provided         and remnants from Jeppesen instrument
the pilot with the established tower en route            approach charts. The binder was found in the
course (as published in the A/FD) involving flight       cockpit between the front seats.
at 5,000 feet, and using the prescribed route
identification of “SCTL26” between the airport           Jeppesen GPS-A IAP chart information.
pairs of Santa Monica and Hemet.                         Terrain to the east-southeast of KENDE intersec-
                                                         tion rises. About 7 1/2 nm and 110 degrees from
The pilot also informed the FSS briefer that his pro-    KENDE a mountain exists with a 4,106-foot peak
posed indicated airspeed was 140 knots, his esti-        elevation, as indicated on the Los Angeles VFR
mated en route flight time was 45 minutes, and his       Terminal Area Chart. This mountain resides with-
proposed departure time was 1445. In response to         in the planview area depicted on the Jeppesen
the briefer’s question, “did you get all the Airmets     GPS-A chart for Hemet, and it is northeast of
and the weather you need,” the pilot said “yes.”         HMT. The mountain’s spot elevation is not shown
                                                         on the Jeppesen’s GPS-A chart that was current
Destination weather                                      for use on the accident date.
At 1455, March ARB, elevation 1,538 feet msl,
reported the following weather conditions: visi-         On the chart current for use on the accident date,
bility 1 1/4 miles, light rain and mist, and over-       a 3,343-foot msl terrain high point (mountain) is
cast ceiling at 400 feet agl. The temperature and        shown. This terrain high point is located south-
dewpoint were both 8 degrees C. The altimeter            east of HMT. An arrow indicates that this is the
was 29.68 inches of Mercury. March ARB is locat-         highest of portrayed terrain high points in the
ed about 15 nm west-northwest of HMT.                    charted planview, according to Jeppesen’s legend.
                                                         The legend further states that higher terrain may
At 1515, HMT, elevation 1,512, reported its surface      exist, which has not been portrayed.
wind was from 200 degrees at 15 knots with gusts
to 20 knots; visibility was 2 miles; sky condition       Following the accident, and after discussions
was broken at 1,000 feet agl and overcast at 1,600       with the NTSB investigator, Jeppesen revised its
feet agl. The altimeter was 29.66 inches of Mercury.     Hemet GPS-A chart to eliminate the arrow point-
At 1525, Hemet’s surface wind was from 200               ing toward the 3,343-foot msl terrain high point.
degrees at 17 knots with gusts to 24 knots; the visi-    The revised chart includes the newly depicted
bility was 5 miles; and the sky condition was scat-      4,106-foot msl terrain high point denoted by an
tered at 1,000 feet agl, broken at 1,800 feet agl, and   arrow indicating that it is the highest point por-
overcast at 5,000 feet agl. The altimeter was 29.66      trayed.
inches of Mercury.
                                                         Garmin GNS 530 moving map capability
Wreckage and impact information                          and terrain elevation information
The accident site is about 3/4 mile east of a            According to Garmin’s chief pilot, when the GSN
mountain that has a peak elevation of 4,106 feet         530 receiver is processing navigation data it can be
msl. The on-scene examination of the accident            set up to display a “moving” map that shows the
site and airplane wreckage revealed the airplane         airplane’s position relative to fixes, desired cours-
impacted the north facing slope of an approxi-           es, and airports. The airplane’s track can be moni-
mately 3,600-foot-high mountain about 8.7 nm             tored when the navigation map page has been
from Hemet-Ryan Airport.                                 selected. Thus, as the airplane proceeds either
The GPS unit was destroyed by fire. The airplane’s       along a specified instrument approach course or is

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                            flying without a preselected desired track, its prox-   trollers instructions followed to the letter. The
                            imity to the destination airport can be visualized.     approach in question was the NDB-A conducted
                            No spot elevation or terrain height information is      as a “GPS overlay”. It is not known if an ADF
                            programmed into the GPS receiver.                       receiver was installed in the Cessna 210.
                                                                                    Beginning the approach at SETER intersection, a
                            Probable cause                                          track of 078 degrees is maintained for 4.2 nm. At
                            The pilot’s loss of situational awareness and his       this point, a track of 154 degrees is required, a
                            failure to adhere to the prescribed instrument          turn of 76 degrees to the right. Most instrument
                            approach procedures, including the track and            approaches that we conduct in the United States
                            altitudes flown. The underlying reasons for the         consist of a straight approach course. When they
                            pilot’s loss of situational awareness are unknown.      don’t, it is usually for a good reason. For this
                                                                                    approach into Hemet, California, mountainous
                            ASF comments                                            terrain lurks just east of the pilots intended
                            This Cessna pilot was well versed in IFR proce-         approach course. In the last moments before the
                            dures. The flight was carefully planned, weather        airplanes target dropped off the radar screen,
                            briefings obtained, flight plan filed, and con-         the controller noticed the pilot straying east of
                                                                                    course into the mountainous terrain. By then it
                                                                                    was too late to notify him as radar/radio cover-
                                                                                    age was spotty because of the high terrain.
                                                                                    Straying off course on a nonprecision approach
                                                                                    is never a good idea. Usually when it happens, it
                                                                                    doesn’t bear such serious consequences. Flight
                                                                                    in mountainous terrain, particularly IMC flight
                                                                                    requires an intimate knowledge of “which
                                                                                    clouds contain rocks.” The approach chart avail-
                                                                                    able to the pilot clearly depicted the terrain he
                                                                                    was flying into. We may never know why the
                                                                                    pilot failed to make that critical 76-degree turn
                                                                                    to the right and continue tracking the inbound
                                                                                    course on the approach.




A-84 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                           AppendixA



Lancair Accidents

SEA04LA040

Date/Time        Aircraft            N Number        Operation        Accident            Aircraft
                                                                      Phase               Damage
02/10/2004 Lancair                   N6503C          Business         Landing             Substantial
0950 PST         Columbia 300
                 IO-550-N25


Injuries         Fatal               Serious         Minor            None
Crew             0                   0               0                2
Passengers       0                   0               0                2
Ground           0                   0               0                0


Location         Redmond, OR                         Flight Plan      None
Itinerary        Bend, OR—Redmond, OR                Runway           10
Airport          Roberts Field (RDM)


Weather          VFR                 Precipitation   None             Wx Briefing         None
Visibility       10 sm               Clouds          None             Type                N/A
Wind             180/10              Ceiling         Clear
Gusts            None                Lighting        Daylight


Experience                           Hours
Certificate      ATP                 Total           21000            Last 90 Days        75
Instrument       Yes                 Make            400              Last 30 Days        25
Curr. Medical Yes                    Instmt          2500

SUMMARY                                              touched down slightly left of the runway cen-
A Lancair Columbia 300 veered off the runway         terline and in a nose high attitude. After the air-
during the landing roll at Roberts Field (RDM)       craft touched down the commercial pilot
Red-mond, Oregon, and collided with a taxi           applied full power. The aircraft veered to the
sign. visual meteorological conditions prevailed     left, and at this time the flight instructor stated
at the time and no flight plan was filed. The air-   that he “got on the rudder pedals and flight
craft was substantially damaged but the com-         controls in an attempt to regain runway head-
mercial pilot, flight instructor and two passen-     ing.” The flight instructor, not realizing at first
gers were not injured.                               that the commercial pilot had applied full
                                                     power, called for the commercial pilot to reduce
The commercial pilot and flight instructor re-       power. Power was reduced, however, the aircraft
ported that the commercial pilot was in the left     exited the runway surface traveling over gravel
seat and at the flight controls for the landing on   and snow. During the landing roll, the right
Runway 10 at RDM. The commercial pilot stat-         wing collided with a taxi sign, the outboard sec-
ed that the approach was normal. When the air-       tion of the right wing flap separated at the two
craft was over the runway, about four feet above     outboard flap hinges, and the right main land-
ground level, the stall warning horn sounded         ing gear tire separated from the gear leg.
and he “chopped the power,” then the aircraft
rapidly descended to the runway. The aircraft

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                            Probable cause                                    ASF comments
                            The pilot rated passenger’s failure to maintain   There is some ambiguity as to exactly who was
                            directional control during the landing roll.      handling the controls, particularly the throttle. It
                                                                              is imperative that positive transfer of control take
                            Factors                                           place when two pilots are sharing the cockpit.
                            Inadequate supervision by the pilot in command    The left seat pilot’s application of full power was
                            (CFI) and a taxiway sign were factors.            not recognized by the CFI in the right seat. Had
                                                                              this been communicated between them, a suc-
                                                                              cessful touch and go or aborted landing might
                                                                              have been accomplished.




A-86 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                           AppendixA




LAX04LA266

Date/Time        Aircraft            N Number        Operation        Accident               Aircraft
                                                                      Phase                  Damage
06/25/2004 Lancair                   N6505L          Personal         Landing                Substantial
1020             Columbia 300
                 I0-550


Injuries         Fatal               Serious         Minor            None
Crew             0                   0               0                1
Passengers       0                   0               0                1
Ground           0                   0               0                0


Location         Show Low, AZ                        Flight Plan      None
Itinerary        Flagstaff, AZ—Show Low, AZ          Runway           24
Airport          Show Low Regional Airport (SOW)


Weather          VFR                 Precipitation   None             Wx Briefing            UNK
Visibility       10 sm               Clouds          None             Type                   UNK
Wind             Var/04              Ceiling         Clear
Gusts            None                Lighting        Daylight


Experience                           Hours
Certificate      Private             Total           UNK              Last 90 Days           UNK
Instrument       UNK                 Make            UNK              Last 30 Days           UNK
Curr. Medical UNK                    Instmt          UNK

SUMMARY                                              The reported weather conditions were clear with
A Lancair Columbia 300 veered off Runway 24          winds 270 degrees at 7 knots.
during the landing roll at Show Low Regional
Airport (SOW), Show Low, Arizona. The private        Probable cause
pilot and one passenger were not injured, but the    Not available at time of publication.
airplane sustained substantial damage.
                                                     ASF comments
According to a witness that had just attempted to    Preliminary. This pilot received a warning from
land prior to the accident pilot, he encountered a   the pilot landing ahead of him about the dust
dust devil, which lifted his Cessna 150 airplane     devil. Such wind phenomena is extremely
approximately 10 feet. He added power and            unpredictable. There is no sure method of guar-
recovered, then completed his landing. As he         anteeing a safe landing. The only sure method is
cleared Runway 24 he radioed a warning to the        avoidance.
accident pilot who was on final.

As the accident pilot landed, the witness watched
the Lancair encounter the same dust devil during
landing. The wind turned the Lancair to the
north, and the airplane traveled off of the right
side of Runway 24 at SOW. The nose gear sheared
from the airplane, and the right wing was punc-
tured after it impacted the ground.

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AppendixA                                                                                                  AOPA Air Safety Foundation




                             A36 Bonanza Accidents

                             LAX01LA095

                             Date/Time        Aircraft           N Number         Operation        Accident            Aircraft
                                                                                                   Phase               Damage
                             02/09/2001 Beechcraft A36           N3191A           Personal         Landing             Substantial
                             1412 PST         Rolls Royce
                                              250-B17F/2
                                              Turboprop


                             Injuries         Fatal              Serious          Minor            None
                             Crew             0                  0                0                1
                             Passengers       0                  0                0                0
                             Ground           0                  0                0                0


                             Location         Palo Alto, CA                       Flight Plan      None
                             Itinerary        Local                               Runway           UNK
                             Airport          Palo Alto Airport (PAO)


                             Weather          VFR                Precipitation    None             Wx Briefing         Yes
                             Visibility       7 sm               Clouds           FEW 2,000 feetType                   Wx service
                             Wind             230/06             Ceiling          BKN 3,000 feet
                             Gusts            None               Lighting         Daylight


                             Experience                          Hours
                             Certificate      Private            Total            619              Last 90 Days        44
                             Instrument       Yes                Make             108              Last 30 Days        3
                             Curr. Medical Yes                   Instmt           6

                            SUMMARY                                               that after examining the airplane the flaps
                            A Beechcraft A36 Bonanza sustained substantial        appeared to be up.
                            damage when it struck the ground during an
                            attempted go-around at Palo Alto Airport (PAO)        The airplane, equipped with a Rolls-Royce Model
                            in California. The private pilot was not injured.     250-B17F/2 Turboprop engine, had been pur-
                                                                                  chased in August 2000. The pilot had received
                            The pilot stated that his intention was to practice   dual instruction in the airplane but his insurance
                            takeoffs and landings. He extended downwind for       carrier required he hold an instrument rating
                            spacing on a slower airplane, and recalls select-     prior to acting as pilot in command. His instru-
                            ing approach flaps but does not recall checking       ment rating was received February 7, 2001. The
                            their position. The final approach was stable at      pilot had received 107.9 hours of dual instruction
                            80 knots but when he was about 10 feet off the        in the airplane and the accident flight was his
                            ground he sensed the airplane was sinking faster      first solo flight in type.
                            than normal and he elected to go around. He
                            added power but did not feel the engine respond.      Probable cause
                            The airplane veered left and the left wing struck     The pilot’s delayed decision to go-around and his
                            the ground, the left gear was sheared off, and the    failure to maintain sufficient airspeed during the
                            propeller was torn off the engine. The pilot said     attempted go-around.

A-88 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                           AppendixA



Factors                                              obtain an instrument rating prior to flying the
The pilot not verifying the flap setting.            airplane solo is also an indication of the skill
                                                     required. His instrument certification came only
ASF comments                                         two days prior to the accident. Although full-flap
The factory equipped A36 Bonanza is a handful        landings are standard in the A36, partial or no
of airplane for a low-time private pilot. Swap the   flap landings are possible although both require
normally aspirated piston engine out for an after-   considerably more finesse. A flatter approach,
market turboprop retrofit and it becomes an          higher approach speed, and correspondingly
entirely new machine. More than 100 hours of         longer runway length are all new factors to take
dual given for a pilot to transition into type       into consideration, items this pilot may have
should send up a warning flag to an instructor.      been seeing for the first time on his final
That the insurance carrier required the pilot to     approach.




                                                                      Technically Advanced Aircraft | www.aopa.org/safetycenter A-89
AppendixA                                                                                                     AOPA Air Safety Foundation




                            CHI02LA258

                            Date/Time        Aircraft              N Number         Operation        Accident             Aircraft
                                                                                                     Phase                Damage
                            08/17/2002 Beechcraft A36              N336CB           Personal         Cruise               Substantial
                            2335 CDT         IO-550


                            Injuries         Fatal                 Serious          Minor            None
                            Crew             0                     0                0                1
                            Passengers       0                     0                0                4
                            Ground           0                     0                0                0


                            Location         Benton, KS                             Flight Plan      IFR
                            Itinerary        Lawrence, KS—Wichita, KS               Runway           N/A
                            Airport          N/A


                            Weather          VFR                   Precipitation    None             Wx Briefing          Yes
                            Visibility       10 sm                 Clouds           OVC              Type                 FSS
                            Wind             060/09                Ceiling          8,000 feet
                            Gusts            None                  Lighting         Night


                            Experience                             Hours
                            Certificate      Commercial            Total            1120             Last 90 Days         60
                            Instrument       Yes                   Make             600              Last 30 Days         15
                            Curr. Medical Yes                      Instmt           59


                            SUMMARY                                                 An FAA inspector examined the aircraft and
                            A Beechcraft A36 Bonanza sustained substantial          found the right fuel tank contained about 25
                            damage during a forced landing about three miles        gallons of fuel and the left tank 3 gallons with 8
                            north of Benton Airport (1K1), Benton, Kansas.          ounces of fuel removed from the tank. The air-
                            Neither the commercial pilot nor his four passen-       craft placard states that the unusable fuel is 3
                            gers were injured. Night VMC prevailed at the time      gallons.
                            of the accident. During cruise flight at 8,000 feet
                            msl, the pilot “noted sluggish and erratic fuel         The POH states, “The auxiliary fuel pump is
                            gauge needle trends on the left gauge.” The engine      placarded Off-Low-High. The Low position is
                            began to run rough during descent from 8,000            used to supply a low boost to the fuel flow dur-
                            feet, so the pilot immediately switched to the right    ing all flight conditions.
                            fuel tank and activated the low boost pump. The
                            engine “spooled down” so he established a 110-          The HI position is used for priming the engine
                            knot glide attitude. He then set the electric fuel      during cold starts and also to provide an alter-
                            pump to high boost and the mixture control to full      nate source of fuel pressure in the event the
                            rich. The engine restarted briefly, then stopped.       engine-driven fuel pump fails. HI boost must
                            The pilot executed a forced landing in a field. Just    not be used during flight unless the engine-
                            before touchdown, the pilot extended the landing        driven fuel pump has failed. The increased
                            gear. The pilot reported that he “did not have suffi-   pressure of the HI will over-drive the fuel con-
                            cient late visual references with which to accurate-    trol unit producing abnormally high fuel flows,
                            ly flare so we impacted the ground at approxi-          which, in turn, will cause engine roughness. In
                            mately 85 knots indicated.” The airplane skidded        some cases, engine combustion may cease.”
                            to a stop in the field.

A-90 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                          AppendixA



Probable cause                                      ASF comments
Fuel starvation due to the pilot’s improper fuel    Although this pilot was certainly familiar with the
management, the pilot’s improper remedial           airplane with approximately 600 hours in type, he
actions during engine restart, and the unsuitable   fell prey to a rather simple mistake. As pilots we
terrain encountered during the forced landing.      deal with only two types of emergencies—those
                                                    that require our immediate input to save the situ-
Factors                                             ation (such as this accident) or those that unfold
Additional factors included the inadequate flare    over the course of time, hours even. It is impera-
and the dark night.                                 tive that we are well versed in handling both
                                                    types of emergencies.




                                                                     Technically Advanced Aircraft | www.aopa.org/safetycenter A-91
AppendixA                                                                                                       AOPA Air Safety Foundation




                            DEN04FA087

                            Date/Time         Aircraft              N Number         Operation         Accident             Aircraft
                                                                                                       Phase                Damage
                            06/07/2004 Beechcraft A36               N6162E           Personal          Cruise               Destroyed
                            1650 MDT          IO-550-B


                            Injuries          Fatal                 Serious          Minor             None
                            Crew              1                     0                0                 0
                            Passengers        1                     1                0                 0
                            Ground            0                     0                0                 0


                            Location          Gilcrest, CO                           Flight Plan       None
                            Itinerary         Longmont, CO—Greeley, CO               Runway            N/A
                            Airport


                            Weather           VFR                   Precipitation    None              Wx Briefing          None
                            Visibility        10 sm                 Clouds           None              Type                 N/A
                            Wind              120/07                Ceiling          Clear
                            Gusts             None                  Lighting         Daylight


                            Experience                              Hours
                            Certificate       Private               Total            139               Last 90 Days         UNK
                            Instrument        None                  Make             75                Last 30 Days         5
                            Curr. Medical Yes                       Instmt           6.5 sim


                            SUMMARY                                                  heard, “Mayday, Mayday, Beechcraft N [witness
                            A Beechcraft A36 Bonanza piloted by a private pilot,     could not recall the N number] east of Longmont,
                            was destroyed when it impacted terrain approxi-          going down, three souls on board.”
                            mately 2 miles south of Gilcrest, Colorado. VMC pre-
                            vailed at the time of the accident, and no flight plan   A hospital interview and subsequent telephone
                            had been filed for the local personal flight. The pri-   interviews were conducted to clarify the surviving
                            vate pilot and the student pilot passenger in the        passenger’s submitted written statement. In those
                            front seat were fatally injured. The rear passenger      interviews he stated that the flight had departed
                            received serious injuries.                               from Vance Brand Airport (2V2) in Longmont,
                                                                                     Colorado, approximately 20 to 30 minutes prior to
                            Witnesses driving north on U.S Highway 85                the accident. They had flown over the pilot’s home
                            observed the airplane flying low above the               and were en route to Greeley when the accident
                            ground in a northerly direction. According to one        occurred. The passenger stated that the front seat
                            witness, the airplane’s wings rocked from side to        passenger, the pilot’s daughter, expressed a wish to
                            side and then the airplane pitched up. The air-          fly the airplane. She remembered she was “typing in
                            plane’s nose dropped then the airplane impacted          the autopilot,” and she recalled the pilot correcting
                            the terrain in a right wing low attitude. The air-       her, “GXY, not GYX,” or words to that effect (GXY is
                            plane came to rest in a sod field approximately          the 3-letter designator for the Greeley-Weld County
                            1/4 mile east of a highway. One witness exited his       Airport, located about 18 miles north of the accident
                            vehicle to help those on board the airplane. While       site). As soon as she disengaged the autopilot, the
                            approaching the wreckage, he noted a strong              “airplane shuttered [sic], and a lot of the alarms on
                            odor of fuel. An FBO owner in Longmont,                  the plane started going off.” The passenger estimat-
                            Colorado, stated he heard a mayday call at the           ed that they were approximately 500 feet agl and
                            approximate time of the accident. He said he             had been attempting to climb. According to the pas-

A-92 www.aopa.org/safetycenter | Technically Advanced Aircraft
AOPA Air Safety Foundation                                                                                                    AppendixA



senger, the pilot “could [not] reach the switch for the     Additional information
gas tanks” so the front seat passenger switched it.         Several flight instructors reported the pilot had
The passenger was not sure if they tried to start the       mentioned to them his inability to reach the fuel
engine. She heard the front seat passenger make a           selector valve. One instructor said the pilot told him
mayday call and could not recall anything after the         he had difficulty feeling the detent position on the
impact.                                                     fuel selector valve. The pilot was scheduled to have a
                                                            specially designed seat installed in his airplane dur-
Personal information                                        ing the week of June 14 to 18 that would accommo-
The pilot held a private pilot certificate with an air-     date his girth.
plane single engine land rating, which was issued
April 27, 2004. The pilot held a third-class medical        According to the Raytheon Pilot Operating Hand-
certificate, dated January 9, 2004, with the limitation     book, each fuel bladder contains 40 gallons, 37 of
“must wear corrective lenses.” According to the             which is useable fuel. No documents were located
pilot’s logbook, he received endorsements for com-          that would indicate when the airplane was last refu-
plex and high performance airplane operations on            eled, or how long the airplane had flown since it was
April 1, 2001. The pilot had logged approximately           last refueled.
139 hours total time, 75 of which was in the accident
airplane.                                                   Probable cause
                                                            Not available at time of publication.
The front seat passenger held a student pilot certifi-
cate, which was issued on January 9, 2004. This third       ASF comments
class medical certificate contained the limitation          Preliminary. The ability to see, reach, and operate all
“must wear corrective lenses.” According to her             controls of an aircraft which one is piloting, is cru-
flight instructor, she had logged approximately 40          cial to the safe operation of the aircraft. The pilot in
hours in a Cessna 172S and had soloed on May 14,            command, by his own admission on more than one
2004. He said he had never flown with her in the A36        occasion, stated his inability to reach the fuel selec-
and to the best of his knowledge she had never              tor. The fuel selector on this aircraft offered a choice
flown in the airplane.                                      between Left, Right, and Off. Obviously, when fuel is
                                                            exhausted from either Left or Right, operating pro-
Meteorological information                                  cedure requires that the other tank containing fuel
According to the Fort Collins-Loveland METAR, 15            be selected. It is imperative that this be accom-
miles northwest of the accident site, the weather at        plished prior to complete starvation of fuel so as not
the time of the accident was: Wind, 120 degrees at 7        to interrupt the engine. The right seat passenger,
knots; visibility, 10 statute miles (or better); sky con-   although possessing limited flight experience was
                                           .;
dition, clear; temperature, 93 degrees F dewpoint,          not familiar with the operation of this particular air-
             .;
30 degrees F altimeter, 29.64 inches of mercury.            craft. It is quite possible that the pilot in command
Density altitude was calculated to be between 8,244         sought assistance from her to operate the fuel selec-
and 8,631 feet at ground level.                             tor valve since he could not reach it. During the
                                                            sequence of events leading up to impact, the fuel
Testing and research                                        valve moved to the Off position. Furthermore, the
The airplane wreckage was taken to Greeley,                 NTSB noted in the accident report that the mixture
Colorado, on June 8, 2004, for further examination.         control was found in the idle cut off position and the
An examination of the engine and engine compo-              auxiliary fuel pump was found Off. The relatively
nents showed no anomalies. The manifold was wet             low-time private pilot, who had purchased the air-
with fuel, but nothing that could be measured. The          plane only six months prior was not attempting a
top spark plug bank was uniform in dark discol-             flight beyond his capabilities. However the combi-
oration. According to a representative from Teledyne        nation of his inability to reach/see the fuel selector
Continental Motors, this is characteristic of a lean        and his lack of familiarity with proper operating
mixture, fuel exhaustion, or starvation.                    procedures for the A36 joined to rapidly get himself
                                                            in “over his head”.
The fuel selector valve was removed for further
examination. The valve was in the Off position.             Witness reports on the ground, photographs of the
There was circular scoring on the faceplate of the          wreckage and the NTSB accident report all suggest
fuel selector valve, leading to the Off position.           that the aircraft entered a stall prior to impact. It is
According to the Raytheon representative, the selec-        always advisable, regardless of the terrain or
tor would have to have been forced to create the cir-       obstructions, to deadstick with a speed above stall
cular scoring. The valve assembly contained residual        speed. Otherwise, the nose drops following aerody-
fuel in the lines leading to the fuel tanks. In addition,   namic stall leaving the pilot with no control of
the electric boost pump contained fuel in the lines.        the landing.

                                                                               Technically Advanced Aircraft | www.aopa.org/safetycenter A-93
AppendixA                                                            AOPA Air Safety Foundation




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