Pilot Debrief

CIRRUS SR22 near CONCORD, NC — 2016-01-08

Final reportERA16LA085
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Date
2016-01-08
Location
CONCORD, NC, USA
Aircraft
CIRRUS SR22
Registration
C-GXXJ
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Approach

Probable cause

The pilot’s inadequate management of the airplane’s automated systems, which resulted in a loss of control during an instrument approach and necessitated his subsequent deployment of the airplane’s parachute system.

NTSB narrative

The instrument-rated private pilot was conducting a cross-country instrument flight rules flight in instrument meteorological conditions. The pilot reported that, during an instrument landing (ILS) approach, he engaged the autopilot with the intent of flying an autopilot-coupled approach, but the airplane subsequently flew below the glideslope and off course. Review of recorded data revealed that the airplane's automated systems were not properly configured to automatically transition from GPS waypoint navigation mode to the navigation (NAV) mode; therefore, the autopilot did not capture the ILS. After the airplane passed the final approach fix (FAF), the pilot disengaged and then re-engaged the autopilot in the attitude hold mode, at which time, the roll attitude was about 15° left. The airplane drifted left of course and subsequently flew below the glideslope. The air traffic controller subsequently canceled the approach clearance and provided radar vectors to another airport about 15 miles away. Based on this information, it is likely the pilot’s mismanagement of the airplane’s automated systems (autopilot, GPS, and navigation radios) led to its failure to capture the ILS and necessitated the missed approach. About 5 minutes after the missed approach, the controller provided the pilot with radar vectors to the FAF for a GPS approach at the diversionary airport. The pilot reported that, he thought he had engaged the autopilot to fly directly to the FAF and that the airplane subsequently began to climb and bank sharply right. The data showed that the pilot had mistakenly programmed the GPS/autopilot to fly to the initial approach fix (IAF), which was behind and right of the airplane, instead of the FAF. Due to the pilot’s mismanagement of the airplane’s automated systems (GPS and autopilot), when he attempted to activate the approach near the FAF, the autopilot attempted to turn the airplane right toward the IAF, contrary to the pilot’s intent. After air traffic control canceled the second approach clearance, they provided the pilot with radar vectors for a third instrument approach attempt. The recorded data showed that the pilot made a series of inputs to the autopilot that resulted in the airplane climbing when he expected it to descend, and shortly thereafter, the autopilot’s underspeed envelope protection mode activated in order to avoid entering an aerodynamic stall. When queried about the airplane’s altitude by air traffic control, the pilot appeared to be confused as to why the airplane was climbing. Further, when the controller queried the pilot about which direction the airplane was headed, he indicated that he thought the autopilot was navigating to a fix, when in reality it was in a mode to follow a prescribed heading. During the final minutes of the flight, after air traffic control provided the pilot a low altitude alert, the autopilot modes changed several times while the airplane began maneuvering to extreme roll and pitch attitudes. During this time, the pilot attempted to activate the autopilot’s straight and level mode three times. The first time the pilot activated the mode, he deactivated it six seconds later. He then attempted to activate the straight and level mode again, but the pilot held the button down, delaying its activation. After the mode activated, the roll returned to level, but the airplane increased its pitch to 20° nose up. As the pitch attitude increased, the autopilot commanded nose down trim, an indication that the autopilot was opposing the pilot’s nose up forces to the control stick. This evidence indicates that the pilot continued to exhibit confusion about the way the airplane’s automated systems worked together with the autopilot. The pilot then disconnected the autopilot and reactivated the straight and level mode for the third and final time after the pitch attitude reached 60° nose up and about 120° left roll. After the activation, the pitch and roll began to decrease toward a wings level attitude. About that time, the pilot activated the airplane’s parachute system. The airplane subsequently descended into a residential area and during the landing, the left wing was substantially damaged. The pilot and passenger were not injured. Postaccident review of all recorded data showed that the airplane and its automated systems performed as expected given the inputs provided by the pilot. It is likely that the pilot’s continuous mismanagement of the airplane’s automated systems ultimately led to his loss of airplane control during the third instrument approach attempt, which necessitated his eventual activation of the airplane’s parachute system.

Analysis

Primary failure mode
Automation / mode confusion
First missed decision gate
Pilot could have ensured correct autopilot mode before ILS approach.

NTSB coding

Evidence available

  • ATC audio
  • Video
  • FDR / data
  • ADS-B / radar
  • Photos
  • 18 docket documents
View NTSB final reportView NTSB docket

Docket documents18

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