Pilot Debrief

CIRRUS SR22 near Jamestown, NY — 2023-06-06

Final reportERA23FA258
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Date
2023-06-06
Location
Jamestown, NY, USA
Airport
KJHW
Aircraft
CIRRUS SR22
Registration
C-GNMT
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Initial climb

Probable cause

The pilots’ failure to maintain airplane control following an anomalous engine indication during the initial climb, which resulted in a loss of control and parachute deployment at an altitude too low for the system to operate effectively. Contributing to the accident was an exceedance of engine manifold air pressure for reasons that could not be determined based on the available evidence.

NTSB narrative

The day before the accident, the pilot and the flight instructor brought the airplane to a maintenance facility due to a low engine manifold air pressure (MAP) indication. The owner of the maintenance facility adjusted the MAP via a set screw on the bottom of the slope controller (turbocharger controller), while the instructor performed ground runs to verify it. The instructor then took a facility maintenance technician on a 30-minute post-maintenance flight. There were no anomalies noted during that flight. On the day of the accident, the pilot and instructor flew a cross-country flight to the destination airport. Recorded data indicated that, during the flight, the MAP momentarily exceeded the maximum value of 37.5 in (37.59 in) for 1 second, which activated a red crew alerting system (CAS) message visual warning; however, there were no further exceedances during the flight. After conducting business at the destination, the pilot and instructor boarded the airplane for the return flight. They conducted one uneventful touch-and-go landing when, following the second touch-and-go, about midfield at 200 ft above ground level, the MAP exceeded 38.5 in (39.91 in), which activated an aural CAS warning, and the fuel flow exceeded 41 gph (49.5 gph); however, the engine’s fuel-to-air ratio remained sufficient, and the engine continued to operate. The airplane subsequently pitched up 13° and rolled left 67° just before the Cirrus Aircraft Parachute System (CAPS) was deployed about 293 ft above ground level, which was too low to allow for full deployment of the parachute system. The airplane impacted terrain and was consumed by a postimpact fire. Subsequent examination of the slope controller did not reveal any preimpact mechanical malfunctions; however, it sustained heat damage due to a postcrash fire and its gasket rubber diaphragm were destroyed consistent with heat damage. Examination of the remainder of wreckage also did not reveal any preimpact mechanical malfunctions. Based on the evidence, the pilot(s) likely overreacted to a distracting anomaly in the cockpit (exceedance of MAP, resulting in an aural cockpit CAS warning), lost control of the airplane, and deployed the CAPS at altitude that was insufficient for it to be effective.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Deploy CAPS at a higher altitude to ensure safe recovery.

NTSB coding

Evidence available

  • Photos
  • 14 docket documents
View NTSB final reportView NTSB docket

Docket documents14

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