Pilot Debrief

CIRRUS DESIGN CORP SR22 near Boynton Beach, FL — 2011-11-13

Final reportERA12FA068
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Date
2011-11-13
Location
Boynton Beach, FL, USA
Aircraft
CIRRUS DESIGN CORP SR22
Registration
N661FT
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Maneuvering

Probable cause

The right seat pilot's decision to attempt a low-altitude aerobatic maneuver in a non-aerobatic airplane.

NTSB narrative

The pilots of the non-aerobatic airplane were returning from an air show and flying in formation with two aerobatic airplanes. A pilot of one of the aerobatic airplanes reported that, shortly after the accident airplane crossed the border of an unpopulated wetland area, the airplane's pitch smoothly increased upward to an angle of about 30 degrees. The accident airplane was flying at a global positioning system-derived altitude of 29 feet. The airplane then began a roll to the left, and, as the airplane rolled toward an inverted attitude, the pitch quickly began decreasing below the horizon. The airplane then began a rapid descent and impacted the marsh below in a 68-degree nose-down pitch attitude. Postaccident examination of the wreckage revealed no evidence of any preimpact mechanical malfunctions or failures with the airframe or engine that would preclude normal operation. Flight data recorded by a device onboard the accident airplane, along with statements provided by witnesses, suggested that one of the pilots likely attempted to perform an aileron roll at low altitude and that the maneuver had been performed on at least two previous occasions, at higher altitudes. The investigation could not determine which of the pilots was physically manipulating the controls at the time of the accident; however, given the right seat pilot's substantial previous flight experience, the provisions of the exclusive agreement under which he rented the accident airplane, and statements from witnesses affirming that the pilot had attempted the maneuver in the past, it is most likely that the right seat pilot was acting as pilot-in-command at the time of the accident and was either manipulating the controls or directing the left seat pilot's manipulation of the controls at the time. The right seat pilot had not logged any previous aerobatic experience, and witnesses described any undocumented experience he may have had as "low." The manufacturer maneuver limits for the accident airplane model prohibit aerobatic maneuvers. The airplane's ballistic recovery parachute system likely activated during the impact sequence and was not activated by either of the occupants before impact given that the system's safety pin was found installed; it is unlikely that activation of the system would have affected the outcome of the event. Additionally, based on observations of the airplane's occupant restraint systems, recovered positions of the pilots' remains, and preaccident photographs recovered from an electronic device onboard the airplane, it is unlikely that the right seat pilot was wearing his shoulder restraint. It could not be determined if this apparent lack of upper body restraint may have inhibited the right seat pilot's ability to control the airplane during the maneuver.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have refrained from attempting aerobatic maneuvers in a non-aerobatic aircraft.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 18 docket documents
View NTSB final reportView NTSB docket

Docket documents18

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