Pilot Debrief

CIRRUS DESIGN CORP SR22 near Mayfield Village, OH — 2009-04-28

Final reportCEN09FA267
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Date
2009-04-28
Location
Mayfield Village, OH, USA
Airport
CGF
Aircraft
CIRRUS DESIGN CORP SR22
Registration
N504MD
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Takeoff roll

Probable cause

The pilot’s failure to maintain control of the airplane while operating in instrument meteorological conditions due to spatial disorientation. Contributing to the accident was the pilot’s inattention to basic aircraft control while attempting to program the autopilot system.

Contributing factors

Contributing to the accident was the pilot’s inattention to basic aircraft control while attempting to program the autopilot system.

NTSB narrative

The instrument certified airplane climbed into instrument meteorological conditions about 30 seconds after takeoff. Radar track data showed that the airplane entered a right turn shortly after takeoff and entered the cloud base. The airplane remained in that right turn until it completed nearly 1-1/2 complete turns. The airplane rolled out and subsequently climbed 1,500 feet over next 17 seconds. The airspeed decreased to 50 knots and the airplane’s heading abruptly transitioned from the south to the north-northwest which could have represented an aerodynamic stall. The airplane then descended before beginning another climb. The airplane completed two additional descent and climb oscillations with minimum airspeeds of 60 knots and 50 knots, respectively. Maximum pitch angles of 50 degrees nose up and nose down, and bank angles of 75 degrees were recorded during the flight. The duration of the accident flight was approximately 4 minutes and 30 seconds. The airplane impacted a wooded area located about 3 miles from the departure airport and was destroyed by impact forces and a postimpact fire. An examination of the airframe and engine did not revealed preimpact anomalies. No flight display and/or autopilot system faults were recorded during the accident flight. Further review of the flight data did not reveal inconsistencies within the data itself. The data indicated that the pilot initially engaged the autopilot about 5 seconds after lifting off when the airplane was approximately 61 feet above ground level. The autopilot bugs were set to the assigned heading and initial altitude prior to takeoff. However, after takeoff the pilot failed to properly engage the autopilot altitude preselect mode; the altitude hold mode was entered instead. As a result, the altitude and vertical speed bug settings were reset automatically to maintain the airplane’s altitude. At that point, the airplane’s altitude was above that specified by the autopilot bug. Subsequent attempts to engage the vertical speed/altitude pre-select mode caused the system to begin a descent to intercept the inadvertent altitude set in the autopilot. About 1 minute into the flight, the pilot reset the altitude bug above the airplane’s current altitude at that time. The data suggests that the pilot never adequately regained control of the airplane. The pilot purchased the accident airplane about 7 months prior to the accident. He completed visual flight rules transition training at the time he took delivery of the airplane. The training did not include an instrument proficiency check. Prior to the transition training, the pilot reported a total flight time of 1,344 hours, which included 20 hours flight time and 4 hours instrument flight time within the one-year period preceding the training.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot could have aborted takeoff due to deteriorating weather conditions.

NTSB coding

Evidence available

  • ATC audio
  • FDR / data
  • Photos
  • 23 docket documents
View NTSB final reportView NTSB docket

Docket documents23

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