Pilot Debrief

CIRRUS DESIGN CORP SR-22 near South Bend, IN — 2011-04-04

Final reportCEN11FA267
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Date
2011-04-04
Location
South Bend, IN, USA
Airport
SBN
Aircraft
CIRRUS DESIGN CORP SR-22
Registration
N847C
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot’s failure to maintain airplane control while on final approach with a gusting crosswind and the subsequent aerodynamic stall and spin during the attempted go-around.

NTSB narrative

The pilot was performing a landing approach with a known, gusting crosswind present. A witness stated that the airplane was being “bounced around” by the wind gusts and that it “stalled and rolled to the left.” Another witness heard the accident airplane go to full power. The airplane was then in a 15- to 30-degree left bank with a nose-down attitude before it impacted the ground. The airplane’s left wing impacted the ground first, then the airplane cartwheeled one-half turn. A postaccident examination of the airplane revealed no preimpact airframe or engine anomalies that would have precluded normal operation of the airplane. About 8 months before the accident, the airplane's annual inspection was completed, and 2 days later the airplane's recoverable data module (RDM) stopped recording data due to a failed transient voltage suppressor (TVS) and did not record data during the accident flight. The airplane underwent a 100-hour inspection about midway through the 8 month period, and the failed RDM was not detected at that time. The system does not provide a failure indication to the pilot, and there is no requirement during the 100-hour inspection to check the RDM. A likely cause of the TVS failure could have been electrical overstress: the airplane was tied down overnight, and lightning was present when the RDM stopped recording. A similar airplane sustained substantial lightning strike airframe and avionics damage while tied down and at least two other airplanes sustained lightning strikes at that time. An Air Force Research Lab report recommended that a “review of the system design be conducted to determine if a cockpit indicator could be installed to alert the pilot when data logging is not functioning."

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot did not request further wind updates before landing.

NTSB coding

Evidence available

  • ATC audio
  • Photos
  • 29 docket documents
View NTSB final reportView NTSB docket

Docket documents29

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