Pilot Debrief

CIRRUS DESIGN CORP SR22 near Phoenix, AZ — 2010-08-04

Final reportWPR10FA383
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Date
2010-08-04
Location
Phoenix, AZ, USA
Airport
DVT
Aircraft
CIRRUS DESIGN CORP SR22
Registration
N146CK
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot‘s failure to maintain airspeed and airplane control during a turn from the base leg to final approach due to his diverted attention.

NTSB narrative

Shortly after takeoff, the pilot notified the tower air traffic controller that he needed to return to the airport to “close a door” on the airplane. The pilot acknowledged the landing clearance and declined further assistance. Review of recorded radar data revealed that after the airplane’s departure, it remained within the airport traffic pattern and ascended to an altitude of about 528 feet above ground level near the downwind-to-base leg of the flight. In addition, a pilot-rated witness located adjacent to the accident site reported observing the airplane depart and remain within a left traffic pattern for the runway. The witness stated that the airplane appeared to be traveling slowly as it began to initiate a left turn from the base leg to final approach before stalling and entering a spin to the left. Security camera images captured the accident airplane in a left-wing-low, nose-down attitude just before impact with the ground. In addition, the left cabin door was observed in an open position before impact. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Witness reports and findings from the wreckage examination are consistent with a loss of control and subsequent aerodynamic stall and spin. It is likely that the pilot was distracted by the open door and failed to maintain sufficient airspeed while turning from the base leg to final approach and lost control of the airplane. Review of the pilot’s Federal Aviation Administration (FAA) medical records showed that the pilot did not report any mental disorders, depression, or anxiety. However, the pilot’s personal medical records revealed that he had been treated for depression for several years, including several episodes of acute exacerbation. Postaccident toxicology testing found venlafaxine and nortriptyline (both used in the treatment of depression) in the postmortem cavity blood that exceed the toxic ranges for peripheral blood set by the FAA Civil Aerospace Medical Institute. However, substances undergo redistribution after death and these results are unlikely to be the result of toxic overdose.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have aborted the flight due to the open door before takeoff.

NTSB coding

Evidence available

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

Docket documents32

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