Pilot Debrief

Cirrus Design Corporation SR22 near Woodruff, WI — 2008-09-12

Final reportCHI08FA282
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Date
2008-09-12
Location
Woodruff, WI, USA
Airport
ARV
Aircraft
Cirrus Design Corporation SR22
Registration
N193BS
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Approach

Probable cause

The pilot’s failure to maintain airspeed during a missed approach leading to the inadvertent stall. Contributing to the accident were the pilot’s lack of experience in the type of operation conducted, the certificate holder’s loss of operational control, and the lack of adequate oversight of the operation by the Federal Aviation Administration.

Contributing factors

Contributing to the accident were the pilot’s lack of experience in the type of operation conducted, the certificate holder’s loss of operational control, and the lack of adequate oversight of the operation by the Federal Aviation Administration.

NTSB narrative

The pilot was attempting a non-precision instrument approach at dusk in instrument meteorological conditions (IMC) that were below the required approach minimums without an alternate airport. Near the missed approach point, the airplane entered a climb and the airspeed decreased. The airplane gave a stall warning and it subsequently crashed. Recorded flight data revealed that pilot was utilizing the autopilot intermittently and then about two minutes before the accident he turned it off, indicating that he was either not proficient in flying in IMC in the accident airplane make and model and/or utilizing its autopilot. This was further supported by the pilot previously failing his initial airman examination flight and his lack of experience in non precision approaches in such conditions. Furthermore, the postaccident investigation determined that the Part 135 certificate holder had used an unapproved airplane training program paid for by the airplane owner and had falsified air carrier records in order to meet air carrier flight training requirements. The assignment of the flight shows a loss of operational control due to the attempted approach in below approach minimums; the lack of an alternate airport; the assignment of a pilot that lacked proficiency and/or experience in the weather conditions that were encountered during the flight; and pilot’s lack of explicit authorization for use of an autopilot in lieu of a second-in-command, which was due to the Federal Aviation Administration (FAA) Principal Operation Inspector's (POI) failure to complete the appropriate form. Additionally, the airplane’s registered owner had placed their airplanes on a previous Part 135 certificate but that certificate holder removed those airplanes from the certificate after the owner improperly exercised operational control instead of the certificate holder. The airplanes were then placed on the current certificate holder’s certificate during which time there are indications that the airplane owner was exercising operation control. At least one inspector from the FAA’s Flight Standard District Office (FSDO) was aware of the history of improper exercise of operational control of flights by the airplane owner (not the certificate holder) and no action was taken to stop this practice. Additionally, the FAA FSDO surveillance records revealed that the certificate holder was rated as satisfactory with no comments noted, although throughout the investigation numerous discrepancies were found that within the company that did not comply with Part 135 operations. A postaccident examination revealed no mechanical anomalies that would have precluded normal airplane operation.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot could have aborted the approach due to low visibility and weather conditions.

NTSB coding

Evidence available

  • ATC audio
  • FDR / data
  • ADS-B / radar
  • Photos
  • 58 docket documents
View NTSB final reportView NTSB docket

Docket documentsshowing 50 of 58

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