Pilot Debrief

CIRRUS DESIGN CORP SR22T near Gulf of Mexico, GM — 2018-01-03

Final reportCEN18FA400
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Date
2018-01-03
Location
Gulf of Mexico, GM, USA
Aircraft
CIRRUS DESIGN CORP SR22T
Registration
N325JK
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Cruise

Probable cause

The pilot's incapacitation resulted in impact with the Gulf of Mexico. The reason the hypoxia recognition system did not descend the airplane as designed could not be determined as the airplane was not located.

NTSB narrative

The pilot was in cruise flight at 19,000 ft mean sea level when he became unresponsive to air traffic control. Military pilots dispatched to intercept the airplane reported that the pilot was seated upright with his head tilted back against his seat and was unresponsive. The airplane continued on its established course at 19,000 ft over the Gulf of Mexico, where radar contact was lost about 3.75 hours after the pilot's last communication with air traffic control. The engine likely lost total power due to fuel exhaustion and the airplane descended into the water. The airplane was equipped with a hypoxia recognition system which was designed to descend the airplane to a lower altitude in the event of pilot incapacitation. Given the altitude of the accident airplane, the system should have activated about 17 minutes after the pilot's last input or interaction with the system. Following the accident, the manufacturer identified a condition under which uncommanded inputs could be made to the airplane's avionics, which could interfere with the normal function of the hypoxia recognition and automated descent features; however, the reason for the accident airplane's continued flight at 19,000 ft could not be determined, as the airplane was not recovered. The last few transmissions by the pilot to air traffic control illustrated a degradation in communication consistent with incapacitation. Given this interaction with the pilot and the lack of response from the pilot when the airplane was intercepted, it is likely that the pilot became incapacitated due to hypoxic hypoxia.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot failed to respond to descent instructions, indicating possible incapacitation.

NTSB coding

Evidence available

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

Docket documents10

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