Pilot Debrief

Cirrus SR20 near Santa Maria, CA — 2020-05-20

Final reportWPR20LA152
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Date
2020-05-20
Location
Santa Maria, CA, USA
Airport
SMX
Aircraft
Cirrus SR20
Registration
N883PJ
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot’s exceedance of the airplane’s critical angle of attack during a steep and descending turn to final approach, which resulted in an aerodynamic stall and loss of control.

NTSB narrative

The student pilot was making his second solo cross-country flight. Following an initial straight in approach to runway 30, he executed a go-around and entered a left traffic pattern for another approach. Flight track data revealed that when the airplane was about two-thirds of the way along an extended downwind leg, it leveled off temporarily about 1,700 ft mean sea level (about 1,440 ft above the ground). Shortly thereafter, the airplane started a left turn and gradual descent. The rate of descent increased as the airplane made a continuous, steepening left turn through the base leg. The airplane crossed the final leg in a steep left turn at a descent rate of about 2,000 ft per minute, made an abrupt right turn, and descended rapidly until the track ended in the vicinity of the accident site about 2 nautical miles short of the runway threshold. All communications with air traffic control were normal, and the pilot did not transmit any distress calls. A witness observed the airplane flying lower than normal airplane traffic and appearing to wobble. Another witness observed the airplane with its wings perpendicular to the ground; the airplane straightened out, wobbled, and descended out of view. Several other witnesses reported hearing a loud noise, and two of them reported looking toward the direction of the sound and observing the airplane in a steep dive with a parachute trailing behind it. Examination of the accident site revealed that the airplane impacted in a nose-low attitude and came to rest inverted; a postimpact fire ensued, destroying a large portion of the airplane. A postaccident airframe and engine examination did not reveal any anomalies that would have precluded normal operations. The witness observations and the flight track data are consistent with the pilot losing control of the airplane during a steep descending turn from the base leg to the final leg of the traffic pattern, which resulted in exceedance of the airplane’s critical angle of attack and the airplane experiencing an aerodynamic stall. The parachute rocket and deployment bag were found about 58 yards from the main wreckage. The parachute straps were extended from the airplane, and the parachute came to rest about 21 yards from the main wreckage. The positions of the rocket, bag, and parachute and the loud noise heard by the witnesses are consistent with the pilot deploying the parachute just before impact. Given the low altitude and high descent rate at the time of deployment, the parachute likely did not have time to inflate. Postmortem toxicology testing of specimens from the pilot was positive for ethanol in the blood and brain at low concentrations and chlorpheniramine in the blood and liver at low concentrations. Given the low concentrations of ethanol and the lack of ethanol in the liver, it is likely the identified ethanol was from sources other than ingestion and did not contribute to the accident. In addition, given the low concentrations of chlorpheniramine, it is unlikely that the effects from the pilot’s use of chlorpheniramine contributed to the accident.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have aborted the approach earlier to avoid the accident.

NTSB coding

Evidence available

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

Docket documents15

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