WPR10FA163
WPR10FA163

HISTORY OF FLIGHT

On March 19, 2010, about 1910 Pacific daylight time, a Cirrus SR22, N224GS, collided with trees and terrain during a forced landing following a loss of engine power near Morton, Washington. The private pilot was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. The airplane was substantially damaged. The pilot was killed and the passenger sustained serious injuries. Visual meteorological conditions prevailed and no flight plan was filed. The flight departed from Buchanan Field Airport, Concord, California, about 1540, and was destined for Renton Municipal Airport, Renton, Washington.

The Safety Board investigator-in-charge interviewed the passenger on Wednesday, March 24, 2010. The passenger indicated that she and the pilot were returning from a business trip. After fueling the airplane, they departed and began the flight home. The passenger stated that while the airplane was in cruise flight, the pilot suddenly placed his hands on the controls, told her that the engine had lost power, and they were going to land at a nearby airport. He entered a steep right turn toward the airport. The passenger could not recall hearing anything unusual at the time of the event. The pilot remained calm throughout the approach to the airport and reassured the passenger during the descent that they would land safely. The pilot also declared a MAYDAY message and spoke on the radio. The passenger sent a text message to a friend at 1909 indicating that they were not going to make it to the airport. She did not recall anything after this point.

The passenger indicated that the pilot had discussed the Cirrus Airframe Parachute System (CAPS) with her prior to the trip and showed her how to activate it in the event of an emergency. The passenger reported that the pilot did not attempt to activate the CAPS during the flight.

Audio obtained from Prescott AFSS indicated at 1906:51, N224GS transmitted "MAYDAY, MAYDAY, Cirrus N4GS" on frequency 121.5. Part of the audio was unintelligible. Another aircraft, N999VK responded immediately to the MAYDAY call with “Cirrus on guard this is N999VK”, then a Seattle Radio controller responded with “Aircraft calling MAYDAY on 121.5, Seattle Radio." N999VK said “Standby center, 9VK is copying a MAYDAY”, and then asked N224GS to go ahead. N224GS said “I’m west of Strom airport, trying to make the field." N999VK asked N224GS how far he was from the field. No additional transmissions were received from N224GS. Prescott AFSS contacted the local sheriff's office.

The wreckage was located immediately following the accident approximately 2.5 miles west-northwest of Strom Field Airport, Morton, Washington.

PERSONNEL INFORMATION

Pilot Information

The pilot, age 39, held a private pilot certificate with an airplane single-engine land rating, and a third-class airman medical certificate issued May 29, 2007, with the limitation that he must wear corrective lenses. Copies of the pilot's logbook were obtained from his family. The last entry was dated February 21, 2010, and showed a total time logged of 219.8 hours. In a second earlier logbook provided by the pilot's family, the total time logged was 258.6 hours. Based on information obtained from the avionics onboard the airplane, the pilot had flown approximately 11 additional hours in the airplane, for a total flight time of 489.4 hours. He had flown 13 hours over the past 30 days and 14.9 hours over the past 90 days. His last flight review was on July 29, 2009.

Maintenance Personnel Information

Director of Maintenance

The Director of Maintenance (DOM) for Auburn Flight Service, the facility that performed the most recent annual inspection on the airplane, was interviewed. He held an aviation maintenance technician certificate with airframe and powerplant (A & P) ratings and also held an inspection authorization (IA). He had worked as an A & P since 1989, and obtained his IA in October of 1999. He had served as the DOM at Auburn Flight Service since October of 2002.

The DOM's normal work schedule consisted of a 40-hour work week, although he indicated that he was "juggling a lot" between work and personal life. He usually worked between 50 to 60 hours per week with 10 to 11-hour days. The number of employees he oversaw varied. During high employment periods, he oversaw five to six mechanics. In February of 2010, he employed three mechanics.

Airframe and Powerplant Technician with Inspection Authorization

The A & P/IA began his maintenance career in the military in 1991. Following the military, he worked in airline heavy line maintenance for seven years. He held employment as a flight engineer and first officer at a cargo company, and then returned to the Seattle area for family reasons. He began work with Auburn Flight Service where he worked for two years until leaving in February of 2010 for career advancement at a different company. The A & P/IA typically worked a 40-hour week with occasional overtime. He never felt like he was asked to do more than he was capable of doing.

Airframe and Powerplant Technician

The A & P held an aviation maintenance technician certificate with airframe and powerplant ratings. He began his maintenance career in the military in 1974 and obtained his A & P in 1986. He began working for Auburn Flight Service in April of 2007. The mechanic generally worked a 40-hour work week although his workload had recently increased due to more work and fewer employees. The mechanic felt that he had adequate time to perform his job duties.

AIRPLANE INFORMATION

The four-seat, low-wing, fixed-gear airplane, serial number (SN) 1326 was manufactured in 2005. It was powered by a Teledyne Continental IO-550-N engine and equipped with a Hartzell PHC-J3YF-1RF propeller.

Maintenance

The maintenance records were reviewed and the last annual inspection noted in the logbooks was October 17, 2008. The Safety Board investigator-in-charge contacted the maintenance facility that performed the annual inspection, Auburn Flight Service, and inquired whether or not a more recent annual inspection had been completed. According to the DOM for Auburn Flight Service, the last annual inspection was completed in February of 2010. He was uncertain why the annual inspection logbook entries were not in the logbooks. A work order dated January 8, 2010, contained a stamp dated February 5, 2010, and was signed by the DOM indicating that the airplane and engine had undergone an annual inspection. The DOM indicated that he did not perform the work on the airplane but had signed it off as airworthy.

The work order for the airplane showed that cylinders 3, 5, and 6 needed to be replaced due to cracks. The cylinders were replaced on February 2, 2010. On February 3, the work order noted "perform gnd run and leak check…check engine specs per TCM MM Table 19-1/TCM SB M89-71R." Both items were initialed by the A & P. The last item noted on the work order was dated February 3, and stated that "during ground runs L/R mag drops rough." Spark plugs were cleaned, tested, and reinstalled. The A & P also initialed this item.

The Cirrus maintenance checklist for the accident airplane was reviewed. The checklist noted the type of inspection as "annual." On page 17, the "Return to Service" checklist, five of the following six items were not initialed as being completed:
1. Close Access
2. Verify all Airworthiness Directives complied with (Initialed)
3. Fuel Injection System (The checklist noted "Functional inspection of fuel injection system in accordance with the manufacturer's approved instructions for continued airworthiness after engine installation, every 100 hours, at annual, or fuel system component replacement.")
4. Perform an airplane run-up (The checklist noted "In accordance with operational/functional check in 5-30. After completing the operational check, perform a walk around to detect fluid leaks or other abnormalities.")
5. Install Engine Cowling
6. Verify airplane papers in proper order

Director of Maintenance Interview

In an interview with the DOM, he indicated that the normal process when an airplane is brought in for maintenance is that the airplane is dropped off by the owner, a work order is created by the DOM, squawks are noted, checklists are compiled, and the package is assigned to a mechanic. If the maintenance includes an annual inspection, then the inspection is assigned to an IA. Due to differences in work requirements, mechanics may shift to other projects throughout an annual inspection. When the work order for an annual inspection is completed, it is returned to the responsible IA, the operations checks and engine cylinder compression checks are completed, the endorsements are made, the checklists and work orders are initialed, and the work order is stamped completed by the responsible IA.

According to the DOM, during an annual inspection of a Cirrus, the fuel system must be checked. Calibrated gauges are used to test metered and unmetered fuel pressure. A steel fuel cap is removed and the gauge is installed. At the completion of the test, the cap is reinstalled, and a leak check is performed.

The DOM stated that the accident airplane had been maintained at Auburn Flight Service since it was new. The annual inspection was due in October of 2009 and in November the owner contacted him about the inspection. The owner brought the airplane to Auburn Flight Service in January of 2010. In addition to the annual inspection and two-year items being due, the inspection had identified three cracked cylinders. Another A & P/IA who worked at Auburn Flight Service was assigned to complete the inspection. Two additional A & Ps worked on the airplane during the maintenance as well.

The DOM stated that following the accident, he asked the A & P/IA if he had signed off the annual inspection. The DOM stated that the IA was certain he had signed it off. A review of records showed that another Cirrus was in the shop at the same time and it also had to have three of its cylinders replaced. The DOM believes that the IA may have remembered completing the endorsement for the other airplane.

A checklist was created during the annual inspection for the airplane and as noted previously, items on the checklist were not initialed. The DOM stated that the IA assigned to complete the job forgot to initial the checklist items, and to complete the endorsements. When asked how he knew the work was completed, the DOM said that he was aware of what was going on in the facility regarding airplanes currently being worked on through daily contact with his technicians, contact with aircraft owners, and through review of the work orders. The DOM indicated that the A & P/IA should have signed off the inspection and maintenance endorsement for the airplane logbooks but overlooked doing so.


Aviation Maintenance Technician with Inspection Authorization Interview

The A & P/IA said that the accident airplane had been in the facility for an annual inspection. He was assigned to perform the annual inspection. During the inspection, three cracked cylinders were identified and they had to be replaced. The annual inspection was completed as far as the maintenance personnel could work until the new parts arrived. Once the parts arrived, an A & P in the shop replaced the cylinders and the A & P/IA replaced a seal on the lower cowling. He could not recall doing any additional maintenance items on the airplane.

The A & P/IA was asked about the throttle and metering assembly and when the fuel inlet cap on the line would be removed. He indicated that although he ran the engine before the annual inspection was conducted, he did not conduct any final checks. He said that in order to check the metered and unmetered fuel pressure, you would refer to a service bulletin and usually connect the gauge at the steel cap fitting. At the completion of the test, the cap is reinstalled and torqued. He indicated that normally torque seal would be used to mark that the cap had been torqued. He indicated that the engine run noted on the work order on February 3, was for the cylinder work and not the return to service run.

The A & P/IA stated that when he finished an annual inspection, he would sign the stamped page on the work order. In this case, the DOM, signed the front page. Additionally, the A & P/IA would have created logbook endorsements. The A & P/IA felt that the DOM may have been pressured to return the airplane to the owner. There was another Cirrus in the facility at the time and the workload was high.

The A & P/IA provided a copy of a logbook page showing the airplanes that he had signed off as airworthy or unairworthy from January 2010 through February 2010. The accident airplane was not listed.


Aviation Maintenance Technician Interview

The A & P recalled the accident airplane being in the shop for an annual inspection. The A & P said that there was nothing out of the ordinary during the maintenance that he performed and that the annual inspection items must be checked and functionally checked by an IA.

The A & P explained the fuel system pressure checks indicating that the line and cap are removed on the metering assembly, the fuel pressures are checked, and then the lines and cap are secured. This is followed by a leak check. The A & P stated that after the check is completed, everything is torque sealed. During the interview, he could not recall what color torque seal he might have used when securing the cap on the throttle and metering assembly.

When the A & P reviewed the annual inspection checklist during the interview, he indicated that several items were not completed by the A & P/IA. During the interview, the A & P indicated that there should have been additional discrepancy items for the A & P/IA's check of the fuel system. The A & P stated that the fuel system check that he (the A & P) performed was required due to the cylinder change as well as annual inspection requirements, and was not the final check. Additionally, he stated that the checklist was not filled out entirely by the A & P/IA. The A & P indicated that once all of the work order discrepancies are accomplished, the A & P/IA takes the work order package, completes the logbook entry, and the airplane is released. The A & P did not recall seeing the A & P/IA doing the final items not initialed on the checklist.

In later correspondence, the A & P stated that he misspoke during the interview and noted that he did not recall removing the test equipment. He reported the following:
"On work order 7631 item #39, I did not sign off removal of equipment or a leak check. In addition on the Cirrus checklist 05-20 page 17 Item 3 was left blank, indicating that check was not completed by the inspector in accordance with FAR 43.15 (c.), (2.), (i.), (ii.), (iii.) and (iv.). Furthermore, on Cirrus Checklist 05-20 page 17, items 1., 4., 5., and 6., were left blank indicating a final inspection/return to service was not documented by the inspector."

Teledyne Continental Motors Guidance

According to Teledyne Continental Motors Service Information Directive (SID) 97-3E, Procedures and Specifics for Adjustment of Teledyne Continental Motors (TCM) Continuous Flow Fuel Injection Systems, after the fuel pressures are checked, the test gages are removed, and all fuel hoses and cap fittings are reinstalled to their original location. Under Section D(3), it states "ASSURE CAP ASSEMBLY 639494 IS CORRECTLY INSTALLED ON INLET TEE FITTING OF COMBINATION THROTTLE BODY/METERING UNITS. TORQUE TO 135-190 INCH POUNDS PER TABLE 1 SPECS. UNDER NO CIRCUMSTANCE ALLOW ANY CAP FITTING OTHER THAN 639494 TO BE INSTALLED DURING ENGINE OPERATION." Following the installation, a complete fuel system leak check must be performed in accordance with the aircraft manufacturer's instructions.

METEOROLOGICAL INFORMATION

The closest official aviation weather was reported 30 miles west of Strom Field at Chehalis-Centralia Airport, Chehalis, Washington, at 1915 PDT. The following weather conditions were reported: visibility 10 statute miles, sky condition clear, temperature 13 degrees Centigrade, dew point 2 degrees Centigrade, wind from 340 degrees at 7 knots, and altimeter 30.13 inches of Mercury.

AIRPORT INFORMATION

Strom Airport is located in mountainous terrain at an elevation of 941 feet, and surrounded by heavily treed terrain that rises to 2,000 feet. It has one asphalt runway, 7/25, that is 1,810 feet in length and 40 feet wide. According to the airport facility directory, trees 41 to 59 feet in height obstruct the ends of the runway.

WRECKAGE AND IMPACT INFORMATION

Investigators responded to the accident site on March 20, 2010. The airplane came to rest in a rural residential area, on soft terrain used for gardening. The first identified point of impact was an area of approximately 50-foot tall trees. A 4-inch diameter section of a tree was broken, and a piece of fiberglass material remained suspended at the top portion of one tree. The outboard section of the right wing containing the navigation light was found in this area and it was located about 130 feet from the main wreckage. From the outboard right wing section moving east, the next identified point of impact was fencing that surrounded a garden. Multiple fence posts and rails were dislodged and found at the main wreckage site. The wings and forward fuselage area sustained significant impact damage. All control surfaces remained attached. An impact crater approximately 2 feet deep was directly in front of the engine and two propeller blades were partially buried in the soft soil. The wreckage came to rest on a heading of about 015 degrees. There was no fire.

The Cirrus Airframe Parachute System (CAPS) was examined. The rocket motor assembly and deployment bag (D-Bag) remained connected to the parachute. The rocket motor propellant was expended. The parachute was connected to the airframe with the harness and ran parallel to the right wing from the wreckage. The parachute canopy remained partially folded with the slider located at the top of the suspension lines. Both reefing line cutters were fired, however, the rear harness remained snubbed. The CAPS activation handle was found seated in the handle holder. The CAPS enclosure cover was found approximately 15 feet from the wreckage on the right side. According to the Cirrus representative, the signatures were consistent with activation due to impact forces.

Approximately 7 gallons of fuel were drained from the left wing fuel tank. The right fuel tank was breached. Investigators obtained approximately 1 cup of fuel from the right header fuel tank following the removal of the wreckage from the accident site.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was completed by the Lewis County Coroner's Office. The cause of death was attributed to blunt force head injuries. The FAA Civil Aerospace Medical Institute (CAMI) completed toxicological testing on specimens from the pilot. The results were negative for carbon monoxide, cyanide, and volatiles. The results were positive for the following:
20.97 (ug/ml,ug/g) Acetaminophen detected in Urine
66.89 (ug/ml, ug/g) Salicylate detected in Urine
Trazodone detected in Liver
0.041 (ug/mL, ug/g) Trazodone detected in Blood
Trazodone detected in Urine

Interviews with the pilot's family revealed that he used Trazodone as a sleep aid.

TESTS AND RESEARCH

Engine Examination

Investigators examined the engine at Teledyne Continental Motors, Mobile, Alabama. The engine exhibited impact damage concentrated at the upper forward and bottom areas. The throttle and metering assembly inlet, fitting cap part number 639494, was discovered missing. The cap was located resting on the number 1 and 3 inter-cylinder baffle. There was no evidence of damage to the cap. There was evidence of light blue staining on the crankcase.

The engine was prepared for a test run by installing a substitute inlet fitting cap and replacing parts that had sustained impact damage as follows: fuel manifold inlet fitting , push rod housings for the number 2, 5, and 6 cylinders exhaust and intake, push rods for the numbers 2 and 6 intake and number 5 intake and exhaust, right magneto, induction system riser for the number 6 cylinder, engine mounts, oil cooler, oil sump, oil suction tube, and the starter adapter. The engine was not disassembled prior to the engine run. During the engine run, the substitute fuel inlet cap was installed finger tight. A fuel system leak check revealed a fuel droplet accumulating at the cap. The engine run was then conducted with the fuel inlet cap finger tight.

The testing showed that with the fuel inlet cap installed finger tight, the operation of the engine was normal and did not reveal any abnormalities that would have prevented normal operation and production of rated horsepower.

Metallurgical Examinations

Fuel Inlet Cap

A metallurgist from the NTSB Materials Laboratory examined the cap from the fuel inlet. Drawings showed that each cap was an assembly of two parts with an internally threaded hex section and a floating end plug with an internal conical recess. When fully engaged, the threaded hex section clamps the conical recess of the plug over the conical end of the male fitting, sealing the male fitting and blocking fluid flow. Additional exemplar caps (used and new) were also submitted for the examination.

Examination of the cap revealed thick granular material covering three or four internal threads nearest the plug. The deposits were white or light tan in color with areas of reddish products. The three threads nearest the cap opening had some similar deposits but were essentially clean. The internal surfaces of the plug were also covered by similar thick corrosion products except on the ring shaped sealing surface of the conical recess.

To examine the pressure flanks of the cap threads, which are the sides of the thread teeth that contact and engage with the teeth of the mating threads, the staking deformations were filed off and the plug pushed through the hex section. High magnification examination of the pressure flanks on the clean threads uncovered circumferential scuffing, indicative of sliding contact with mating threads.

To establish the typical length of thread engagement, a laboratory supplied plug fitting was threaded into the new exemplar cap and firmly wrench tightened. The combined plug and cap were then cross sectioned. Three full threads on the cap were engaged by the mating threads on the plug. The engaged threads corresponded to the scuffed threads noted on the cap. The void space in the assembled joint corresponded to the locations of the noted corrosion deposits.

Mixture Cable

The mixture cable was found fractured at the accident site. It was examined by the NTSB Materials Laboratory. The cable fractured in the threads near the jam nut where it threads into the end fitting. The fracture showed rough matte gray features with deformation and secondary cracks adjacent to the fracture consistent with overstress fracture under bending loads. On the fitting side of the fracture, a shiny area was observed on the fracture surface adjacent to the surface at the tension side of the bend. The features were smooth and not replicated on the mating surface, consistent with post-fracture damage.

Cockpit Displays

The airplane was equipped with an Avidyne Entegra EXP5000 Primary Flight Display (PFD) and EX5000 Multi-function Display (MFD). The NTSB Recorders Laboratory examined the units. The PFD samples and stores several data streams in a sequential fashion; when the recording limit of the PFD is reached the oldest record is dropped and a new record is added. The MFD receives GPS position, time, and track data from the aircraft's GPS receiver. The MFD also receives information concerning altitude, engine, and electrical system parameters, and outside air temperature. The MFD generates new data files for each MFD power-on cycle. Similar to the PFD, the oldest record is dropped and replaced by a new recording once the storage limit has been reached.

The recording began with the airplane on the ground at Buchanan Field, Concord, California. The time of the beginning of the takeoff roll was approximately 1542:34. At 1543:16, the airplane was established in a climb, passing through 500 feet pressure altitude and on a northerly heading. The way point was changed to "KRNT", the airport identifier for Renton, Washington. At 1857, the altitude bug changed from 8,500 feet to 5,000 feet and the airplane began a shallow descent, fluctuating between 200 and 500 feet per minute (fpm). At 1904:16, the MFD data indicated a sharp reduction in exhaust gas temperature (EGT) on all cylinders, accompanied by a gradual decrease in cylinder head temperature (CHT) on all cylinders. Engine RPM decreased from the cruise value of approximately 2,450 RPM and varied between 1,200 RPM and 1,750 RPM for the remainder of the recording. At 1905:34, recorded fuel flow spiked, decreased slightly and then pegged at 30 gallons per hour, the maximum range of the fuel flow sensor, where it remained until the end of the recording. After the power loss, the descent rate increased, fluctuating between 1,000 and 1,700 fpm. The airplane turned to the east, then slightly back to the north, and finally settled on an easterly course heading directly towards Strom Airport during the descent. Indicated airspeed decreased to approximately 100 knots (KIAS). The SR22 Airplane Flight Manual (AFM) indicates speed for best glide is 87 or 88 KIAS, depending on weight. However, the AFM notes additional glide range may be achieved with a windmilling propeller by increasing airspeed by 5 to 10 knots.

According to the Cirrus representative, based on the pilot's position when the loss of engine power occurred, Morton (9 miles to the east) would have been the nearest airport with a hard surface runway. There were several grass airstrips to the west of the airplane's position, and Toledo, Washington airport was approximately 16 miles west.

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