WPR12FA235
WPR12FA235

HISTORY OF FLIGHT

On May 29, 2012, about 1258 mountain daylight time, a Cirrus SR20 airplane, N187PG, was substantially damaged following impact with remote mountainous terrain while maneuvering near Duck Creek Village, Utah. The rental airplane was operated by Elite Aviation of the North Las Vegas Airport (VGT), Las Vegas, Nevada. The certified private pilot and three passengers sustained fatal injuries. Visual meteorological conditions prevailed for the cross-country flight, which was being operated in accordance with 14 Code of Federal Regulations (CFR) Part 91, and no flight plan had been filed. The flight departed the Mesquite Airport (67L), about 1114 Pacific daylight time, with Bryce Canyon Airport (BCE), Bryce Canyon, Utah, as its reported destination.

The investigation revealed that the purpose of the flight was for the pilot and his three passengers to fly to Bryce Canyon for a fishing trip; fishing rods, tackle, and fishing licenses were located at the accident site. According to the Federal Aviation Administration (FAA), the pilot activated a visual flight rules (VFR) flight plan in Las Vegas at 0954, and subsequently canceled it after flying clear of McCarran International Airport (LAS), Las Vegas, Nevada, Class Bravo (B) airspace about 1005. When the airplane departed VGT, it had 41 gallons of aviation fuel on board. At the time of departure from VGT, the airplane was estimated to be over its maximum gross takeoff weight limitation by 210 pounds.

After departing VGT, the pilot flew direct to the Mesquite Airport (67L), Mesquite, Nevada, where it landed about 1100. Recorded non-volatile memory data revealed that the airplane had consumed 7.6 gallons of fuel during the flight. Prior to departing 67L, the pilot added about 10 gallons of 100LL aviation fuel. The airplane subsequently departed 67L for BCE about 1214, a flight of approximately 105 nautical miles (nm). At the time of departure, the airplane was estimated to be in excess of its maximum takeoff weight by about 225 pounds.

According to radar data, about 1245, which was about 30 minutes after departure from 67L, the airplane was climbing through 6,600 feet mean sea level (msl) on a northeasterly heading. At 1250, it was ascending through 7,100 feet msl, and at 1254:28 the airplane reached its highest recorded altitude for the flight, which was 7,847 feet msl. At this time, and directly in front of the airplane about 4 miles distant, was rising terrain; the lowest ridge was 8,470 feet high, with terrain measuring more than 9,000 feet in elevation bordering the ridge on both sides.

Data recovered from the airplane’s Recoverable Data Module (RDM)revealed that about 3 minutes prior to the accident, at 1255:10, the stall warning activated for the majority of the remaining 188 seconds of recorded data. At 1257:57, the airplane began a roll excursion to the left and reached a 54-degree, left wing down attitude, before briefly recovering to 8 degrees left wing down. The airplane then rolled to the left in a nearly inverted attitude at the end of the data. The airplane was in a climb attitude of between 10 to 15 degrees of pitch until about 1258:11, when it pitched to a 67-degree nose down attitude at the end of the data, which was recorded at 1258:20.

Local law enforcement personnel located the wreckage about 1930 on May 30, 2012. The airplane came to rest inverted on the west face of a mountain ridge, and about 100 feet below the top of the crest. An onsite examination of the wreckage revealed that all components necessary for flight were accounted for. The wreckage was recovered to a secured storage facility for further examination.

In a statement provided to the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), the Mesquite Airport facility manager reported that on the day of the accident, while he was refueling another airplane at the fueling island, he instructed the accident airplane as it pulled up to the fuel pump. He said that one of the four men in the airplane mentioned to him that they were all helicopter pilots, and that another one who was doing the refueling said that the fuel in the right wing was above the tab, and that he added fuel to the left side to balance it out; 9.98 gallons of fuel was added to the left tank. The witness further stated that as the men were boarding the airplane, he heard one of them ask whose turn it was to take the front seat. He concluded by stating that after taking off he observed the airplane do one touch-and-go, and then heard someone say that it looked like [the airplane] took an unusually long time to [gain] altitude.

Elite Aviation rented the airplane to the pilot. A post-accident interview with their management personnel revealed that the pilot refueled the airplane at their facility. He then taxied the airplane to another area on the airport to load his passengers and baggage. This location was about 0.25 miles away from the Elite facility, and was not visible from their business. Elite personnel also reported that on a previous occasion, which occurred just after the accident pilot had been checked out in the airplane, he was observed loading the airplane for a flight. Elite management personnel noticed that the airplane would be overweight, at which time the pilot was informed that he could not take that much baggage on the flight. Also during the interview, Elite management personnel revealed that the accident pilot would always try to circumvent things with the female office receptionists, but not with any of the male office personnel. In one instance, it was described that the accident pilot mentioned to the wife of one of the company’s owners that he could fly the rental airplane without renter’s insurance; the company co-owner said that this was not true. Elite personnel also reported that there were a few times when the accident pilot attempted to bargain airplane rental fees.

PERSONNEL INFORMATION

Pilot number 1 (pilot-in-command who occupied the right front cockpit seat position)

The pilot, age 44, possessed an Airline Transport Pilot certificate and flight instructor certificate for rotorcraft-helicopter. He also held a private pilot certificate, issued on May 7, 2010, for airplane single-engine land, and also possessed an instrument airplane rating. The pilot received his most recent second-class Federal Aviation Administration (FAA) medical certificate on December 1, 2011, with no limitations noted. At the time of the accident, the pilot was employed as a commercial helicopter pilot by a local sightseeing and tour company, which was based in Las Vegas, Nevada.

A review of the pilot’s personal and company flight records revealed that he had accumulated a total time in all aircraft of 5,668 hours, of which 5,465 hours were in helicopters and 160 hours were in airplanes. Additionally, the pilot had logged 1,003 hours of flight instruction given in helicopters. It was also revealed that as of March 31, 2012, the pilot had a total time of 109.5 hours in all Cirrus aircraft, which included 43.1 hours in the accident make and model, the SR20, and 66.4 hours in the SR22. Records indicated that the pilot’s most recent flight in an SR20 airplane prior to the accident flight was conducted on September 15, 2010, at which time he had accumulated a total of 16.7 hours as pilot in command in make and model.

Pilot number 2 (left front cockpit seat position)

The pilot, age 31, possessed a commercial pilot certificate with rotorcraft-helicopter instrument helicopter ratings. He also held a flight instructor certificate, with rotorcraft-helicopter and instrument helicopter ratings. Additionally, the pilot held a mechanic’s certificate with an airframe rating. The pilot’s most recent second-class FAA medical certificate was dated July 6, 2011, with no limitations. He did not possess a pilot certificate for airplanes.

AIRCRAFT INFORMATION

The accident airplane was a Cirrus Design model SR20, serial number 1892. It was a four-place, low wing, single-engine airplane, with a tricycle landing gear configuration. The airplane was issued an FAA normal category standard airworthiness certificate on January 14, 2008. It was equipped with Avidyne MFD & PFD, STEC 55X, dual Garmin GNS 430s, EMax, Stormscope, Skywatch, and an Xm weather/radio. The airplane was powered by a 210-horsepower Continental Motors, Inc. (CMI) IO-360-ES21 six-cylinder, reciprocating engine, serial number 360550. The engine was manufactured on December 2, 2007

A review of the operator’s maintenance records revealed that the airplane’s most recent annual inspection was performed on May 3, 2012, at an airplane total time of 1,739.6 hours. The most recent 100-hour inspection was performed on May 23, 2012, at an airplane total time of 1,839.6 hours. When examined at the post-accident layout examination, the HOBBS meter for the accident airplane indicated 2,068.4 hours. The FLIGHT Hobbs meter indicated 1,847.2 hours.

WEIGHT AND BALANCE

During the investigation, and with data recovered from the airplane’s Recoverable Data Module (RDM), weight and balance computations were calculated by Cirrus Aircraft and confirmed by the IIC for the takeoffs at both VGT and 67L, as well as for the estimated condition about the time of the accident.

With 41 gallons of fuel on board and considering the medical weights of the four occupants and weighed baggage, it was calculated that the airplane was 207 pounds over the maximum takeoff weight (MTOW) of 3,050 pounds when it departed VGT. After the calculated fuel burn from VGT to 67L and refueling after landing, the airplane was estimated to be about 221 pounds over the MTOW when it departed 67L. It was further calculated that the airplane was 177 pounds in excess of its maximum gross weight near the time of the accident. (Refer to the weight and balance calculations located in the Cirrus Final Mishap Report for additional details.)

PERFORMANCE

During the investigation, and at the request of the IIC, a Cirrus Aircraft Flight Test Engineer reviewed the non-volatile memory data to determine the climb performance of the accident airplane.

The engineer reported that just prior to the loss of control the pressure altitude was 7,250 feet msl, and the outside air temperature was 15.5 degrees Celsius (C). Based on Cirrus certification data for climb performance, the airplane loaded to 3,227 pounds should have been able to climb at +375 feet per minute, assuming that the engine was operating normally at the maximum available power of 2,700 revolutions per minute (rpm) and that the best rate of climb (Vy) of 93 knots indicated airspeed (IAS) was being flown by the pilot. The engineer also reported that based on the Cirrus engine power model and the recorded engine data, at 1856:20, the engine should have been producing 108 horsepower. Further, applying this reduced engine power to the Cirrus certification data, the climb performance would have been reduced to +22 feet per minute, again assuming that Vy was being flown by the pilot. The engineer added that the data appeared to indicate that the airplane was not being flown at Vy at this point in time, but in fact the airspeed was nearly at stall, which was 73 knots indicated airspeed (IAS). The engineer added that as the speed decreases towards a stall, the climb performance is reduced to zero. The 0% flap stall speed for the SR20 at 3,050 pounds is 69 knots IAS. Correcting for a weight of 3,227 pounds yields a stall speed of 71 knots IAS.

METEROROLOGICAL INFORMATION

At 1258, the weather reporting facility located at Swains Creek, Utah, which was about 9 nautical miles east-northeast of the accident site, reported wind from the southwest at 6 miles per hour (mph), gust at 8 mph, temperature 80 degrees Fahrenheit (F), dew point 23 degrees F, sky clear, and an altimeter setting of 30.21 inches of mercury.

At 1253, the recorded weather observation at the Cedar City Regional Airport (CDC), Cedar City, Utah, which is located about 26 nautical miles northwest of the accident site, reported wind variable at 4 knots gusting to 17 knots, visibility 10 miles, sky clear, temperature 75 degree F, dew point 14 degrees F, and an altimeter setting of 30.10 inches of mercury.

A Terminal Area Forecast (TAF) for Bryce Canyon Airport (BCE), which was issued at 1143 on May 29, 2012, and was valid from 1200 May 29 to 1200 May 30, revealed wind 220 degrees at 10 knots, with gusts to 18 knots, sky clear, and visibility greater than 6 miles.

There were no AIRMETS or SIGMETS in effect in the vicinity and timeframe of the accident.

WRECKAGE AND IMPACT INFORMATION

An on-site examination of the wreckage was conducted under the supervision of the NTSB IIC, who was accompanied by representatives from the FAA, Cirrus Aircraft Design, and CMI. A detailed survey of the wreckage revealed that all components necessary for flight were accounted for at the accident site.

The accident site was located in mountainous terrain about 7 nm southwest of Duck Creek Village, Utah, on the west face of a ridge about 100 feet below the top of the crest. A GPS reading taken at the site revealed that the main wreckage was located at 37 degrees 26.101 minutes north latitude and 112 degrees 45.899 west longitude, at an elevation of 7,172 feet msl.

The main wreckage came to rest inverted on a measured magnetic heading of about 180 degrees, and the energy path was oriented on a measured magnetic heading of 277 degrees. A tall pine tree between 20 to 25 feet tall was located uphill about 15 to 20 feet from the initial point of impact. There were no signatures observed to the tree consistent with impact by the airplane. The initial point of impact was evidenced by various shrubs and branches that had been cut off at a 15 to 20 degree angle to the ground. Immediately adjacent to the shrubs and down slope, a ground scar was observed in the dirt. The ground scar widened out downhill in line with the main wreckage, and contained multiple window fragments throughout the area. Facing downhill from the initial point of impact, another pine tree, about 8 inches in diameter and located on the right side of the debris field, was observed broken off about 1 foot above the ground. On the left side of the energy path, a third pine tree, about 1 foot in diameter, had stripped bark missing from its trunk, about 2 to 4 feet above the ground. The airplane’s propeller was observed separated from the engine, and laying on the ground partially hidden by shrubs. The two trees were estimated to be about 20 to 25 feet apart. The main wreckage came to rest 52 feet from the initial point of impact.

The forward fuselage was heavily damaged. The engine and engine compartment were found embedded in the ground, with fragments of the upper cowling and windscreen located uphill from the main wreckage. The forward cabin was observed crushed aft, with the instrument panel crushed and fragmented.

The right cabin door separated from the fuselage and was located near the initial point of impact. The left cabin door was fractured into two main pieces consisting of the top and bottom halves. The baggage compartment door separated from the airplane. All three doors exhibited impact damage.

The left wing was fractured and separated laterally at the inboard aileron attachment point. The wing was also fractured laterally about 2 feet further outboard. The inboard section of the wing contained 45-degree wrinkling starting forward inboard and then going aft outboard. The left flap was observed basically intact, however, it did contain some downward bending at the outboard most corner. The left aileron was also mostly intact, but was fractured and separated from all attach points. The aileron was observed bent and wrinkled. The left fuel cap was secured, and the fuel cap tab was extended. The fuel tank was breached. The left main landing gear sustained minimal damage. The forward most area of the wheel pant was cracked.

The right wing was observed fractured and separated at mid-span. Scratches along the longitudinal axis were also observed with organic debris adhering to the underside of the wing. The right flap was wrinkled throughout its span. The flap hinge was bent outboard and almost flush with the wing. The outboard 6 inches of the flap was bent upward. The right aileron was observed bent in two places, about one-third of the way inboard from the outboard extreme and also about mid-span. The aileron was also observed separated from the trailing edge of the wing at all attach points. The right fuel tank was breach; the fuel cap was observed secured. The right elevator was not damaged, with the exception to a crack along the forward and outboard section of the component. The right main landing gear remained attached and secured at all attach points. The only visible damage was a slight crack to its wheel pant.

Aileron control cable continuity from the left kickout pulley to the left aileron actuation pulley to the right aileron actuation pulley and back to the right kickout pulley was verified on site.

The flap actuator shaft separated from the flap motor. Approximately 3.5 inches of actuator was extended, which was consistent with a flaps UP position.

The entire empennage aft of the aft cabin bulkhead was intact. The right horizontal stabilizer and right elevator remained attached to the fuselage at all inboard attached points. Both sustained only minimal damage to their outboard leading edges. The left elevator and left horizontal stabilizer were not damaged. The rudder was intact and sustained only some minimal damage. Rudder control cable continuity from the FS306 bulkhead to the back seats was verified on site. Rudder control continuity from the backseats to the rudder pedal torque tubes was also confirmed. The rudder also exhibited powder residue from the Cirrus Airframe Parachute System rocket.

The nose landing gear was fractured and separated from the engine mount attachment point. The wheel remained secured to its attach point.

The engine was partially separated and came to rest upright at a heading of 130 degrees. There were no significant visual anomalies, or indications of catastrophic failure. The propeller governor control lever was found full in, and the propeller cable was separated. The throttle was at idle, and the mixture lever showed to be somewhere mid-travel.

The airplane was equipped with a Hartzell three-bladed propeller assembly. The propeller separated from the crankshaft just aft of the propeller flange. Spiral cracking and 45-degree shear lips were observed. The spinner was crushed aft and had fractured in multiple locations.

All three propeller blades were loose in the hub. Two blades exhibited polishing on the cambered side. One propeller blade was bent toward the cambered side. The second propeller blade was bent slightly toward the non-cambered side. The third propeller blade was slightly curled at the tip.

Cirrus Airframe Parachute System (CAPS)

The activation handle was in the handle holder. The safety pin was not observed. The rocket motor was located under the vertical stabilizer in the main wreckage. The pickup collar assembly was on the rocket. The lanyards were discolored brown consistent with rocket exhaust. The incremental bridle had not unzipped. The right side of the vertical stabilizer and rudder had brown discoloration consistent with rocket exhaust. The packed parachute assembly lay on the ground just forward of the vertical stabilizer. The rear harness remained snubbed, and the reefing line cutters had not been activated. The Sheriff noted that the first responders had cut the CAPS harnesses, and utilized them to extricate the decedents from the wreckage. The CAPS enclosure cover was located under the outboard portion of the right wing in the main wreckage.

MEDICAL AND PATHOLOGICAL INFORMATION

Pilot #1 (right front cockpit seat position)

On May 31, 2012, an autopsy was performed on the pilot at the facilities of the Utah Department of Health, Salt Lake City, Utah. The results of the examination revealed that the cause of death was determined to have been due to “blunt force injuries.” The report also indicated that toxicological testing results were negative for all substances in the screening profile.

Pilot #2 (left front cockpit seat position)

On May 31, 2012, an autopsy was performed on the pilot at the facilities of the Utah Department of Health, Salt Lake City, Utah. The results of the examination revealed that the cause of death was determined to have been due to “blunt force injuries.”

The Forensic Toxicology Fatal Accident Report for pilot number 2 was prepared by the FAA Civil Aeronautical Institute Oklahoma City, Oklahoma. The report indicated that specimens were unsuitable for analysis of carbon monoxide, and that no cyanide and no ethanol detected in Blood. The following value of Acetaminophen was noted in the report:

2.447 (ug/ml, ug/g) Acetaminophen detected in Blood

TESTS AND RESEARCH

The NTSB IIC secured the airplane’s primary flight display (PFD) and Recoverable Data Module (RDM), and forwarded them to the NTSB Vehicle Recorder Laboratory in Washington, D.C., for evaluation. An NTSB Vehicle Recorder specialist reported the following:

Primary Flight Display (PFD)

The Avidyne Entegra PFD unit includes a solid state Air Data and Attitude Heading Reference System (ADAHRS), and displays aircraft parameter data including altitude, airspeed, attitude, vertical speed, and heading. The PFD unit has external pitot/static inputs for altitude, airspeed, and vertical speed information. The PFD contains two flash memory devices mounted on a riser card. The flash memory stores information the PFD unit uses to generate the various PFD displays. Additionally, the PFD has a data logging function, which is used by the manufacturer for maintenance and diagnostics. Maintenance and diagnostic information recording consists of system information, event data, and flight data.

An examination of the PFD revealed that while it had been damaged by impact forces, the specialist was successful in extracting the 2 Flash memory chips from the damaged housing and placed in a surrogate PFD unit for download. The download revealed that the PFD contained about 17 hours of flight data, including the accident flight.

Recoverable Data Module (RDM)

The Aerosance RDM is a crash hardened flight recording device installed in the tail of the airplane that records critical flight information at a 1 Hz recording rate. This RDM stored approximately 200 hours of flight data at a 1 Hz recording rate. An examination of the unit revealed that the RDM card was undamaged, and the data was recovered normally.

Flight and Engine Data

A review of the basic flight data and engine data from the accident flight revealed that the airplane departed Mesquite Airport approximately 1114 PDT, 1214 MDT, and flew in a northeasterly direction. Fifty percent flaps were used for departure and were retracted at 1214:37 MDT. They remained retracted for the rest of the flight. At 1216:30 MDT, the cylinder head temperature on the number five cylinder reached 453° F. According to the Cirrus SR20 Pilot Operating Handbook, for the CMI IO-360-ES engine installed on N187PG, cylinder head temperatures are limited to 460° F. At 1216:40 MDT, the engine rpm decreased from approximately 2450 rpm to 2300 rpm. The engine oil temperature was within 5° F of the 240° F limitation for much of the flight, exceeding it at 1258:14 MDT. The autopilot was briefly active from 1229:42 to 1229:45 MDT.

At 1255:10 MDT, the stall warning activated for the majority of the remaining 188 seconds of data. At 1257:57 MDT, the airplane began a roll excursion to the left, reaching 54° left wing down, briefly recovering to 8° left wing down before rolling to the left nearly inverted at the end of the data. The airplane was climbing between 10-15° of pitch [up] until approximately 1258:11 when it pitched down to 67° nose down at the end of the data. The final RDM data was recorded at 1258:18 MDT and the final PFD data was recorded at 1258:20 MDT. (Refer to the Vehicle Recorder Specialist’s Factual Report, which is appended to the docket.)

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