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Aviation Accident

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NTSB Identification: CEN09FA267
14 CFR Part 91: General Aviation
Accident occurred Tuesday, April 28, 2009 in Mayfield Village, OH
Probable Cause Approval Date: 01/07/2011
Aircraft: CIRRUS DESIGN CORP SR22, registration: N504MD
Injuries: 2 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

The instrument certified airplane climbed into instrument meteorological conditions about 30 seconds after takeoff. Radar track data showed that the airplane entered a right turn shortly after takeoff and entered the cloud base. The airplane remained in that right turn until it completed nearly 1-1/2 complete turns. The airplane rolled out and subsequently climbed 1,500 feet over next 17 seconds. The airspeed decreased to 50 knots and the airplane’s heading abruptly transitioned from the south to the north-northwest which could have represented an aerodynamic stall. The airplane then descended before beginning another climb. The airplane completed two additional descent and climb oscillations with minimum airspeeds of 60 knots and 50 knots, respectively. Maximum pitch angles of 50 degrees nose up and nose down, and bank angles of 75 degrees were recorded during the flight. The duration of the accident flight was approximately 4 minutes and 30 seconds.

The airplane impacted a wooded area located about 3 miles from the departure airport and was destroyed by impact forces and a postimpact fire. An examination of the airframe and engine did not revealed preimpact anomalies. No flight display and/or autopilot system faults were recorded during the accident flight. Further review of the flight data did not reveal inconsistencies within the data itself. The data indicated that the pilot initially engaged the autopilot about 5 seconds after lifting off when the airplane was approximately 61 feet above ground level. The autopilot bugs were set to the assigned heading and initial altitude prior to takeoff. However, after takeoff the pilot failed to properly engage the autopilot altitude preselect mode; the altitude hold mode was entered instead. As a result, the altitude and vertical speed bug settings were reset automatically to maintain the airplane’s altitude. At that point, the airplane’s altitude was above that specified by the autopilot bug. Subsequent attempts to engage the vertical speed/altitude pre-select mode caused the system to begin a descent to intercept the inadvertent altitude set in the autopilot.

About 1 minute into the flight, the pilot reset the altitude bug above the airplane’s current altitude at that time. The data suggests that the pilot never adequately regained control of the airplane. The pilot purchased the accident airplane about 7 months prior to the accident. He completed visual flight rules transition training at the time he took delivery of the airplane. The training did not include an instrument proficiency check. Prior to the transition training, the pilot reported a total flight time of 1,344 hours, which included 20 hours flight time and 4 hours instrument flight time within the one-year period preceding the training.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
  • The pilot’s failure to maintain control of the airplane while operating in instrument meteorological conditions due to spatial disorientation. Contributing to the accident was the pilot’s inattention to basic aircraft control while attempting to program the autopilot system.