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After The Accident: A Cirrus Mystery Crash Shrouded In Technology

The fatal loss of control of a Cirrus SR20 in areas of thunderstorms underscores the need for human management of safety features.

A Cirrus SR20 similar to the accident airplane.
A Cirrus SR20 similar to the accident airplane.
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No matter how many bells and whistles you may be fortunate enough to have at your disposal when flying, they won’t do you a bit of good if you don’t know how and when to use them to save you from danger or don’t have the presence of mind to realize that it’s time to reach out for a technological helping hand.

In its report on the Sept. 5, 2017, crash of a Cirrus SR20 at Jacksonburg, West Virginia, in which the private pilot and his passenger were killed, the NTSB concluded that the probable cause of the accident was the pilot’s loss of airplane control due to spatial disorientation while flying in instrument meteorological conditions in the vicinity of adverse weather conditions.

What the Safety Board didn’t mention is that there potentially may have been ways out of the unfolding disaster that the pilot either didn’t recognize or, for some reason, was unable to use. Among these would be turning over control of the airplane to the autopilot for continuing straight and level flight if not already using it or even deploying the airframe parachute system that comes standard with every Cirrus.

The four-seat, fixed gear, single-engine SR20 was manufactured in 2000 and was powered by a Continental IO-360-ES 200-horsepower engine equipped with a Hartzell three-blade, controllable-pitch propeller. Its maximum certificated gross weight was 3,150 pounds. The airplane was equipped with: an Aspen Pro EFD 1000 electronic flight display; panel-mounted Garmin 696 multifunction display, described as an all-in-one navigator; XM weather/audio; JP Instruments EDM-730 engine temperature monitor; Garmin 430 panel mount GPS and nav/comm; Garmin420 GPS/comm transceiver; S-TEC autopilot; and a Garmin GTX 327 transponder.

The 72-year-old pilot held a private certificate with ratings for airplane single-engine land and instrument airplane. When investigators reviewed his logbooks, they found he had 1,077 total hours of flight experience logged as of July 29, 2017. The time included 92 hours in the SR20. The logbooks showed 37.6 total hours of actual instrument time, of which 24.9 hours were accumulated while flying the SR20. His most recent FAA Third-Class Medical certificate was issued on Feb. 24, 2016.

The accident occurred at about 11:48 eastern daylight time in instrument meteorological conditions. An IFR flight plan had been filed for the flight that originated at Delaware Coastal Airport (GED), Georgetown, Delaware, and was destined for Fleming-Mason Airport (FGX), Flemingsburg, Kentucky.

The pilot had received a weather briefing from Leidos Flight Service at 8:25 a.m. The Leidos briefing included the latest SIGMETs that were in effect for the proposed route of flight, METARs, TAFs, PIREPs, AIRMETs, the Winds Aloft Forecast and more. The pilot was advised of forecast thunderstorms with tops to 45,000 feet along the route.

At about 10:39, the pilot was handed off to the controller working the Linden Sector at the Washington Air Route Traffic Control Center. The pilot checked in level at 6,000 feet and was given the local altimeter setting. At 10:44:17, the pilot was instructed to climb to and maintain 7,000 feet, which was the controller’s minimum altitude for handling IFR aircraft in that sector.

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About five minutes later, the pilot radioed Washington Center that he had a request, and the controller told him to go ahead. The pilot stated, “On my weather radar in the plane, it looks like I’ve got, uh, all kinds of weather cells right in my path. If I turn to, uh, Fleming-Mason, uh, does your, you, have weather at your location?”

A few seconds later, the controller radioed back, “You’re cleared direct destination.” The pilot responded, “Can you give me any weather advisories?”

Of course, despite what the pilot had advised the controller in a previous transmission, the pilot did not have installed airborne weather radar, which would have given him a real-time idea of what was ahead along with the capability to do some scanning above and below.

By referring to his “radar,” the pilot was surely referring to NEXRAD radar images that he could receive while airborne. Those images are not real time but are subject to processing and transmission delays. Investigators did not determine exactly what he might have been seeing, but the Safety Board did report that the airplane was equipped for XM weather service. SiriusXM advertises that its radar images are subject to 2.5-minute transmission and update rates and that its service should not be used to navigate close to storms or to pick one’s way through storms.

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At about 10:49:32, the Washington Center controller advised, “The only weather I show is, uh, some moderate to extreme precipitation beginning about, uh, ten miles northeast of the Elkins Airport, extending northeast bound about 30 miles and then west of that, uh, about 80 to 100 miles near the Henderson VOR. I show some, another area of moderate to extreme precipitation ten miles wide.”

The pilot acknowledged receiving the information, and then the controller radioed, “You wanna go direct to destination or you wanna continue on your route over Elkins?” The pilot replied that he would continue over Elkins.

At 10:59:15, the controller advised the pilot, “I can give you direct destination, and that’ll keep you south of the weather that’s to your north now, and it won’t be a factor for about another hundred miles or so, and then Indianapolis Center can probably help you out with any deviations or anything, or Charleston Approach, rather.” The controller likely was talking about Clarksburg Approach, since that would be the next controller to whom the pilot would be handed off.

The pilot responded, “According to my weather radar, I’m okay to go to Elkins, then York. I think I may be able to skirt this staying on that path.” The controller said, “I’ll just leave you there, then,” and the pilot thanked the controller.

Then at 11:05:20, the controller issued an alert to all aircraft on the frequency that a new convective SIGMET had been issued, and full details were available from flight service or on HIWAS. A few seconds later, the accident pilot was instructed to contact Clarksburg Approach.

 “The pilot stated, ‘On my weather radar in the plane, it looks like I’ve got, uh, all kinds of weather cells right in my path.’”

Shortly thereafter, at 11:06:18, the pilot reported level at 7,000 feet on the assigned frequency for Clarksburg Approach, and the controller acknowledged with the current altimeter setting.

At 11:14:07, the pilot radioed that he had a request. “Look at, uh, altering course to Parkersburg VOR, Juliet Papa Uniform, to avoid weather.” The controller cleared the pilot from his present position to the Parkersburg VOR. And the pilot acknowledged. Then, about five seconds later, the controller added, “Cleared direct Parkersburg VOR then direct Foxtrot Golf Xray,” which was the Fleming-Mason Airport. The pilot acknowledged, and the controller asked the pilot whether he’d like to be put at 6,000 feet or 8,000 feet to be at the correct altitude for the direction in which he’d be flying. “Doesn’t make a difference to me, you got a recommendation?” the pilot replied. The controller told him to stand by.

At 11:15:59, the controller radioed that there was an aircraft about 20 miles ahead of him that also was going to Parkersburg, and it was at 8,000 feet. The pilot responded, “We’ll try eight.” The controller cleared the pilot to climb to 8,000 feet, and the pilot acknowledged. Pilots picking their way around bad weather often follow the flight path of an aircraft ahead.

Sure enough, at 11:29:30, the controller advised the pilot, “The aircraft that was ahead of you also headed to the, uh, Parkersburg VOR is deviating right around an area of weather that he’s depicting as, uh, thunderstorms. Would you like a heading to the east of it also?” The pilot indicated that he saw weather ahead, and the controller offered a heading of 330 degrees that “would take you to the east of it.” The pilot accepted, and the controller issued a vector to fly 330 degrees.

All seemed to be normal when, at 11:41:58, the controller asked the pilot about his flight conditions, and the pilot replied, “We are level at eight thousand. We are, uh, almost passed the, uh, what I would consider thunderstorms. Another ten miles or so should do it but we are in the clouds level at five thou, er, level at eight thousand.”

The controller advised the Cirrus pilot to expect a turn to the destination airport in about 8 miles, but the pilot said he’d expect a turn to the Parkersburg VOR. The controller asked if he was still landing at Fleming-Mason, and the pilot said he was but would rather go to the VOR before turning toward the airport. The controller told him to expect to go to the VOR and then go to the destination. It’s not known whether the pilot had programmed a route incorporating the VOR and was reluctant to change it or just why he wanted to go to the VOR station.

At 11:42:51, the pilot radioed, “Just started, uh, receiving moderate to heavy precip.” The controller said, “If you need to get out of that, uh, turn to zero four zero. Should take you east of it.” The pilot replied, “Negative, we’re okay.”

Then at 11:46:37, the pilot radioed that he was clear of the precipitation and requested a turn toward the VOR. The controller cleared him direct to the Parkersburg VOR, which the pilot acknowledged.

At 11:50:08, the controller tried to contact the pilot, but there was no response. He tried two more times, and at 11:50:30 the pilot asked, “How do you read?” The controller apparently did not hear the pilot and asked the pilot of another aircraft to try to raise the Cirrus pilot. There was no further radio contact with the accident pilot despite repeated attempts that also involved a second aircraft that was asked to try to raise the Cirrus.

“It’s not known whether the pilot had programmed a route incorporating the VOR and was reluctant to change it or just why he wanted to go to the VOR.”

A review of the airplane’s flight track data showed that it descended in a left turn, then made a sharp right turn followed by a sharp left turn.

The wreckage was located three days later in a densely wooded area about 1,500 feet from its last known radar position. Both occupants were killed in the crash. Trees and branches showed signs of having been slashed by the airplane’s propeller. The airplane itself was completely fragmented in a debris path that was only about 50 feet long.

Members of the Marion County and Monongalia County Homeland Security Emergency Management Agency had conducted the search for the airplane that included using a drone to scan the wooded area and look for disturbances to the tops of trees.

All major components of the airplane were located within the debris field. All flight controls and flight control instruments were destroyed. The avionics were so badly damaged that it was not possible to retrieve information from them. The Cirrus Airframe Parachute System (CAPS) was not deployed, but the rocket motor had shown signs of firing in a manner consistent with impact damage.

Examination of what was left of the airframe and engine failed to reveal signs of anything that would have precluded normal operation.

The Safety Board said that its review of weather information indicated that the pilot was operating in instrument conditions and likely turbulence associated with the thunderstorm activity. However, radar showed that there were no echoes located above the accident site at about the time the pilot radioed he was clear of precipitation. There were no lightning flashes or strikes located within 10 miles of the accident flight between 11:39 and 11:51.

The weather observation at 11:53 at the North Central West Virginia Airport in Clarksburg, West Virginia, 21 miles southeast of the accident site, showed the wind from 210 degrees at 12 knots, 10 miles visibility, a broken ceiling at 1,800 feet with broken clouds at 2,300 feet and 9,500 feet, temperature 22 degrees C., dew point 18 degrees C., and an altimeter setting of 29.82. There were thunderstorms in the vicinity of the airport.

The Safety Board attributed the airplane’s descents and changes in direction before being lost from radar and being shattered by a high-energy impact as being consistent with the known effects of spatial disorientation and a subsequent loss of control. But it didn’t tell us why spatial disorientation should prevent a pilot from switching on the autopilot or pulling a parachute handle in a desperate attempt to find a way out of a desperate situation.

Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other news concerning the National Transportation Safety Board. To subscribe, visit www.ntsbreporter.us or write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.

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