N420SS

Substantial
Fatal

Cirrus Aircraft SR22S/N: 8750

Accident Details

Date
Thursday, September 1, 2022
NTSB Number
CEN22FA405
Location
Tomball, TX
Event ID
20220902105849
Coordinates
30.082972, -95.556658
Aircraft Damage
Substantial
Highest Injury
Fatal
Fatalities
1
Serious Injuries
2
Minor Injuries
0
Uninjured
0
Total Aboard
3

Probable Cause and Findings

The flight instructor’s inadequate supervision of the flight, which allowed for an unintentional movement of the mixture control to the cutoff position that remained unnoticed until the airplane lost engine power due to fuel starvation and descended below the minimum altitude required for a normal deployment of the airframe parachute system. Contributing to the accident was the impairment of the pilot due to his illness, the flight instructor being distracted by his physiological distress, and the apparent lack of communication between the pilot and flight instructor about who was responsible for the safety of the flight, all of which created a situation where neither individual was adequately monitoring the engine operation during a critical phase of flight.

Aircraft Information

Registration
Make
CIRRUS AIRCRAFT
Serial Number
8750
Engine Type
Reciprocating
Year Built
2022
Model / ICAO
SR22SR22
Aircraft Type
Fixed Wing Single Engine
No. of Engines
1
Seats
4
FAA Model
SR22

Registered Owner (Current)

Name
ZARDOZ AVIATION INC
Address
10002 OXTED LN
City
SPRING
State / Zip Code
TX 77379-6669
Country
United States

Analysis

HISTORY OF FLIGHTOn September 1, 2022, about 1707 central daylight time, a Cirrus Aircraft SR22 airplane, N420SS, was substantially damaged when it was involved in an accident near Tomball, Texas. The flight instructor was fatally injured; the pilot and passenger sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight.

Earlier in the week, on August 29, 2022, the pilot accepted delivery of his factory-new Cirrus SR22 airplane at the Cirrus Aircraft Vision Center located at the McGhee Tyson Airport (TYS), near Knoxville, Tennessee. He had no previous flying experience in a Cirrus airplane besides a 30-minute demonstration flight that was flown about 1.5 years before the accident. As part of his purchase agreement, the pilot was scheduled to receive transition training in his new airplane for the remainder of the week. The pilot’s first interaction with his assigned Cirrus Aircraft Factory Flight Instructor was the night before he accepted delivery of his airplane. During the phone call, the flight instructor asked what the pilot wanted to accomplish during his flight training, and the pilot replied that he needed to learn how to fly instrument approaches and to make takeoff and landings in the airplane.

According to the pilot, his first flight in the airplane consisted of a takeoff, traffic pattern, and landing. No flight instruction was provided during this initial 10 to15 minute delivery flight that was completed with another Cirrus Aircraft pilot. After the pilot accepted delivery of his airplane, the assigned flight instructor began the pilot’s transition training. The first task completed was to review operating parameters for and demonstrate how to use the Cirrus Airframe Parachute System (CAPS) using a simulator. Afterwards, they reviewed the airplane’s fuel and electrical systems on a whiteboard and introduced the Cirrus Perspective+ integrated avionics system using a tabletop simulator.

On August 30, 2022, the pilot and his flight instructor began flight training in his airplane. Before their flight they discussed how to preflight the airplane. Due to engine power restrictions (maintain at least 75% power) for a new airplane, they were unable to conduct traffic pattern work and the pilot felt they “couldn’t really learn anything” that he hoped to achieve on the flight. Instead, they focused on using the Cirrus Perspective+ system. The pilot stated that the flight instructor did not provide more feedback on how to fly the airplane, such as providing the different airspeeds to be flown during the different phases of flight. When interviewed, the pilot expressed his concern that Cirrus Aircraft “didn’t have some syllabus for me” dictating what he was to learn each day.

On August 31, 2022, the weather at TYS was windy, so the pilot asked his flight instructor if they could fly to an uncontrolled airport where they could work on flying the airplane in the traffic pattern and practice takeoff and landings. According to the pilot, it was during this flight that the flight instructor first provided the reference airspeeds for downwind, base, and final approach. The pilot stated that he placed a note with the reference airspeeds on the cockpit dashboard.

The pilot stated that before the fourth day of transition training, he woke up overnight shivering and sweating. On the morning of September 1, 2022, the pilot told his flight instructor that he did not feel well, and the decision was made to fly to the pilot’s homebase located at David Wayne Hooks Memorial Airport (DWH), Spring, Texas. Based on interviews, it was not clear with whom the pilot would have continued his transition training after returning to his homebase. Cirrus Aircraft’s Chief Pilot stated the pilot would have likely resumed training with a local Cirrus Standardized Instructor Pilot (CSIP), while the pilot was under the impression that he would have continued with the factory flight instructor if he was feeling better the next day. The flight instructor had not planned on flying to DWH and, as such, he had to reschedule some other work obligations and kennel his dog for at least one night. The pilot stated that before they departed on the cross-country flight, he and the instructor did not communicate what roles each would have should an emergency arise during the flight.

The first flight leg was supposed to be from TYS to Alexandria International Airport (AEX), Alexandria, Louisiana. However, due to adverse weather that impacted their intended route, the flight diverted to Monroe Regional Airport (MLU), Monroe, Louisiana. The pilot stated that the flight instructor appeared to briefly fall asleep during the flight from TYS to MLU. The pilot stated that he flew most of the flight with the airplane’s automatic flight control system (AFCS) engaged, making necessary heading changes using the heading bug on the primary flight display (PFD).

The pilot stated the airplane was topped-off with fuel after landing at MLU and that they were on the ground for about 30-45 minutes, during which the pilot and the passenger each drank a cup of coffee, and the flight instructor drank a soda. The pilot stated that shortly after they departed MLU, about 10 minutes into the flight, the flight instructor told him that he needed to urinate. The pilot offered the flight instructor one of his “Little John” pilot urinals, but the flight instructor declined to use the urinal. The pilot stated that the flight instructor appeared to be in discomfort (shifting around in his seat and grimacing) for the remainder of the flight and did not speak much or provide any feedback until they got closer to DWH.

The pilot stated that the airplane’s AFCS was engaged for most of the flight from MLU to DWH, and that he used the heading bug on the PFD to make any heading changes that were issued by air traffic control. The flight was on an instrument flight rules flight plan, and the controller issued several vectors to keep the airplane clear from areas of adverse weather. As the flight approached DWH, the pilot listened to the Automatic Terminal Information Service broadcast and selected the RNAV runway 17R instrument approach at DWH using the Cirrus Perspective+ system, but he was unsure if he activated the approach.

While the flight tracked north toward Conroe, Texas, the controller asked if they wanted the full RNAV runway 17R approach or the visual approach to runway 17R. The flight instructor replied to the controller that he wanted the visual approach to runway 17R. The pilot told his flight instructor that he had never flown a visual approach before and asked how to use the Cirrus Perspective+ system during this type of approach. The flight instructor then showed the pilot how to “scroll-down” on the display to see data associated with a visual approach. When interviewed, the pilot stated that he did not know how the visual approach was supposed to work in the Cirrus Perspective+ system and that he was confused that there was no altitude step downs or waypoints visible after the visual approach was selected. The controller issued a heading to intercept the final approach course to runway 17R at DWH, cleared the flight for the visual approach, and told the pilots to contact the DWH tower controller.

The pilot stated that he saw the runway and its associated precision approach path indicators (PAPI) lights after the airplane turned onto the final approach course and that the airplane appeared to be on a proper descent path to the runway. The airplane’s airspeed began to decrease as the flight continued toward the runway, and the flight instructor told him to “give it some throttle” to increase airspeed. The pilot increased the throttle slightly but noted that he did not hear the engine “roar” with power. The flight instructor stated “My airplane” or “I’ve got the controls” shortly after the pilot increased the throttle. The pilot estimated “a few seconds” transpired between his increase of throttle and when the flight instructor took control of the airplane.

The pilot stated that after the flight instructor took control of the airplane, the airplane descended below the proper glidepath where he could no longer see the PAPI system or the runway. The pilot stated that in the moments before the accident the flight instructor rolled the airplane into a left-wing-down attitude, likely trying to maneuver the airplane into a clearing left of the airplane’s position. The airplane impacted several trees before it came to rest in a wooded mobile home neighborhood.

When asked, the pilot did not recall completing the pre-landing checklist but stated that he believed it was something that would have been completed before the accident. Additionally, he could not specifically recall individual positions of the throttle, mixture control, and fuel selector at the time of the accident; however, he recalled the ignition/magneto switch was positioned to both. The pilot stated that he believed the airplane’s automatic flight control system (AFCS) was still engaged when the flight instructor took control of the airplane. The pilot stated that the flight instructor did not ask him to verify control positions or troubleshoot anything in the moments before the accident, nor did they discuss any anomalies with the airplane or if they should deploy the CAPS. The pilot stated that he believed the engine was operating at the time of the accident, but thought it was odd that he did not hear the engine “roar” with power after the flight instructor took control of the airplane and increased the throttle. The pilot, flight instructor, and passenger were wearing noise-canceling headsets during the flight.

The pilot did not recall completing any emergency action procedures before impact. Further, the pilot reported that he did not interfere with, nor did he remember the instructor interfering with the fuel mixture control throughout t...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# CEN22FA405