N990PT – Cirrus Aircraft SR22 – 2024-07-25 NTSB Accident Report

On July 25, 2024, about 1227 eastern daylight time, a Cirrus Design Corp SR22 airplane, N990PT, was destroyed when it was involved in an accident near Trenton, Maine. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

According to FAA air traffic control information, the flight departed Morristown Municipal Airport (MMU), Morristown, New Jersey, at 1016 destined for Hancock County/Bar Harbor Airport (BHB), Bar Harbor, Maine. A review of an air traffic control recording from the FAA Bangor Approach Control facility revealed that, about 1220, an air traffic controller advised the pilot that the flight was about 5 nm from the final approach fix for the ILS runway 22 approach at BHB, provided the pilot with a radar vector, cleared the flight for the ILS runway 22 approach, and advised the pilot to maintain an altitude of 3,000 ft msl until established on the approach. The controller also advised the pilot that he could cancel his IFR flight plan once on the ground, approved the change to the BHB common traffic advisory frequency, and advised the pilot that, in the event he needed to execute a missed approach, the controller would talk to him on the current frequency.

According to the published instrument approach procedure for the ILS runway 22 approach, the decision height was 200 ft agl (283 ft msl), and the minimum visibility was 3/4 mile. The missed approach procedure specified a straight ahead climb to 2,000 ft msl, then a right turn and climb to 4,000 ft msl to the designated missed approach fix.

A review of flight track and data parameters recovered from the airplane’s Appareo RDM-300 revealed that the airplane’s autopilot was engaged shortly after takeoff and remained engaged until the final 17 seconds of the flight. After the controller provided the pilot with the approach clearance, the airplane’s flight track turned to the assigned heading then turned to a heading consistent with the final approach course. About 1222, the airplane was descending from about 2,000 ft msl with 50% flaps on a consistent heading toward runway 22; full flaps were applied about 1222:55.

The data showed that, about 1226:46, the airplane’s autopilot was disengaged. At the time, the airplane had descended to an altitude of about 200 ft msl while about 0.4-mile from the runway 22 threshold. During the next 8 seconds, the airplane’s pitch angle increased to about 30° nose-up, its vertical ascent rate reached about 2,350 fpm as it climbed on the runway heading, and the flaps were reduced to 50%. By 1226:56, the airplane’s altitude reached about 450 ft msl, where it remained for about 2 seconds. Between 1226:56 and 1227:00, the airplane’s pitch angle rapidly decreased to about 25° nose-down, its left bank angle reached a maximum of about 68° before rolling back toward wings-level, and its engine power increased from about 35% to about 80%; during this time, the airplane reached a vertical descent rate of about 2,800 fpm, and its altitude decreased to about 300 ft msl. By the time the data ended at 1227:03, the airplane again entered a left bank, and its descent rate was about 4,000 fpm.

A witness at BHB who was outside working on the approach lighting at the end of runway 22 stated he heard an airplane approaching for landing. He heard the airplane’s engine noise go to full power, and, when he looked up, he saw the airplane in a sharp left turn then “fall to the ground.” He further described that the weather conditions were “brutal” and that he could barely see the airplane at 200 yards away due to the thick fog.

Video recorded by a witness in a moving car showed the airplane in an uncontrolled descent, coming into view as it descended below a low cloud/fog layer. It was visible at the approach end of runway 22 in a steep, descending turn to the left before impacting the ground and erupting into a postcrash fire.

The pilot’s logbooks were not recovered. During the pilot’s last medical examination dated March 22, 2023, he documented that he had 4,384 hours of total flight experience. He also reported that his medical history included gout. He reported using the medications febuxostat (a prescription medication that may be used in the treatment of gout) and tamsulosin (a prescription medication that may be used to treat symptoms of a large prostate). He was issued a third-class medical certificate with the limitation to use corrective lenses to meet vision standards at all distances.

The airplane’s maintenance logbooks were not recovered.

BHB was equipped with an Automated Weather Observing System, and the reported conditions at 1156 included visibility of 1.5 miles in light rain and mist, an overcast ceiling at 300 ft agl, temperature of 17°C, and dew point of 17°C. All reported observations between 0956 and 1256 included overcast ceilings between 100 ft and 300 ft agl.

The pilot had a ForeFlight account through which he filed his IFR flight plan and requested and received a weather briefing package at 0535. The weather forecast information applicable for the accident location and time included text and graphical AIRMETs for IFR conditions due to precipitation and mist. Graphical Forecasts for Aviation products applicable for the accident location at 1100 and 1400 indicated overcast cloud cover with cloud bases to 300 ft msl and could tops between 12,000 ft and 24,000 ft msl.

The TAF for BHB valid at 0535 forecast a ceiling of 300 ft agl for the intended arrival time at the destination airport. A TAF issued at 1100 forecast an overcast ceiling at 100 ft agl for the intended arrival time.

The wreckage was located about 600 ft to the left of the approach end of runway 22 on top of the airport perimeter fence. The airplane came to rest in a wooded area and was oriented on a magnetic heading of 040°. The airframe was largely consumed by a postimpact fire. All major components of the airplane were accounted for within the compact wreckage area. The flap actuator jackscrew was found extended 2.75 inches, consistent with a “Flaps 50%” position.

The engine was thermally damaged. The fuel pump was removed, and the shaft was intact but stiff to rotate consistent with the effects of the thermal damage. The fuel flow divider was intact, but the diaphragm was destroyed by fire. The fuel injectors were thermally damaged, and injectors for cylinder Nos. 1 and 5 contained some obstructions. The magnetos were thermally damaged, and, when the magneto input drives were rotated by hand, no spark was produced on any leads. The top spark plugs were removed, and all were clean and clear of debris. The engine’s crankshaft rotated smoothly when turned by hand at the propeller, and compression was observed on all cylinders except No. 3. The No. 3 cylinder was impact damaged, and the rocker arm covers were crushed into the push rods.

A review of engine parameter data recovered from the airplane’s Appareo RDM-300 revealed that the engine was running normally during the entire flight.

According to the Office of Chief Medical Examiner, State of Maine, autopsy report, the cause of death for the pilot was multiple injuries. The pilot’s autopsy identified evidence of hypertensive and atherosclerotic cardiovascular disease, including an enlarged heart with a thickened left ventricle, and 50% narrowing of the left main coronary artery and left anterior descending coronary artery by plaque, with a left-dominant coronary circulation, and focal areas of fibrosis of the heart muscle (scarring of the type that may be seen from old heart attack) in the posterior left ventricle and papillary muscles. Prominent fat streaking of the aorta and focal plaques in the arteries at the base of the brain also were present, as were kidney tissue changes of the type that may be seen with chronic high blood pressure. The aortic valve leaflets were calcified. The liver was cirrhotic and the spleen was enlarged. The prostate was enlarged and nodular. A medical port was present in the right upper chest.

Toxicology testing performed by the FAA’s Forensic Services Laboratory on the pilot detected codeine at 439 ng/mL in urine and 4 ng/mL in heart blood, and it detected morphine 152 ng/mL in urine. Thebaine was detected in heart blood and urine. Colchicine and tamsulosin were detected in heart blood and urine. Naproxen was detected in heart blood; naproxen testing in urine was inconclusive.

Codeine is an opioid drug. Medicinal uses of codeine include treating pain, cough, and diarrhea. Codeine is a federally controlled substance and usually requires a prescription in the United States, although a few states allow “behind the counter” sales of certain cough-and-cold products containing codeine without a prescription. Products containing codeine often carry a warning that the drug may impair mental or physical abilities needed to perform potentially hazardous activities such as driving a car or operating machinery. The FAA states that codeine may be used by pilots occasionally for some time-limited conditions, but that pilots should not fly after using codeine until enough time has elapsed for the drug to be cleared from circulation. In a living person, the typical therapeutic range of codeine in plasma is about 30-250 ng/mL, the typical elimination half-life of codeine is about 1-4 hours, and the ratio of the codeine concentration in blood to that in plasma is about 0.9. Codeine may undergo postmortem redistribution, which may sometimes increase its concentration in heart blood after death. Morphine is a metabolite of codeine; it is also an opioid drug. Additionally, codeine and morphine may sometimes be detected after poppyseed consumption.

Thebaine is a chemical in the poppy plant that also may sometimes be detected after poppyseed consumption, and that is not present in pharmaceutical codeine or morphine.

Colchicine is a prescription medication that can be used to help treat gout flares and to prevent flares when starting certain other gout medications. Colchicine may also be used for other reasons, including risk reduction in atherosclerotic cardiovascular disease. Naproxen is a non-steroidal anti-inflammatory drug (NSAID) widely available without a prescription for treatment of pain, inflammation, and fever. Tamsulosin is a prescription medication commonly used to treat symptoms of a large prostate. Colchicine, naproxen, and tamsulosin are not typically impairing.

According to the FAA’s “Pilot’s Handbook of Aeronautical Knowledge,” (FAA-H-8083-C), “under normal flight conditions, when there is a visual reference to the horizon and ground, the sensory system in the inner ear helps to identify the pitch, roll, and yaw movements of the aircraft. When visual contact with the horizon is lost, the vestibular system becomes unreliable. Without visual references outside the airplane, there are many situations where combinations of normal motions and forces can create convincing illusions that are difficult to overcome.”

One such type of vestibular illusion can occur when an “abrupt upward vertical acceleration” stimulates the otolith organs of the inner ear “to create the illusion of being in a climb. This is known as ‘elevator illusion.’ The disoriented pilot may push the aircraft into a nose-low attitude.” Another type of vestibular illusion can result from “an abrupt change from climb to straight-and-level flight, [which] can stimulate the otolith organs enough to create the illusion of tumbling backwards, known as the ‘inversion illusion.’ The disoriented pilot may push the aircraft abruptly into a nose-low attitude, which may intensify this illusion.”