|Narrative Type: NTSB FINAL NARRATIVE (6120.4)
|While simulating an engine failure on climb-out, the airplane was observed to enter a left teardrop maneuver as it attempted to return to the airport. During the turn, the airplane stalled, entered a spin, and impacted level terrain 1 nautical mile northeast of the departure end of runway 06. The reported winds were 060 degrees at 15 knots. According to the air traffic controller working the local control position, after completing several touch-and-go landings on runway 06, the instructor requested the first of two teardrop return to runway engine-out maneuvers. During the first one, the airplane made a left teardrop 180-degree turn as it attempted to land on runway 24. During the turn, the airplane appeared to lose a significant amount of altitude. The controller stated that the airplane recovered prior to landing, and then executed a go-around to reenter the traffic pattern. During the second attempt, the airplane again entered a teardrop turn to the left and then "spin to the ground." An examination of the wreckage revealed that the airplane impacted the terrain in a 70-degree nose down, left wing low attitude. All flight control surfaces, engine, propeller, and Cirrus Airframe Parachute System (CAPS) components were located at the site. The engine and propeller were embedded in the ground approximately 2 feet, and all three propeller blades exhibited rotational scoring. Recorded data was retrieved from the Avidyne Primary Flight Display (PFD) and Multi-Function Display (MFD). The data log retrieved for the accident flight included data from a time stamp of 12:17:36 to 13:32:00 on January 9, 2006. The next scheduled data-logging event would have been at 13:33:00; however, the unit operation ceased prior to reaching the next recording point. At the last data sampling point, the engine rpm (revolutions per minute) was at 2,680 rpm, the engine manifold pressure was 27.5 inches, and the airplane electrical bus voltage was 27.5 volts. The recorded data did not show any engine or system anomalies. The information from the download of the MFD was consistent with the visual information provided by witnesses.
|Narrative Type: NTSB PRELIMINARY NARRATIVE (6120.19)
|1.1 HISTORY OF FLIGHT
On January 9, 2006, at 1332 Pacific standard time, a Cirrus SR20, N526CD, impacted terrain while maneuvering to return to the runway following a simulated engine failure at General William J. Fox Airfield (WJF), Lancaster, California. Gene Hudson Flight Training was operating the airplane under the provisions of 14 CFR Part 91. The certified flight instructor (CFI) pilot and the private pilot undergoing instruction (PUI) sustained fatal injuries; the airplane was destroyed. The local instructional flight departed Van Nuys, California, about 1250. Visual meteorological conditions prevailed, and no flight plan had been filed. The approximate global positioning system (GPS) coordinates of the primary wreckage were 34 degrees 45.048 minutes north latitude and 118 degrees 11.738 minutes west longitude.
The National Transportation Safety Board investigator-in-charge (IIC) interviewed the WJF air traffic controllers who were on duty at the time of the accident. The controllers reported that the Cirrus reported inbound to WJF from the south and requested to do multiple touch-and-go takeoffs and landings. The Cirrus was cleared into the pattern and advised to use runway 6. After the Cirrus had completed multiple touch-and-go takeoffs and landings, the pilot requested to make a low approach to runway 6 and on climb out, simulate an engine failure, execute a teardrop maneuver, and land using runway 24. The controller advised that the winds were 060 degrees and 10 knots, gusting to 17, and approved the pilot's requested maneuver.
The controllers observed the Cirrus make the low approach to runway 6. At the departure end of the runway, the Cirrus made a slight right turn, followed by a sweeping left turn. The controllers said the Cirrus lost a significant amount of altitude before aborting the landing. The pilot then executed a go-around, and the airplane flew north of the runway and parallel. The pilot requested to "try that again," and the tower controller advised the Cirrus that the winds were 060 degrees and 15 knots.
The controllers observed the Cirrus make another low approach to runway 6; on the upwind leg, the airplane made a slight right turn followed by a sweeping left turn. The controller did not see the airplane impact the ground as a pillar in the control tower momentarily blocked the controller's view.
Ground witnesses, just south of the accident site, observed the airplane make a left turn and then "spin into the ground."
The Safety Board IIC reviewed transcripts and recordings from communications between WJF control tower personnel and the accident airplane pilots. The first radio contact with the Cirrus occurred at 1303:04 (all times related herein have been converted from universal coordinated time to Pacific standard time). At that time, the pilot stated that the airplane was 8.8 miles to the southwest and would be doing "touch-and-goes." The Cirrus made a straight in approach to runway 06, and completed several touch-and-go landings. At 1324:59, the CFI contacted the tower with the following request, "We want to do a turn back to the runway if there's nobody around. Wanna do an engine out at the top of the climb here and then just do a turn back to land the other way. Is this a good time?" The controller responded that the Cirrus was the only one in the pattern at the time. The controller also advised, "However, wind 060 at 10 gusting 17." The CFI responded that they would "like to do that." The controller cleared the Cirrus to land on runway 24.
As indicated above in the controller's statement, at approximately 1326, the Cirrus executed the first of two engine-out maneuvers to runway 06. At 1326:57, the Cirrus advised the tower "we are just to go back in the pattern and do normal stuff." The controller acknowledged the transmission and indicated that "you're the only one I have right now in the class delta, so advise whenever you want that approach." The pilot acknowledged the tower, continuing "we, we… if that stays that way we'll do it right now, thanks." The controller then confirmed, "Understand that you're going to be doing that this pass." The pilot responded "yes." The controller then cleared the Cirrus for a touch-and-go.
At 1331:36, the pilot advised that, "We're going to do the tear drop turning back again." The controller confirmed and reported, "wind 060 at 15, clear to land runway 24." As indicated above in the controller's statement, the Cirrus executed a low pass over runway 06, and, during the climb out, the Cirrus began a second "tear-drop" turn towards the left. The controller momentarily lost site of the Cirrus. At approximately 1332, the Cirrus impacted the terrain.
1.5 PERSONNEL INFORMATION
1.5.1 CERTIFIED FLIGHT INSTRUCTOR (CFI)
A review of Federal Aviation Administration (FAA) airman records revealed that the pilot held a commercial pilot certificate with ratings for airplane single engine land, and instrument airplane. The pilot also held a certified flight instructor (CFI) certificate with ratings for airplane single engine land.
The CFI held a second-class medical certificate issued in April 2005. It had the limitations that the pilot must wear corrective lenses and possess glasses for near and intermediate vision.
An examination of the pilot's logbook indicated an estimated total flight time of 1,052 hours. He logged 92 hours in the last 90 days, and 31 hours in the last 30 days. He had an estimated 34 hours in this make and model. He obtained his CFI rating on September 14, 2005.
1.5.2 PILOT UNDER INSTRUCTION (PUI)
A review of FAA airman records revealed that the pilot held a private pilot certificate with a rating for rotorcraft-helicopter. The pilot obtained this rating in October 1998.
The pilot held a third-class medical certificate issued March 2004. It had the limitation that the pilot must have available glasses for near vision.
An examination of the pilot's logbook indicated an estimated total flight time of 429.9 hours. He had an estimated 57.9 hours in this make and model.
1.6 AIRCRAFT INFORMATION
The airplane was a Cirrus SR20, serial number 1545, which received its airworthiness certificate on August 8, 2006, with a total flight time of 5.3 hours. A review of the airplane's logbooks revealed that the airplane had a total airframe time of 300.4 hours at the last 100-hour inspection that was completed on December 10, 2005. The Hobbs hour meter read 342.8 hours at the accident site.
The engine was a Teledyne Continental Motors (TCM) IO-360-ES6, serial number 360052, which was manufactured on July 8, 2005. Total time recorded on the engine at the last 100-hour inspection was 300.4 hours.
The propeller was a Hartzell PHC-J3YF-1RF, serial number FP3880B. Total time recorded on the propeller at the last 100-hour inspection was 300.4 hours.
Examination of the maintenance and flight department records revealed no unresolved maintenance discrepancies against the airplane prior to departure.
1.7 METEOROLOGICAL CONDITIONS
The closest official weather observation station was at General William J. Fox Airfield (WJF), Lancaster, which was located 1.5 nautical miles (nm) southwest of the accident site. The elevation of the weather observation station was 2,348 feet mean sea level (msl). An aviation routine weather report (METAR) for WJF was issued at 1256. It stated: winds from 070 degrees at 10 knots; visibility 10 statute miles; skies clear; temperature 14 degrees Celsius; dew point -04 degrees Celsius; altimeter 30.31 inHg.
According to the tower transcript, when the CFI requested the touch-and-go with the simulated engine failure, the tower controller reported that the wind was 060 degrees at 10 knots, gusting to 17 knots. About 6 minutes later when the CFI requested the second attempt, the tower controller reported that the wind was 060 degrees at 15 knots.
At 1356, the METAR for WJF reported winds from 070 degrees at 12 knots; visibility 10 statute miles; skies clear; temperature 15 degrees Celsius; dew point -04 degrees Celsius; altimeter 30.29 inHg.
1.10 AIRPORT INFORMATION
The Airport/Facility Directory, Southwest U. S., indicated that WJF runway 06/24 was 7,201 feet long and 150 feet wide. The runway surface was asphalt.
1.12 WRECKAGE AND IMPACT INFORMATION
Investigators from the Safety Board, the FAA, Cirrus Design, Teledyne Continental Motors (TCM), and BRS Parachutes examined the wreckage at the accident scene.
The first identified point of contact (FIPC) was a 35-foot-long ground scar along a magnetic heading of 110 degrees in an open field approximately 1 nautical mile northeast of the departure end of runway 06. The debris path was along a magnetic heading of 100 degrees.
The main impact point was centered 34 degrees 45.048 minutes north latitude and 118 degrees 11.738 minutes west longitude. The orientation of the wreckage was as follows: engine/fuselage, 020 heading; the fractured and separated empennage, 090-degree heading; wing spar (tip to tip), 110 degrees. There were no ground scars leading up to the main impact point.
The debris field extended out from the main impact point between 010 degrees to 150 degrees. The main debris field was between 060 degrees and 120 degrees, with a section of fuselage skin, the furthermost component, coming to rest approximately 65 feet at 070 degrees from the main impact point. Both cabin doors and the upper engine cowling were located within the main debris field and in close proximity to the main impact point. The right aileron was located approximately 60 feet at 150 degrees from the main impact point.
The engine and propeller were located in the center of the main impact point. Both were embedded in the ground approximately 2 feet at a 70-degree angle. All flight control surfaces and components of the airplane were located at the main impact site. The 35-foot ground scar was observed on the ground adjacent to the leading edge of the wing assembly. The Cirrus' red navigation lens was intact and located on the western most end of the ground scar.
Impact forces destroyed the fuselage. The engine and engine mounts, which remained attached to the firewall, exhibited aft crushing. The separated upper engine cowling exhibited leading edge crushing. The instrument panel exhibited aft crushing. The upper portion of the fuselage was separated and fractured in several locations. The cabin floor remained attached to the lower fuselage. The cabin floor and baggage compartment floor exhibited aft crushing. The front seats were separated from the fuselage. The rear seats remained attached to the aft floor. The fuselage was fractured at the fuselage station 222 bulkhead. The empennage was separated from the fuselage at the 222 bulkhead.
Impact forces destroyed the wing assembly. The wing assembly exhibited leading edge crushing. The wing spar remained intact; however, the upper and lower wing skins were fractured and had separated at various locations along with wing spar. The upper and lower wing skins exhibited aft crushing and compression buckling. The left and right flaps remained attached to the wing assembly. The left aileron remained attached to its respective wing. The right aileron was located approximately 60 feet at 150 degrees from the main impact point.
Investigators confirmed flight control continuity from the left-hand aileron actuator pulley through the cockpit controls to the right hand aileron actuator pulley. The roll trim motor was in the neutral position. The flap actuator shaft was extended approximately 4 inches, which, according to the manufacturer's representative, indicated zero percent of flap extension.
The rudder and vertical stabilizers remained attached to the empennage but exhibited impact damage. The rudder attachment hardware and safeties were present at all three attachment points. Investigators confirmed control continuity from the rudder pedal torque tube to the rudder bellcrank at the fuselage station 306 bulkhead. The elevator and horizontal stabilizer remained attached to the empennage but exhibited impact damage. The elevator attachment hardware and safeties were present. Investigators confirmed control continuity from the elevator control torque tube to the elevator bellcrank at the fuselage station 306 bulkhead. The pitch trim motor was in the neutral position.
1.12.4 LANDING GEAR
The nose landing gear assembly was folded back under the firewall and remained attached to the engine mount. The left and right main landing gear assemblies remained attached to the wing.
1.12.5 SEATS AND RESTRAINTS
The left and right front seats separated from the fuselage. The outboard left and right front seat tracks remained attached to the fuselage. The buckled left and right front airbag seat belts remained attached to the seat frames, and had deployed. The left and right front energy absorption modules were separated from the respective front seat frames and exhibited impact damage. When measured, approximately 50 percent of the left front seat's energy absorption module was less than 0.5 inches in thickness. When measured, approximately 75 percent of the right front seat's energy absorption module was less than 0.5 inches in thickness.
The left and right rear seats remained attached to the floor.
1.12.6 COCKPIT DOCUMENTATION
The ignition switch was located in the "Both" position. The BAT1, BAT2, and ALT1 switches were in the "ON" position. The ALT2 and Avionics switches were in the "OFF" position. The fuel selector lever was in the "Right" position. The flap selector valve was in the "Up" position. The power lever was in the full aft position.
The Primary Flight Display (PFD) and the Multi-Function Display (PFD) exhibited impact damage and had separated from their respective places in the instrument panel. The airspeed indicator exhibited impact damage. The attitude indicator was indicating a 150-degree left roll with a 25- to 30-degree nose down attitude. The altimeter exhibited impact damage, and the indication scale had separated from its housing. The altimeter's 100-foot pointer was missing. The altimeter's 1,000-foot pointer was indicating approximately 2,400 feet. The altimeter's 10,000-foot pointer was indicating approximately 98,000 feet. The Kohlsman window was set to approximately 30.14 inHg. The Hobbs meter reading was 342.8 hours.
The emergency locator transmitter (ELT) had activated, but emergency responders switched it to the "off" position by emergency personnel. All remaining instruments and gauges exhibited impact damage.
1.12.7 CIRRUS AIRFRAME PARACHUTE SYSTEM (CAPS)
The CAPS was found deployed. The CAPS safety pin with the "remove before flight" tag was located approximately 10 feet from the main impact point at 303 degrees. The CAPS activation handle was stowed in the activation handle holder. The CAPS activation cable separated from the fuselage attachment points in several locations. The CAPS activation cable housing was severed at a point approximately 3 feet forward of the igniter. The parachute enclosure cover was located on the ground near the right side of the empennage. The CAPS rocket motor, incremental bridle, and deployment bag were located approximately 90 feet at 180 degrees from the main impact point. All remaining parachute components were still attached and intact.
The three-bladed propeller separated from the engine at the crankshaft, aft of the propeller flange. The propeller spinner exhibited impact damage. Blade 1 separated from the propeller hub and exhibited S-bending and chordwise scratching on the cambered surface. Blade 2 exhibited chordwise scratching on the cambered surface. Blade 3 exhibited heavy chordwise scratching on the chambered surface.
1.13 MEDICAL AND PATHOLOGICAL INFORMATION
The Los Angeles County Coroner completed an autopsy of both the CFI and the PUI. The cause of death for both pilots was listed as multiple traumatic injuries sustained in an airplane crash.
1.13.1 CERTIFIED FLIGHT INSTRUCTOR
Both the Los Angeles County Coroner and the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of specimens of the CFI.
Analysis of the specimens contained no findings for volatiles. The coroner's report identified an inconclusive amount of carbon monoxide in the liver. The coroner's report contained the following positive findings for tested drugs: 98 ng/gm Tetrahydrocannabinol in the liver.
The FAA report contained the following positive findings for tested drugs: Tetrahydrocannabinol (marihuana) detected in the lung; 0.085 (ug/ml, ug/g) Tetrahydrocannabinol carboxylic acid (marihuana) detected in the urine; and 0.0484 (ug/ml, ug/g) Tetrahydrocannabinol carboxylic acid (marihuana) detected in the liver.
1.13.2 PILOT UNDER INSTRUCTION
Both the Los Angeles County Coroner and the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, performed toxicological testing of specimens of the PUI.
Analysis of the specimens contained no findings for volatiles. The coroner's report identified less than 10 percent saturation for carbon monoxide in the blood. The coroner's report contained the following findings for tested drugs: 0.14 ug/ml Paroxetine in the blood.
The FAA report contained the following positive findings for tested drugs: 2.586 (ug/ml, ug/g) paroxetine detected in the liver; and 0.507 (ug/ml, ug/g) paroxetine detected in the kidney.
1.16 TESTS AND RESEARCH
The Safety Board, the FAA, Cirrus Design, Teledyne Continental Motors, and BRS Parachutes were parties to the investigation. Investigators examined the wreckage at Aircraft Recovery Service, Littlerock, California, on January 11, 2006.
The engine exhibited impact damage. The engine remained intact; however, the alternator and both magnetos separated from their respective mounting pads. The oil cooler was pushed forward. There was a hole in the bottom aft portion of the oil sump. The oil filler neck was separated and crushed. The ignition leads were separated from all of the top spark plugs. The number 2 intake valve cover was cracked. The number 6 cylinder exhaust valve cover was dented, and the number 6 cylinder exhaust push rod tube was dented. The number 1 push cylinder push rod was bent. The intake pipes were cracked and pushed down. The exhaust pipes were pushed up and to the rear.
Investigators removed the top spark plugs. All of the spark plugs displayed light gray deposits in the electrode area. The electrode areas of the bottom spark plugs one, three, and five were oil coated. The spark plug electrodes were gray in color, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart.
The propeller governor was not damaged; however, the drive shaft would not rotate. The unit was disassembled, and the oil pump gears were not damaged and were coated with oil. The fly-weights were not damaged. The oil screen was clean and clear of foreign debris.
Both magnetos separated from the engine. The right magneto had light impact damage, while the left magneto was broken in half. Investigators manually rotated the right magneto, which produced spark at all posts. The left magneto was disassembled with no abnormalities noted with the internal components.
All six cylinders were removed and examined. They all contained light scoring in the barrels and light deposits on the domes. All of the valves were in place, and the rocker arms were coated with oil. All of the valve springs were in place. The pistons were intact with light deposits on the heads. All of the piston rings were in place and were coated with oil, but were free to move. The connecting rods were coated in oil; however, they remained in place and undamaged. The camshaft was not damaged and was coated with oil. The accessory case was removed. The aft crankshaft and camshaft gears were not damaged and were coated with oil. The oil pump was free to rotate. It was disassembled. The rotor gears were intact and coated with oil.
The fuel pump was in place and broken in half. The drive coupling was not damaged. The pump was disassembled, and the rotor vanes were not damaged. No fuel was discovered in the fuel pump. The safety wire was in place on the fuel manifold. The fuel manifold was opened; the diaphragm and spring were not damaged. The fuel screen was clean and clear of debris. No fuel was observed in the manifold.
The oil filter was separated and had impact damage. The filter was opened; no metal particles were observed in the element.
1.16.2 PRIMARY FLIGHT DISPLAY (PFD) Multi-Function Display (MFD) DATA LOG RETRIEVAL
The PFD and flash memory card from the Avidyne MFD were provided to Avidyne for extraction of flight data. The PFD showed signs of significant physical damage and exposure to a blue liquid.
The MFD flash memory card was installed into an Avidyne MFD, and power was applied to the unit. The unit showed that on January 9, 2006, both navigation and obstacle databases in use were up-to-date and current, and aircraft checklist version 1.04 was installed in the unit. A Zip drive was attached to the MFD to download logged data files. The data log retrieved for the accident flight included data from a time stamp of 12:17:36, to 13:32.
The last flight entry was made at 13:32:00 on January 9, 2006. The next scheduled data-logging event would have been at 13:33:00. The unit operation ceased prior to reaching the next recording point.
At the last data sampling point, the engine rpm (revolutions per minute) was reported at 2,680 rpm, the engine manifold pressure was 27.5 inches, and the airplane electrical bus voltage was 27.5 volts.
The information from the download of the MFD was consistent with the visual information provided by witnesses. A full diagram of the flight tracks is in the public docket for this report.
The PFD was disassembled to gain access to the memory chips. The PFD's Boot ROM (read only memory) was placed on an evaluation Avionics Computing Resource (ACR) test bench at the Avidyne service center. The device was operational but showed a visible crack. Avidyne personnel soldered the device, but they were unable to make it function.
1.16.3 CIRRUS INFORMATION
A review of the Cirrus Pilot's Operating Handbook (POH) revealed no guidance for a Return to Airport maneuver following an engine failure.
During a February 16, 2004, presentation, a Cirrus Owner's and Pilot's Association (COPA) member provided information on a Return to Airport maneuver following an engine failure. The presenter indicated that a successful Return to Airport maneuver requires the following: A steep climb close to the airport; a steep turn into the crosswind (approximately 45 degrees) immediately after the engine failure (no flaps, 80 to 90 knots); and establish the best glide once the turn is complete (if less than 500 feet agl and the runway is not assured, employ CAPS). The COPA presentation indicated that a downwind departure is a better option for most pilots. It provides more flexibility in dealing with engine failures or other emergencies.
1.18 ADDITIONAL INFORMATION
The IIC released the wreckage to the owner's representative on May 1, 2006.
|Narrative Type: NTSB PROBABLE CAUSE NARRATIVE
|The student pilot's failure to maintain an adequate airspeed while maneuvering, and, the flight instructor's inadequate supervision of the flight. A factor in the accident was the strong tailwind encountered as the airplane turned from an upwind to a downwind during the teardrop maneuver.