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Any further information may be obtained from: German Federal Bureau of Aircraft Accident InvestigationBundesstelle Fur Flugenfalluntersuchung (BFU)Hermann-Blenk Strasse 1638108 BraunschweigGermanyPhone: +49 5 31 – 35 48 – 0Telefax: +49 5 31 – 35 48 – 246www.bfu-web.de This report is for informational purposes only and contains only information released by, or obtained from, the BFU of Germany. |
The pilot reported that, while on final approach to land, he was “concerned they had too much speed” to stop in time but elected to continue with the landing. |
About midfield, as the airplane was floating down the airstrip, the pilot aborted the landing and applied full power. |
During the climb out, the airplane was unable to out climb rising terrain or maneuver in the narrow canyon to return to the airstrip. |
The airplane subsequently collided with trees and terrain. |
A post-accident fire destroyed the airplane. |
The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. |
The pilot's decision to continue the approach for landing with excess airspeed, which resulted in an aborted landing and subsequent collision with trees. |
After touching down the airplane veered to the left. |
The pilot added right rudder to correct back to the centerline, however, it continued toward the right side of the runway. |
The airplane subsequently went off of the runway and impacted a taxiway sign, which resulted in substantial damage to the rear right wing spar. |
A postaccident examination of the airplane by a Federal Aviation Administration aviation safety inspector revealed no preimpact anomalies that would have precluded normal operation. |
The pilot's failure to maintain control of the airplane during the landing roll, which resulted in a runway excursion and subsequent impact with a taxiway sign. |
About 18 months prior to the accident flight, the airplane underwent maintenance to remove and replace both the left and right flaps. |
While on pattern downwind, the pilot adjusted flaps from up to half, at which time the right flap rod end separated from the right flap actuation fitting. |
The pilot initiated a climb and struggled to maintain roll control. |
He briefly adjusted flaps to the up position in an attempt to alleviate the problem, and then adjusted the flaps back to half. |
The pilot then adjusted the flaps from half to full and the airplane began to roll right due to flap asymmetry, eventually reaching 86 degrees of right bank. |
The airplane began to stall and the pilot initiated the airplane’s ballistic parachute recovery system about 509 feet above ground level. |
Subsequently, the airplane descended to the ground with the aid of the parachute and came to rest upright on a frozen lake. |
A postflight examination of the right flap rod end area revealed the mounting bolt and washer were missing and lying under the airplane. |
No evidence of a safety wire was present on the mounting bolt or on the right flap actuation fitting. |
The safety wire was most likely not installed when the right flap was reinstalled and went unnoticed for over 211 hours of operation. |
During this time there was a subsequent annual inspection at 114 hours prior to the accident and a pre-buy inspection at 101 hours prior to the accident. |
The National Transportation Safety Board determines the probable cause(s) of this accident to be:The improper reinstallation of the right flap by maintenance personnel. |
Contributing factors were an inadequate examination of the right flap during the subsequent annual, pre-buy, and pre-flight inspections. |
**This report was modified on 9/20/2013. |
Please see the public docket for this accident to view the original report.** On March 29, 2013, about 1045 central daylight time, a Cirrus SR22T airplane, N1967N, was substantially damaged after impact with terrain (frozen lake) near the Chandler Field Airport (AXN), Alexandria, Minnesota. |
The private pilot and one passenger sustained minor injuries, and two passengers were not injured. |
The airplane was registered to MWBS Holdings LLC and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 with no flight plan filed. |
Day visual meteorological conditions prevailed for the flight, which originated from the Marv Skie-Lincoln County Airport (Y14), Tea, South Dakota about 0904. |
While on pattern downwind to AXN, the pilot reported a loud noise during flap extension. |
The pilot initiated a climb as he struggled to maintain roll control. |
He attempted to reduce the airplane’s rolling tendency by adjusting flap position. |
As his control of the airplane worsened, the pilot pulled the ballistic recovery system handle. |
The parachute deployed and the airplane descended onto a frozen lake. |
The flight recording device was recovered from the accident airplane and forwarded to the National Transportation Safety Board’s Vehicle Recorder Laboratory for evaluation. |
While on pattern downwind, the recorder indicated that the flaps were adjusted from up to half and the airplane made several left bank turns, with a maximum of 30 degrees of left bank. |
About 18 seconds after initial flap movement, the flaps were briefly adjusted to up and returned to half. |
About 36 seconds after initial flap movement, the flaps were adjusted from half to full and the airplane began a right roll to a steep right bank attitude. |
A stall indication was recorded 38 seconds after the flaps were adjusted to full. |
The Cirrus Airframe Parachute System (CAPS) was deployed two seconds after the stall indication. |
The CAPS handle pull occurred at a pitch of 22 degrees nose down, a roll attitude of 86 degrees right bank, and an altitude of about 519 feet above ground level. |
The airplane was examined at the accident site by Federal Aviation Administration (FAA) inspectors and a representative of Cirrus Design Corporation. |
The right flap rod end was found disconnected from the right flap actuation fitting. |
The right flap rod end mounting bolt and washer were found lying on the snow under the airplane. |
No evidence of a safety wire was present on the mounting bolt or on the right flap actuation fitting. |
An examination of the CAPS Rear Harness assembly revealed that both reefing line cutters had fired but the rear harness remained “snubbed.” The impact scars on the snow and Ice, and the damage to the aircraft indicated that touch-down occurred while the airplane was in a 40-50 degree nose-down attitude. |
This nose-down attitude is consistent with a touch-down prior to “tail drop.” A review of maintenance records indicated that the right flap was reinstalled on August 3, 2011, at a Hobbs time of 66.4. |
According to maintenance manual procedures, the mounting bolt and washer hardware were to be torqued to a measured 50-70 inch pounds, then safety wired to the flap actuation fitting. |
An annual inspection was conducted on July 10, 2012 (163.9 Hobbs), a pre-buy inspection was conducted on November 5, 2012 (177.2 Hobbs) and the accident occurred with a Hobbs time of 278.0. |
According to the Cirrus SR22T pilot operating handbook, the preflight checklist states to "inspect flap hinges, actuation arm, bolts, and cotter pins.....secure." |
The pilot reported that he was performing a soft-field takeoff in preparation for his upcoming private pilot checkride when after the nose wheel lifted off the runway, the airplane yawed to the left. |
He applied right rudder in an attempt to maintain control; however, when a runway excursion seemed imminent, he applied full brake pressure on both pedals. |
The airplane veered “sharply” to the left, exited the runway, and impacted a ditch before coming to rest in an adjacent field. |
The airplane sustained substantial damage to the forward fuselage and left wing. |
The pilot reported no preaccident mechanical failures or malfunctions that would have precluded normal operation. |
The pilot reported that attempting to steer the airplane back toward the runway centerline and not applying the brakes might have prevented the accident. |
The pilot's failure to maintain directional control during a soft field takeoff. |
The instrument-rated pilot and one passenger were approaching the destination airport following an instrument flight rules cross-country flight in instrument meteorological conditions; the reported weather at the destination included ceilings between 400 and 600 ft above ground level and visibility of 2 miles in mist. |
The controller cleared the airplane for the instrument landing system (ILS) approach; the pilot intercepted the localizer and immediately descended below the minimum altitude he was required to maintain prior to crossing the final approach fix (FAF). |
The controller issued a low altitude alert as the airplane was crossing the FAF about 700 ft below the minimum altitude. |
The pilot responded that he was climbing; he did not report any problems or issues with his airplane to the controller. |
The airplane then drifted right of the localizer course and the controller advised the pilot of such, but there was no response. |
The airplane subsequently proceeded left of the localizer course, after which the controller issued another low altitude alert and asked the pilot if he was still on the approach. |
The pilot responded that he was not on the approach and that he was "pulling." During the final minute of the flight, the airplane was observed in rapid, turning climbs and descents until radar contact was lost. |
The airplane impacted terrain about 4.2 miles east-southeast of the airport. |
Accident site evidence and impact damage to the airplane were indicative of a high-velocity impact. |
Examination of the wreckage revealed no evidence of any preimpact mechanical anomalies, and analysis of a video doorbell that captured audio of the airplane in flight revealed an engine speed consistent with high power. |
The reduced visibility conditions present at the time of the accident and the high workload associated with the instrument approach were conducive to the onset of pilot spatial disorientation, and the airplane's erratic maneuvering and the high-energy impact are both consistent with the known effects of spatial disorientation. |
Therefore, it is likely that the pilot became spatially disoriented during the instrument approach, which resulted in a loss of airplane control. |
The pilots' loss of control during an instrument approach in instrument meteorological conditions as a result of spatial disorientation. |
On September 15, 2018, about 1103 eastern daylight time, a Columbia Aircraft Mfg LC41-550FG, N2536T, was destroyed when it was involved in an accident at Woburn, Massachusetts. |
The pilot and one passenger were fatally injured. |
The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. |
According to air traffic control information, the accident airplane was cleared for the instrument landing system (ILS) approach to runway 29 at Laurence G. |
Hanscom Field (BED), Bedford, Massachusetts. |
At 1100:15, the pilot contacted the BED tower controller and reported that he was 2.5 miles from the final approach fix (FAF) for the ILS to runway 29. |
At 1100:26, the accident airplane was cleared to land. |
The pilot intercepted the localizer about 2 miles from the FAF and continued to descend to 1,060 ft mean sea level (msl); the minimum altitude before crossing the FAF was 1,800 ft msl. |
As the airplane crossed the FAF, the controller issued a low altitude alert to the pilot. |
The pilot acknowledged the call and stated, at 1101:56, that he was climbing. |
About 14 seconds later, the controller advised the pilot that the airplane was drifting north of course. |
The pilot did not acknowledge the call. |
At 1102:35, the controller issued a second low altitude alert, as the airplane was at 1,200 ft msl, and asked the pilot if he was still on the approach. |
The pilot responded, "three six tango no I'm pulling." At that time, the airplane was south of the localizer course. |
At 1102:49, the pilot stated, "okay, okay." At 1102:51, the pilot stated an expletive. |
During the last minute of flight, the airplane was observed in rapid turning climbs and descents. |
Radar and radio contact were lost about 1103. |
After the accident, a resident who lived near the accident site reported that her video doorbell captured audio of the airplane before the accident. |
A copy of the video file was provided to investigators. |
The airplane could not be seen; however, the sound of an engine running was evident on the video, culminating in the sound of an impact. |
The file was analyzed by the propeller manufacturer, who identified a 127.5-Hz frequency that belonged to the propeller. |
A sound spectrum study revealed that the engine was operating near 2,550 rpm during the recording and before impact (maximum rated engine rpm was 2,700). |
The pilot completed a flight review on January 15, 2018, and an instrument proficiency check on July 31, 2017. |
He logged 9 instrument approaches and 4.7 hours of actual instrument experience during the 6 months before the accident. |
He logged two flights and 3.3 hours of flight time during the 90 days before the accident. |
Federal Aviation Administration (FAA) records revealed that the pilot purchased the airplane new in 2006. |