The private pilot and his passenger departed on a cross-country flight. Shortly after takeoff, the pilot reported to the controller that he was having an engine problem and wanted to return to the airport.
One witness heard the engine surge during the takeoff roll. Another witness stated that the Cirrus SR22 was on the ground longer than he expected, but did not report hearing anything abnormal with the engine. A third witness stated that the engine sounded normal and a fourth witness reported seeing the airplane in a steep bank.
The airplane was damaged by impact and a post-impact fire, while both the pilot and passenger died in the crash.
The damage to the airplane and the marks on the ground were consistent with the airplane being in a flat spin at the time of impact.
The density altitude at the time of the accident was 7,446 feet mean sea level.
The majority of the pilot’s flight experience was conducted at airports with a lower field elevation and he had flown to the accident airport in Colorado Springs on only two other occasions.
It is likely that, after takeoff, he misinterpreted the airplane’s reduced engine power and decreased climb performance, due to the high density altitude conditions, as an engine malfunction.
During the turn back to the airport he exceeded the airplane’s critical angle of attack and experienced an aerodynamic stall and spin.
Although there was evidence that the pilot had used marijuana at some time prior, it is unlikely that he was impaired by marijuana at the time of the accident. He had been diagnosed with mild depression two months before the accident and had started treatment with sertraline. He had not yet followed up with his physician after starting treatment. Therefore, the investigation was unable to determine if he may have been impaired by the symptoms of his depression.
The pilot was using diphenhydramine, cetirizine, and sertraline, which in combination significantly increased the risk of impairment over each medication alone.
The experienced pilot was exposed to a high workload environment following the degradation of airplane performance, but would have been expected to safely fly the airplane. Therefore, it is likely that when he was exposed to a high workload environment, due to the airplane’s degraded takeoff performance, the combination of multiple medications likely impaired his ability to respond safely and, therefore contributed to the subsequent loss of control.
Probable cause: The pilot’s loss of airplane control during the turn back to the airport after takeoff in high density altitude conditions, which resulted in an inadvertent aerodynamic stall and subsequent spin. Contributing to the accident was the pilot’s impaired performance due to his use of a combination of potentially impairing medications.
NTSB Identification: CEN16FA034
This November 2015 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.
Wonder why he didn’t pull the magic handle? That’s the pretty glass on the instrument panel and the parachute are the reasons he bought the airplane.
The combination of drugs either legal or illegal and this persons’ lack of experience with altitude fields was a lethal mix. SOTP flying is for sober people not mellow pilots. My father was say it was the NUT holding the wheel or in this case the side stick. Glass will not fix stupid. He should have grounded himself as any reasonable person would do. “You owe it to your passengers.”
If a pilot has no SOTP (seat of the pants) feel for an airplane as to when it’s approaching stall AOA say during a semi-panicked turn back after takeoff he/she is almost guaranteed to inadvertently stall the airplane. SOTP feel for detecting an approaching stall can only come with experience doing stalls at 1G and higher. SOTP feel in a coordinated turn while closely monitoring the airspeed indicator should be all that’s really needed to avoid an accelerated stall that could and often does lead to a spin if the control pressure and AOB are not relaxed/reduced at the first indication of an approaching stall. We hear a lot about AOA indicators for GA airplanes these days and while they are nice to have, they are not essential for safe operation of any GA airplane including the popular Cirrus SR22.
SOTP flying is kinda tough to do if the pilot is under the influence, distracted, afraid, suffering from depression), etc. Maybe the problem isn’t lack of SOTP, it’s failure to STOP before takeoff.
AoA meters work. Period. Usually those criticizing them do not have them. Same goes for glass over steam gauges. And metal/rivet planes versus carbon fiber.
Btw. A stall in a Cirrus is less pronounced than in lesser aircraft due to the anti-stall characteristics of the wing. But the advanced warning is much longer in a Cirrus. This pilot panicked in some odd way either from impairment or from a lack of experience flying at higher altitudes and at higher DA.
Warren Webb Jr says
AoA indicator? He had multiple pitch indicators including airspeed, attitude, altimeter, vertical speed, and what may have been the easiest to use, the horizon. Will another instrument make the difference – I doubt it. In these panicked turn-backs, the eyes are probably locked on the airport/runway area, further explaining why so many pitch references don’t avert a stall/spin. As another commenter mentioned, ground and flight training (turning back to the runway under safe controlled conditions) to me would help much more than an AoA indicator, as well as emphasis and execution of descending within 30 degrees straight ahead as recommended in the FAA Airplane Flying Handbook. Actually if training is done as intended, where the pilot acquires a feel for the controls and airplane, no instruments are needed.
Warren Webb Jr says
Training for emergencies on the initial climb is critical to develop skill and judgement. Actually I think things are moving in the right direction. Checkrides are putting much more emphasis in this area, and Cirrus has done the same.
Mike S. says
Should have deployed the “aerial lifeboat”, aka parachute. Standard equipment on lesser airplanes.
The accident reports a cocktail of OTC, Rx, and recreational (MJ) drugs were found in the pilot’s blood, lung tissues, and urine. “The testing detected sertraline at 90 ng/ml, diphenhydramine at 52 ng/ml, and cetirizine in cavity blood. Both diphenhydramine and cetirizine are potentially impairing. Additionally, Rosuvastatin, a prescription cholesterol lowering medication, and salicylate, a metabolite of aspirin, were detected in urine. Tetrahydrocannabinol (THC), the psychoactive component of marijuana, was detected in lung, but not cavity blood, and its inactive metabolite tetrahydrocannabinol carboxylic acid was detected in tissues and urine.” No information is available of whether the pilot was rested or fatigued, though the NTSB Final report says he was in treatment for depression.
The Final Report said the aircraft’s engine monitor likely displayed anomalous indications for two of the six cylinders. Panel readouts from the EDM would have displayed engine monitor readouts that should have suggested follow up prior to takeoff, though there is no indication of whether these anomalous indications were recent (for this flight) or long term and known to the pilot. The pilot had limited experience with high DA airports. DA was nearly 7500′ at the time of the accident.
Maybe the pilot was capable of normal ops with the drug cocktail in his system. But with the drugs plus his psychological issues he couldn’t have been as sharp in his execution of aggressive maneuvers he employed in his attempt to return to the airport. May he and his wife rest in peace, and his family recover from their loss.
cindy brickner says
“Experienced pilot” flying an SR-22. If he has the bucks to buy an SR, he’s probably not a spring chicken. If “most of his flying” is not concerned with density altitude…. he lives in the central states at average elevation of ~800 msl. Throw together high density altitude and a couple types of antihistamines, and you have a clear recipe for histo-toxic plus plain ole hypoxia. If he’s an older guy, throw in the possibility of a history of smoking and even lesser aerobic lung function. There’s not enough juice getting into the grey matter…..
Then, add a high performance machine that likely has a more abrupt stall characteristic. There is huge reluctance to do meaningful stall training in GA in this decade. Let’s just do stall avoidance training, or add an AoA indicator. That new gadget will keep me safe. And GA “never” does simulations of real returns to the runway in departure training ( as do glider training programs).
Introduce the lesser departure performance. Fellow doesn’t know why it isn’t climbing at normal rate. Brain isn’t calculating at his normal speed. Decides to “turn back”, and doesn’t watch nose attitude and stalls. It is really too bad he took out another expensive airplane and an unsuspecting citizen.
It is a classic case of “macho”, the rules don’t apply to me…. I will self medicate and still fly, because I am a great pilot in a cool machine. CFI’s – take this to heart, and take it back to your BFR discussions.
Glenn Swiatek says
There was a great book published some years ago, “ Fate Is The Hunter “.
But they don’t make pilots like that anymore. I know I’m not one.