New aircraft, new instructor

The accident chain in this well-researched GA incident is lengthy and highlights the benefits of flight data monitoring (FDM) to get a clear picture of what happened.The crash occurred on the delivery flight of a brand-new Cirrus SR22 on September 1, 2022. The new owner was going through the required transition training, which is typically a five-day course. The training was conducted by a new instructor at the Cirrus Delivery Center in Knoxville, Tennessee. The owner was several days into the course when he started feeling ill and decided to fly home with the aircraft and the CFI. He was diagnosed with COVID-19 after the crash.

The flight

An IFR flight was planned from Knoxville (TYS) to Alexandria Airport (AEX), in Alexandria, Louisiana, with the new owner, a female passenger, and the CFI. Thunderstorms caused a diversion to Monroe Regional Airport (MLU) in Monroe, Louisiana, for refueling and refreshment. The owner flew most of the flight on autopilot which is not unusual on cross-country flights. The instructor, according to the owner, didn’t say much and appeared to sleep much of the way.

The second leg was from Monroe to David Wayne Hooks Memorial Airport (DWH) in Spring, Texas. The flight had only been airborne for about 10 minutes into the roughly 1.5-hour flight when the instructor said he had to urinate. The owner offered him one of his in-flight urinals, but the instructor declined. “The owner said the instructor appeared uncomfortable (shifting around in his seat and grimacing) during the flight and did not speak much or provide any feedback until they were approaching DWH,” the NTSB report says.

The flight was cleared for a visual approach. According to the NTSB, “The owner 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 [were] no altitude step downs or waypoints visible after the visual approach was selected.

“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.

According to the NTSB, the pilot said the airplane then descended below the proper glidepath and 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.”

About one minute before the crash there was a total loss of fuel flow and subsequent loss of power. The Cirrus was 988 feet above ground level (agl) and 2.26 nautical miles from the end of the runway. Fifteen seconds after that, the autopilot was turned off. There was some throttle movement after the owner and instructor noticed the power loss.

At 42 seconds after the fuel flow interruption, the Cirrus descended through 407 feet agl and 1.23 miles from the displaced runway threshold. The Cirrus Airplane Parachute Systems (CAPS) has a minimum deployment altitude of 600 feet agl and was not deployed. The flaps were retracted at about 400 feet agl. Twenty seconds later, the Cirrus impacted trees in a wooded mobile home park. According to the airspeed recording, the aircraft stalled 200 feet agl at 74 knots. To note, the best glide speed is 92 knots with flaps up. The owner and rear seat passenger survived with serious injuries. The instructor did not survive.

Owner and instructor

In this event, although the NTSB notes that was never an understanding as to who would act as pilot in command (PIC), by default it would be the CFI. The FAA and NTSB, through long precedent, almost always look at the more highly certificated pilot with access to controls as the PIC. Additionally, the owner did not qualify under his insurance policy and was still in training with a factory instructor on board.

The owner held a private certificate with an instrument rating. He reported about 2,000 hours total flight time with nearly 1,700 hours in a Cessna 182. He had received 12 hours of instruction in the Cirrus. The 31-year-old CFI had just more than 800 hours total flight time. He had no Cirrus experience prior to the Cirrus instructing job. At the time of the crash, he had logged 109 hours of Cirrus time, of which 44 hours was his own transition training.

The factory instructor pilot who conducted the transition training noted that the new CFI had difficulties. His training records documented concerns about maintaining situational awareness while operating in areas of high traffic airspace, “staying ahead” of the airplane in dynamic situations, and decision making regarding CAPS deployment.

The NTSB final report notes that after 23.9 hours of
dual instruction completed over a nine-day period,
the supervisory instructor believed the accident
flight instructor was not ready to fly solo and
required additional training. “The training records
also listed difficulties with managing airplane automation and airplane handling. The consensus
from the instructors interviewed was that while the accident flight instructor did require additional time
and performed slightly below average in comparison
to other new hires in training, he did ultimately
perform to a satisfactory level and was proficient enough to work with customers as a Cirrus Factory Flight Instructor.”

Data analysis

The presence of flight data monitoring and the on-board witness information provided an exceptionally clear picture of what likely happened in this accident. The post-crash analysis could find no fault with the engine. Fuel was present in both tanks. No significant leaks were noted, as confirmed by the absence of blue fuel stain anywhere in the fuel system.

During post-crash follow up, however, while in a Cirrus simulator the NTSB investigator inadvertently managed to move the mixture to idle cutoff when reducing power. The sim instructor suggested repositioning his hand on the throttle. None of the other instructors at the training center reported having ever seen such an occurrence. However, such a movement provided an identical temperature/fuel flow signature to the crash on the flight data monitor.

The NTSB attributed the probable cause to “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 the 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 the flight instructor about who was responsible for the safety of flight, all of which created a situation where neither individual was adequately monitoring the engine operation during the critical phase of flight.”

Commentary

As shown in the image above, the mixture control is both color and shape differentiated. Some aircraft have detents or lockouts to further prevent inadvertent fuel shutoff. However, never underestimate the power of distraction and stress to allow us to do the wrong thing. As CFIs, the responsibility is always ours. I had a student pull the mixture while intending to turn on a Cessna 150’s carburetor heat while on downwind. This was long before autopilots or noise canceling headsets in training aircraft but it got my immediate attention.

While most of us would be more comfortable at home during illness, making an extended cross-country to fly home while sick is just not a good idea. As noted in the report, both pilots were clearly not at the top of their game. The owner was suffering from COVID-19 and not qualified in the aircraft, and the CFI was distracted by an overfull bladder.

It is purely speculative, but under the circumstances, a little embarrassment and perhaps having a “modesty” hand towel (I always carry one) would have relieved the CFI. An obligatory preflight requirement is to visit the restroom.

The NTSB noted that low noise level from reduced power and noise canceling headsets would have masked the total loss of power until the throttle was advanced when it would become obvious. Not deploying the parachute was a critical oversight, and yet I understand the CFI was task-saturated at that point. Here’s where strict adherence to procedure applies.

This new CFI was looking forward to a professional flying career and had just gotten a dream job on the second rung of a long ladder. His marginal training record and lack of experience manifested itself in a rapidly deteriorating situation at low altitude.

It’s easy to second guess on this somewhat unusual chain of events and it reminds me of my early teaching days. Sometimes, though, you don’t get a second chance.