NTSB report on Lexington accident

Here is the NTSB report on the Lexington accident:

NTSB Identification: NYC02LA071

Accident occurred Saturday, March 16, 2002 at Lexington, KY
Aircraft:Cirrus Design Corp. SR-20, registration: N244CD
Injuries: 2 Uninjured.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed.
On March 16, 2002, about 1240 eastern standard time, a Cirrus Design Corporation SR-20, N244CD, was substantially damaged during an emergency landing in Lexington, Kentucky. The certificated private pilot and a pilot rated passenger were not injured. Instrument meteorological conditions prevailed and an instrument flight rules flight plan had been filed for the flight that departed the Blue Grass Airport (LEX), Lexington, Kentucky. The personal flight was conducted under 14 CFR Part 91.
The instrument rated pilot stated he had intended to perform some practice instrument approaches in actual instrument meteorological conditions. The passenger was a friend of the pilot and also held a private pilot certificate, with an instrument rating.
According to the pilot, after a normal preflight check, the airplane departed from runway 04, at LEX. The pilot maintained runway heading until 1,400 feet, then set the autopilot to fly the “heading bug,” and the “VS” to climb. He then initiated a climbing right turn by setting the heading bug to 090 degrees, and entered the overcast layer at about 1,600 feet. Air traffic control (ATC) then cleared the airplane to the initial approach fix for the “GPS RW 04” approach. The pilot was in the process of selecting the approach in the airplane’s global positioning satellite (GPS) receiver, when he noticed that the turn coordinator was “pegged to the left, with no flag,” and that the airplane was losing altitude rapidly. The pilot disengaged the autopilot and attempted to stabilize the airplane. In a written statement, he further added:
“…I let [the passenger] know I was disengaging the autopilot. By then we were in a steep dive. At this moment, I had no confidence in the instruments other than airspeed, altimeter and vertical speed indicator. The airspeed was high, perhaps in the yellow arch. When we broke out of the clouds, I pulled up hard and the plane responded. Our momentum carried us back into the clouds and somewhere near 3,000 feet, I had control of the altitude momentarily and thought for a minute we might be able to recover. I tried to fly straight and level, which I believe we did for a short time and then everything started to unravel again. The attitude indicator (AI) was now unreliable. I suspect the AI tumbled during recovery from the previous dive. Next we were climbing and probably turning and generally out of control…”
The airplane was equipped with a Cirrus Airplane Parachute System (CAPS). The pilot indicated he pulled the CAPS activation handle repeatedly; however, the cable did not extend and “nothing seemed to happen.” He further stated:
“…Finally I decided that it must have already deployed, but still we were carrying 120-140 knots of airspeed and descending faster than I expected we would if the chute had deployed. After we broke out [of the cloud layer] we began to search for a suitable landing site. We were still uncertain as to whether or not we were under the canopy, but continued to fly as if we were not…”
The airplane touched down in field and struck trees, about 3 miles northeast of LEX. Witnesses near the accident reported that the CAPS parachute deployed after ground contact.
Initial examination of the wreckage by a Federal Aviation Administration (FAA) inspector did not reveal any pre-impact instrumentation, or autopilot failures. The CAPS system also functioned normally; however, it was noted that the pull forces to activate the CAPS parachute varied significantly during post accident testing.
According to the airplane manufacturer, the CAPS system was designed to bring the aircraft and its occupants safely to the ground in the event of a life-threatening emergency. The CAPS system consisted of a parachute, a solid-propellant rocket to deploy the parachute, a rocket activation handle, and a harness imbedded within the fuselage structure.
On February 25, 2002, Cirrus Design Corporation issued Service Bulletin (SB) 22-95-01. The SB was also the subject of FAA Airworthiness Directive (AD) 2002-05-05, which became effective on March 19, 2002. The service bulletin and subsequent AD, entailed the installation of a cable clamp external to the rocket cone adapter which would provide positive retention of the activation cable housing.
On February 28, 2002, Cirrus Design Corporation issued SB 20-95-02, after it was discovered that some production airplanes may exhibit a condition where the pull force required to activate the CAPS system may by greater than desired. The SB entailed the installation of a clamp to positively restrain the cable housing at the CAPS Handle Adapter, loosen and straighten the activation cable above the headliner, and to remove an Adel clamp securing the activation cable adjacent to the rocket cone adapter.
The accident airplane had been operated for about 150 hours since new. On March 4, 2002, maintenance was performed on the airplane which included compliance with SB 22-95-01/AD 2002-05-05. Service Bulletin 20-95-02, had not been complied with at the time of the accident.
The pilot reported he had experienced the exact same type of turn coordinator failure on a previous occasion. Maintenance records revealed a turn coordinator was replaced on the airplane on June 25, 2001, after 57 hours of operation.
The turn coordinator, autopilot control box, and autopilot roll trim actuator were removed from the airplane for further testing.
The weather reported at LEX, at 1254, was: wind from 360 degrees at 7 knots, visibility 5 miles in mist, ceiling 600 feet overcast, temperature 6 degrees C, dew point 6 degrees C, altimeter 30.18 in/hg.

The autopilot part sounds like what happened to me. The autopilot lost the ability to control bank was still controlling the pitch. There were no warnings or alarms. The plane would then start to bank, the altitude would decrease, the autopilot would try to level the wings without effect, and increase pitch to recover the altitude. Increasing the pitch without leveling the wings would only steepen the bank and increase the descent rate which would cause the autopilot to increase the pitch … The plane very quickly entered a spiral.

My biggest fear in flying is that despite thinking of myself as a pilot of reasonable skill, that I’ll perform as amazingly badly as the pilot in that report if I ever get in to a serious problem. It sounds like an unusual attitude on partial panel, something completely solvable in a less stressful situation. The fact that the pilot didn’t even know if he was under canopy or not and simply “decided” to let the airplane crash is amazing, and probably a result of the severe, mind stopping stress of the situation. Moreover, after recovering in VMC, the pilot’s recovery was so overdone that he put himself back in the clouds.

In my opinion, there is not a single pilot on this planet that would think themselves capable of such bad piloting, yet I imagine this pilot is probably as good a pilot as any under normal circumstances. This, in my mind, is yet another good argument for the CAPS (at least when it works). In extreme situations, I think even the best pilot would be lucky to remember how to pull the handle, let alone think clearly enough to evaluate which instrument(s) to trust and how to best recover.

This accidemt report is a really fascinating example of the foolishness of thinking that the GA accident rate can be solved (and is a result of) pilot skills. Who the hell has skills when you’re freaking out from pulling 4 Gs in a spiral dive while your brain is completely confused about which way is up. Being out of control is a horrible experience, and unless you’ve toyed with it, you are probably brazenly operating under the assumption that you can function in such a situation.

Uh huh. Try out the 3-axis or 5-axis motion simulators at NASA’s Space Camp sometime. After a minute or so in those, you learn to ignore your vestibular apparatus unless you want to lose your lunch. perhaps IFR pilots should have access to and use one of those for a few minutes very couple of months to remember how to ignore proprioceptor input in IMC. (…hummm, one or two at every FSDO, they can’t be too expensive to build, and they’re stone simple to operate…). We could add it to the currency requirements (6 approaches, holding, intercept and track, 10 min of disorientation simulator work,). Yet another regulation that would be worthless, since stress short-circuits rational thinking skills anyway…

When stress makes you resort to thinking with your reflexes instead of your higher cortical processors, the game is over. If you can’t control the stress and / or corrective action isn’t engrained to the point of reflex, its time to pull the 'chute and be there to accept the insurance check. (Ask the Kennedys.) That’s why test pilots are hard to come by and die fast.

Personally, I’ve had the “leans” enough times on first entering IMC that I’m not in a position to critique any other pilot’s skills in such a condition as was described in the report.

In reply to:

Personally, I’ve had the “leans” enough times on first entering IMC that I’m not in a position to critique any other pilot’s skills in such a condition as was described in the report.

That makes at least two of us.

  • Mike.