NTSB Factual Report

HISTORY OF FLIGHT

On June 18, 2016, about 1411 mountain daylight time, a Cirrus Design Corporation SR22 airplane, N678Z, descended under the canopy of the cirrus airframe parachute system (CAPS) and impacted terrain near Colorado Springs, Colorado, following an inflight loss of engine power. The pilot, a safety pilot in the right seat, and a pilot rated rear-seated passenger sustained minor injuries. The airplane sustained substantial damage during the impact. The airplane was registered to N678Z LLC and was operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight. Day visual meteorological conditions prevailed in the area of the accident and the flight was not operated on a flight plan. The local flight originated about 1345 from the City of Colorado Springs Municipal Airport (COS), near Colorado Springs, Colorado.

The pilot of the accident airplane reported that he was participating in a Cirrus Owners and Pilots Association flying clinic. He departed from COS with two passengers to conduct training in a local practice area located about 15 miles east of COS. The pilot stated that after 20 minutes of air work, at approximately 8,500 feet above mean sea level (msl), he noticed a roughness in the engine and that the oil pressure reading indicated within the green arc but lower than normal. The engine continued to run rough and lose power. Air traffic controllers were advised that the flight was headed back to COS with an engine problem. He said that with the reduced engine power available, the airplane began losing altitude and airspeed. The pilot determined the flight could not make a landing at COS, which was about 11 nautical miles west of the airplane's position, or Meadow Lake Airport, which was about 6 nautical miles north. He indicated that no suitable landing areas were identified and he pulled the CAPS handle. The CAPS rocket fired and separated from its lanyard. The parachute subsequently deployed. The airplane impacted the ground in a nose down attitude. The impact occurred with the aft harness in a snubbed position, prior to tail drop. The airplane subsequently stabilized upright on its main landing gear.

The safety pilot seated in the front right seat of the accident airplane, reported that he flew the accident airplane earlier in the morning during the demonstration phase of training and noted no issues or anomalies with the accident airplane. He indicated that his purpose during the flight was to demonstrate and teach formation-flying techniques. He reported that after a preflight brief he held an additional briefing emphasizing that the airplane owner would be the pilot-in-command and is responsible for all emergencies as he, as a safety pilot, was not familiar with the owner's equipment.

According to the safety pilot, the rear seated passenger noticed the oil light illuminated before the takeoff run when the engine was at idle. However, the light went off during the engine run up so he did not think it was a problem. The safety pilot related that he had observed his oil pressure light illuminated while at idle numerous times with a warm engine.

The safety pilot indicated that the takeoff, rendezvous, and initial formation training were normal. As a wingman, the pilot is usually unaware of the flight's location, altitude, or airspeed. Additionally, he said that a wingman's attention revolves around the lead airplane where you do not have time to monitor engine instrumentation. The safety pilot said, "If you have never flown as a wingman you just don't understand how much you have to trust your plane while keeping your eyes on lead AT ALL TIMES. I even commented on this during the initial 4-hour brief - if you have a weak engine don't fly. When there is a lead change it takes a moment for you to figure out where you are."

The safety pilot reported that this loss of engine power during the flight was extremely subtle. At no time did he notice any indications out of normal parameters. The pilot mentioned his oil pressure looked low at 27 psi. The safety pilot asked what was normal but the pilot did not know. The safety pilot stated that the oil pressure and all other engine indications were within their respective green arcs, showing normal engine parameters. The accident airplane had fallen behind the lead airplane and was five plane lengths away on his right wing. The safety pilot said that a slow "pinging" about every 10 - 15 seconds started and that is when the pilot elected to return to the airport. The formation flew as briefed where the accident airplane took over as the lead airplane. The pilot informed air traffic control of engine problem. An intermediate engine power setting was set and all of the engine indications remained within their green arcs. The safety pilot reported that the pinging interval started to decrease and that the engine did not sputter.

An air traffic controller advised the flight of bearings and distances to three nearby airfields. The safety pilot stated that with the remaining altitude, they immediately knew they could not reach any of them. He noticed and told the pilot the airspeed was low with an indication of 100 knots while the airplane was at 7,100 feet msl. The pilot told him that the throttle was full forward. The safety pilot immediately transmitted a Mayday call and advised the pilot to deploy the CAPS.

The safety pilot reported that the pilot in command would pull the CAPS unless incapacitated, as briefed during preflight briefing. According to the safety pilot, the pilot's previous and overriding training habit kicked as he looked for a place to land. The pilot verified with the safety pilot that he intended to deploy the CAPS and pulled the CAPS handle at the safety pilot's second request. The airplane's altitude was 7,000 feet msl and its indicated airspeed was 80 knots. The handle came out and down. However, it took a strong second pull to get the rocket to fire. The safety pilot estimated that the CAPS deployment occurred about 800 feet above ground level (agl).

The safety pilot said that there was a huge deceleration after the CAPS deployment. There was a moment of weightlessness and then the airplane pitched nose down. The safety pilot, in part, said:

All I saw was the ground rushing up rapidly. ... We violently impacted

nose down. I screamed in pain. It felt as if I was stabbed in my neck

and lower back, all on the left side. It took a few seconds to access my

condition. Wiggle fingers and toes, move head, etc. When I realized I

was alive I looked over at [the pilot]. It initially looked like he was

slumped over to the left but then observed him move with purpose. He

stated his door was jammed, grabbed the hammer and started

whacking away at the forward part of his door window. [The rear

seated passenger] ... told me to try my door. It opened, I crawled out

and went to move the seat forward but [the rear seated passenger] had

already slithered out so I went down the wing.

The safety pilot flying in the other formation airplane, in part, said:

I observed N678Z deploy CAPS, and informed Approach that I saw a

"good chute". I did not look at the altimeter, but I recall thinking that

we were very low. N678Z struck the ground within just a few seconds,

in a nose-low attitude that I estimate at about 80 degrees. A large dust

cloud was raised; the impact appeared violent to me, and I was not

sure that it was survivable by any of the occupants.

The passenger in the rear seat of the accident airplane helped the accident pilot egress out of the right-side door. The safety pilot in the accident airplane reported that first responders helped deflate and wrap up the chute. After that, his neck started hurting again. The three occupants were subsequently transported to a hospital to be evaluated.

PERSONNEL INFORMATION

The 64-year-old pilot held a Federal Aviation Administration (FAA) commercial pilot certificate with an airplane single engine land and instrument ratings. He held a flight instructor certificate for single engine airplanes. He also held a third-class medical certificate that was issued on June 1, 2016, with a limitation that he must wear corrective lenses. The pilot reported that he had accumulated 1,289 hours of total flight time and accumulated 30 hours in the same make and model as the accident airplane.

AIRCRAFT INFORMATION

N678Z, a 2002 model Cirrus Design Corporation SR22, serial number 0311, was a four-place single engine low-wing airplane powered by a six-cylinder, Continental Motors model IO-550-N engine with serial number 686307, that drove a three-bladed Hartzell constant speed propeller. According to airplane logbook entries, an annual inspection was completed on November 13, 2015. The airplane accumulated 787.9 hours of total flight time at the time of that inspection. Another entry indicated that a Forced Aeromotive Technologies, Inc. (FAT) supercharger was installed on the engine on June 11, 2016, and the airplane accumulated 817.6 hours of total flight time at the time of that installation.

According to technical information from the supercharger manufacturer's website, the supercharger is belt driven off the accessory drive, similar to the alternator. The supercharger will run much cooler than a turbocharger and should result in much lower maintenance costs. It will add 7 to 8,000 feet of altitude performance to the Cirrus SR-22. The supercharger's impeller speed is a function of engine RPM and therefore over-speed and bootstrapping are not operational considerations. There are no manifold pressure fluctuations while adjusting the throttle, or mixture. Additionally, according to the manufacturer, after landing idle cool down periods are not necessary and the manifold pressure is limited to 29.60 inches at full engine power.

Engine manifold pressure is maintained automatically by an electronic boost controller designed for the SR22 by FAT. The controller reacts to throttle changes in less than one second. The boost controller is not affected by cold oil temperatures or cold take off conditions and will operate quickly to control boost even down to -50° F.

The airplane was equipped with an Avidyne Multi-Function Display (MFD). The MFD unit can display engine information, pilot checklists, terrain/map information, approach chart information and other airplane/operational information depending on the specific configuration and options that are installed. One of the options available is a display of comprehensive engine monitoring and performance data. Each MFD contains a compact flash (CF) memory card. This memory card contains all the software that the MFD needs to operate. Additionally, this card contains checklists, approach charts, and map information that the unit uses to generate the various cockpit displays.

During operation, the MFD display receives information from several other devices that are installed on the airplane. Specifically, the MFD receives GPS position, time and track data from the airplane's GPS receiver. The MFD may also receive information from the airplane concerning altitude, engine and electrical system parameters, and outside air temperature. This data is also stored on the unit's CF memory card.

The MFD generates new data files for each MFD power-on cycle. The oldest file is dropped and replaced by a new recording once the storage limit has been reached. MFD data are sampled every six seconds and recorded to memory once every minute. If an interruption of power occurs during the minute between MFD memory write cycles, data sampled during that portion of a minute are not recorded.

The airplane was fitted with a CAPS designed to recover the airplane and its occupants to the ground in the event of an in-flight emergency. The CAPS contains a parachute (within a deployment bag) located within a fiberglass CAPS enclosure compartment, a solid-propellant rocket contained within a launch tube to deploy the parachute, a pick-up collar assembly and attached Teflon-coated steel cable lanyard and incremental bridle, a rocket activation system that consisted of an activation handle, an activation cable, and a rocket igniter, and a harness assembly, which attached the parachute to the fuselage. Upon deployment by the pilot, a rocket fires from the parachute bay located behind the cabin, knocking the cover panel off the parachute bay in the process. The pickup collar assembly is carried by the rocket for rapid deployment of the parachute.

METEOROLOGICAL INFORMATION

At 1354, the recorded weather at COS was: Wind 170° at 9 knots gusting to 16 knots; visibility 9 statute miles; sky condition few clouds at 7000 feet; temperature 29° C; dew point 11° C; altimeter 30.36 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

The airplane was found upright about 11 miles east of COS. Its engine and cowling were bent upward forward of the firewall. The CAPS parachute was found deployed. A recovery company relocated the wreckage. The CF memory chip from the MFD, the engine, and components of the CAPS system, to include the rocket lanyard, incremental bridle, incremental bridle sheath, deployment bag, and retaining harness, were subsequently shipped for additional examinations. However, the rocket, the pickup collar, pickup collar support, and the cable stop sleeves from the pickup collar assembly were not recovered.

Examination of the wreckage revealed a witness mark on the lower forward left side of the vertical stabilizer. The hour meter indicated 823.0 hours. The electric fuel pump was able to pump a fluid when electric power was applied. Disassembly of the pump did not reveal any anomalies that would have prevented its operation.

TESTS AND RESEARCH

The engine was shipped to and examined at Continental Motors in Mobile, Alabama. Both front engine mounts were damaged and replaced with exemplar mounts. The engine was mounted on a test stand and placed in a test cell. During the initial engine test run, the engine reached an indicated manifold pressure of 35 inches of mercury at 2,700 RPM. The altitude control valve was connected and the indicated engine performance was within the supplemental type certificate holder's specifications and no anomalies were noted.

The CF memory chip from the MFD was shipped to the National Transportation Safety Board (NTSB) Recorder Laboratory. The MFD card was received in good condition and a senior recorder specialist downloaded and examined the card's data. The recorder specialist subsequently produced a report that showed the MFD card contained 138 data files, representing data from 69 electrical power cycles. The last 2 files recorded were identified as the accident flight. The data from the accident flight and the previous 11 engine cycles before the accident were plotted. According to the pilot, some preceding flights were to retrieve the airplane after the installation of the supercharger and then to return back to Centennial Airport (APA), near Denver, from COS for a 2-hour inspection. The engine was reported to have operated nominally on the flights to/from APA, as well as on the first flight on the day of the accident. Some of the recorded engine cycles occurred with the airplane on the ground and were only a few minutes in duration. Although review of the engine operation data showed fluctuations in their values, the recorded data did not reveal any anomalies that could explain the engine power loss.

The occupants of the other airplane in the formation flight collected GPS and photographic data during the accident airplane's power loss and descent. A review of the images revealed the parachute traveled aftward and below the airplane. The parachute subsequently inflated, the airplane descended downward in a nose low attitude, and impacted terrain in a nose low attitude.

The CAPS components were shipped to the NTSB Materials Laboratory. A senior materials engineer examined the components and produced Materials Laboratory Factual Report No. 17-009.

In the accident airplane, the cable for the rocket lanyard (included in the pickup collar assembly) had separated.

As designed, the rocket lanyard from the pickup collar assembly attach to the incremental bridle. The othe

NTSB Probable Cause

A hard landing on rough terrain due to a faulty deployment of the airplane’s airframe parachute system following a partial loss of engine power for reasons that could not be determined, because postaccident examination revealed no malfunctions or anomalies that would have precluded normal operation. Contributing to the accident was the low altitude deployment of the parachute system.