FACTUAL REPORT AVIATION

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1 Aircraft Registration Number: N223S Occurrence Date: Occurrence Type: 0/03/2002 Accident Most Critical Injury: Investigated By: NTSB Location/Time Nearest City/Place Lewisville State Zip Code Local Time Time Zone TX CDT Airport Proximity: Off Airport/Airstrip Aircraft Information Summary Aircraft Manufacturer Cirrus Design Corp. Distance From Landing Facility: Model/Series SR-22 Direction From Airport: Type of Aircraft Airplane Sightseeing Flight: No Air Medical Transport Flight: Narrative Brief narrative statement of facts, conditions and circumstances pertinent to the accident/incident: HISTORY OF FLIGHT No On October 3, 2002, approximately 440 central daylight time, a Cirrus Design Corporation SR-22 single-engine airplane, N223S, sustained substantial damage when it impacted trees and terrain during a forced landing following an in-flight separation of the left aileron during cruise flight near Lewisville, Texas. The private pilot, who was the sole occupant of the airplane, was not injured. The airplane was registered to and operated by NS Enterprises, Inc., of Dallas, Texas. Visual meteorological conditions prevailed, and a flight plan was not filed for the 4 Code of Federal Regulations Part 9 personal flight. The flight departed the Addison Airport (ADS), Addison, Texas, approximately 430, and was destined for the Dallas Executive Airport (RBD), Dallas, Texas. In an interview with the NTSB investigator-in-charge (IIC), the pilot reported that on October 2, 2002, a Cirrus authorized service center at ADS completed service bulletin (SB) , Replacement of CAPS (Cirrus Airframe Parachute System) Activation Cable, and SB A , Trim Cartridge Self-Locking Nut Replacement, on the airplane. The pilot confirmed with the service center personnel that the maintenance on the airplane was completed and then proceeded to preflight the airplane for a flight to RBD, where the airplane was based. The service center informed the pilot that the logbook entry for completed maintenance was not included in the logbooks at that time. During the preflight and pre-takeoff checks, the pilot noted a "failed" message when testing the autopilot in "navigation" mode, no additional anomalies or discrepancies were noted. The airplane departed from runway 3, and the pilot executed a left turn to the east. After the airplane was level at 2,000 feet mean sea level (msl) for approximately one minute, the pilot noticed that the airplane began "pulling" to the left. The pilot attempted to troubleshoot the problem and concentrated on the autopilot system due to the failure noted during the pre-flight check. After several unsuccessful attempts to disengage the autopilot with the control yoke switch, the pilot attempted to pull the autopilot circuit breaker. As the pilot bent over to pull the circuit breaker, he noticed that the left aileron was separated at one hinge attach point. While attempting to maintain level flight with two hands on the control stick, the pilot declared an emergency to the ADS air traffic control tower controller. The pilot proceeded toward an unpopulated area and climbed to an altitude of 2,500 feet msl. With the nose of the airplane heading into the wind, at 20 knots indicated airspeed, the pilot shutdown the engine and deployed the CAPS. During the deployment sequence of the CAPS, the left aileron separated from the airplane. Subsequently, the airplane descended to the ground with the aid of the parachute canopy and came to rest upright in a field of mesquite trees. According to an FAA inspector who responded to the accident, the left aileron was located approximately 250 yards from the airplane. - Page

2 Occurrence Date: 0/03/2002 Narrative (Continued) PERSONNEL INFORMATION The pilot held a private pilot certificate, with airplane single-engine land and instrument airplane ratings. The private pilot was issued a third class medical certificate on December 3, 2000, with the limitation "Holder shall wear corrective lenses." According to the Pilot/Operator Aircraft Accident Report (NTSB Form 620./2), the pilot reported he had accumulated a total of 366 flight hours, of which 25 hours were accumulated in the same make and model as the accident airplane. The pilot's most recent biennial flight review (BFR) was accomplished on October 2, 200, in a Cirrus Design Corporation SR-22. A review of the pilot training records revealed the pilot completed the Cirrus Pilot Transition Training course, sponsored by the Cirrus Design Corporation, on October 9, 200, in Dallas, Texas. According to the course syllabus, the pilot underwent training for the CAPS system in the following areas: components of the CAPS system, activation of system and stages of deployment, decision making process involved in activation of system, hazards of deployment and risk benefit in various situations, and how to deploy the system. AIRCRAFT INFORMATION The 200-model Cirrus Design Corporation SR-22 airplane, serial number 05, was a low-wing, fixed tri-cycle landing gear, primarily composite, and monocoque design airplane. The airplane was powered by a six cylinder, horizontally opposed, air-cooled, fuel injected Teledyne Continental Motors (TCM) IO-550-N engine (serial number ), rated at 30 horsepower. The airplane was equipped with a three-blade Hartzell constant speed, aluminum alloy propeller. The airplane was configured to carry four occupants. The airplane was issued a standard airworthiness certificate on October 8, 200, and was certificated for normal category operations. The airplane was registered to the owner on April 8, At the time of the accident, the airplane had accumulated a total time of 45 hours. According to the FAA approved Cirrus Design SR22 Pilot's Operating Handbook (POH), the airplane uses conventional flight controls for the ailerons, elevator and rudder. The control surfaces are pilot controlled through either of the two single-handed side control yokes which are mounted beneath the instrument panel. The flight control system contains a combination of push rods, cables, and bell cranks for the control of the sufaces. The ailerons are a conventional design with skin, spar and ribs manufactured of aluminum. The ailerons are attached to the wing shear web at two hinge points. Aileron control is generated through the control yokes by rotating the yokes in pivoting bearing carriages. Push rods link the carriages to a pulley system in which cables run from a center cockpit sector, beneath the cabin floor, and then aft of the rear spar. The cables are routed in each wing to a vertical crank arm that rotates the aileron through a right angle conical drive arm. According to the FAA approved Cirrus Design maintenance manual , revision, dated November 20, 2000, the aileron is attached to the wing at an outboard and inboard fixed hinge bracket. The outboard hinge point attach hardware included: one outer aileron hinge bolt, three thick washers, one thin washer, one self-locking nut, and safety wire. According to maintenance manual procedures, the bolt and washer hardware were to be torqued to a measured inch pounds, then safety wired to a actuation fitting. After installation, the manual required a verification of proper hinge bolt installation and torque on the outboard hinge. A review of SB A revealed that during compliance, the left aileron would have been removed and reinstalled. The SB instructions for the reinstallation of the aileron are the following: "Install LH aileron. (Refer to AMM 57-50)". "AMM 57-50" is the following: Airplane Maintenance Manual, Chapter 57 (Wings), -50 (Flight Surfaces). - Page a

3 Occurrence Date: 0/03/2002 Narrative (Continued) METEOROLOGICAL INFORMATION At 353, the Denton Municipal Airport Automated Surface Observation System (located approximately 5 nautical miles northwest of the accident site) reported the wind from 0 degrees at 9 knots, gusting to 5 knots, visibility 0 statute miles, few clouds at 4,500 feet, scattered clouds at 5,500 feet, temperature 90 degrees Fahrenheit, dew point 66 degrees Fahrenheit, and an altimeter setting of inches of Mercury. WRECKAGE AND IMPACT INFORMATION The airplane impacted mesquite trees and the terrain, and came to rest upright. The accident site was located approximately 33 degrees 02 minutes North latitude, and 096 degrees 57 minutes West longitude, at an estimated elevation of 475 feet. The airplane came to rest intact with the exception of the left aileron separation. The parachute canopy, suspension lines, and fuselage harness of the CAPS remained attached to the fuselage and came to rest in the mesquite trees. According to the FAA inspector who responded to the accident site, flight control continuity was established from the cockpit controls to the flight control surfaces (with the exception of the left aileron). The airplane was recovered to the facility of Air Salvage of Dallas, near Lancaster, Texas. PATHELOGICAL INFORMATION No toxicological tests were performed on the pilot. SURVIVAL ASPECTS The Cirrus Airplane Parachute System consists of a parachute, a solid-propellent rocket, a rocket activation handle, and a harness imbedded within the fuselage structure. A composite box, which is attached to the airframe, houses the parachute and rocket assembly, and the parachute is contained in a deployment bag. The deployment bag creates an orderly deployment process by allowing the canopy to inflate after the rocket has pulled the suspension lines and harness. A three-point harness connects the airplane to the parachute. The aft harness strap is stowed in the parachute canister, and the forward harness straps are routed from the parachute canister to the firewall attach points and stowed under the fuselage skin. The parachute is a 2,400 square foot round canopy connected to the harness straps by suspension lines. The CAPS is activated by pulling the T-handle installed in the cabin ceiling above the pilot's right shoulder. A maintenance safety pin is provided to ensure that the activation handle is not pulled during maintenance. A "Remove Before Flight" streamer is attached to the pin. When CAPS is activated, the rocket is launched, the parachute assembly is pulled outward, and in approximately two seconds, the canopy begins inflation. As the canopy inflates, the airplane's forward speed will be slowed. This deceleration should be less than 3 g's. Eight seconds after activation, the aircraft will configure into an approximate level attitude. The vertical descent rate is expected to be between,600 and,800 feet per minute, and a ground impact equivalent to touchdown from a height of approximately 3 feet. The horizontal velocity and direction is based on the current wind conditions. The pilot and each passenger seat is equipped with a seatbelt and shoulder harness assembly with inertia reels. Cirrus Design Corporation recommends that the CAPS deployment occur at an altitude of 2,000 feet - Page b

4 Occurrence Date: 0/03/2002 Narrative (Continued) agl or higher, wings level attitude, fuel, mixture, throttle and magnetos in the OFF position, seatbelts tight, battery and alternator master switches in the OFF position. The POH recommends the CAPS may be appropriate in the following possible scenariors: Mid-air Collision, Structural Failure, Loss of Control, Landing Required in Terrain not Permitting a Safe Landing, and Pilot Incapacitation. The CAPS deployment is expected to result in the destruction of the airframe, and possible severe injury or death to the occupants. TEST AND RESEARCH On October 4, 2002, the airplane was examined by the NTSB IIC, FAA inspectors, representatives of Cirrus Design Corporation, and a representative of Ballastic Recovery Systems (BRS; the manufacturer of the parachute system), at the Air Salvage of Dallas facility. Examination of the left aileron and the airframe aileron hinges revealed that the outboard aileron hinge bolt was missing, and no evidence of safety wire was noted. No damage was noted on the outboard hinge assembly, and the threads on the self-locking nut were intact. The inboard aileron hinge bolt was found pulled from the airframe aileron hinge bearing. The inboard aileron hinge bolt and inboard aileron bearing race remained attached to the aileron, and the outer bearing race remained attached to the hinge structure attached to the wing. The safety wire remained attached to the bolt and the safety wire tab on the aileron. No other anomalies were noted with the airplane or the CAPS. In a written statement, a mechanic, who did not sign off the maintenance that was completed, stated, "Upon completion of work performed on N223S the replacement of the trim drum screw the work was inspected for proper completion as per the SB. No defects in the completion of the work were noted. Safeties were inspected and found to be intact upon completion of the work." The statement was received by the NTSB IIC on April 7, ADDITIONAL INFORMATION The airplane was released to the owner's representative on October 4, Page c

5 Occurrence Date: 0/03/2002 Landing Facility/Approach Information Airport Name Airport ID: Airport Elevation Runway Used Runway Length Runway Width Ft. MSL Runway Surface Type: Unknown Runway Surface Condition: Unknown Type Instrument Approach: Unknown VFR Approach/Landing: Unknown Aircraft Information Aircraft Manufacturer Cirrus Design Corp. Model/Series SR-22 Serial Number 05 Airworthiness Certificate(s): Normal Landing Gear Type: Tricycle Homebuilt Aircraft? No Number of Seats: 4 Certified Max Gross Wt LBS Number of Engines: Engine Type: Reciprocating Engine Manufacturer: Continental Model/Series: IO-550-N Rated Power: 30 HP - Aircraft Inspection Information Type of Last Inspection Date of Last Inspection Time Since Last Inspection Airframe Total Time Continuous Airworthiness 0/2002 Hours 45 Hours - Emergency Locator Transmitter (ELT) Information ELT Installed? Yes ELT Operated? No ELT Aided in Locating Accident Site? No Owner/Operator Information Registered Aircraft Owner NS Enterprises, Inc. Operator of Aircraft Same as Reg'd Aircraft Owner Street Address 400 Turtle Creek Blvd. City Dallas Street Address Same as Reg'd Aircraft Owner City State TX State Zip Code Zip Code Operator Does Business As: Operator Designator Code: - Type of U.S. Certificate(s) Held: Air Carrier Operating Certificate(s): Operating Certificate: Operator Certificate: Regulation Flight Conducted Under: Part 9: General Aviation Type of Flight Operation Conducted: Personal - Page 2

6 Occurrence Date: 0/03/2002 First Pilot Information Name City State Date of Birth Age On File On File On File On File 53 Sex: M Seat Occupied: Left Principal Profession: Unknown Certificate Number: On File Certificate(s): Private Airplane Rating(s): Single-engine Land Rotorcraft/Glider/LTA: Instrument Rating(s): Instructor Rating(s): Airplane Type Rating/Endorsement for Accident/Incident Aircraft? Current Biennial Flight Review? 0/200 Medical Cert.: Class 3 Medical Cert. Status: Valid Medical--w/ waivers/lim. Date of Last Medical Exam: 2/ Flight Time Matrix All A/C This Make and Model Airplane Single Engine Airplane Mult-Engine Night Actual Instrument Simulated Rotorcraft Glider Lighter Than Air Total Time Pilot In Command(PIC) Instructor Last 90 Days Last 30 Days Last 24 Hours Seatbelt Used? Yes Shoulder Harness Used? Yes Toxicology Performed? No Second Pilot? No Flight Plan/Itinerary Type of Flight Plan Filed: Departure Point State Airport Identifier Departure Time Time Zone Addison TX ADS 430 CDT Destination State Airport Identifier Dallas TX RBD Type of Clearance: Type of Airspace: Class E Weather Information Source of Briefing: Unknown Method of Briefing: Unknown - Page 3

7 Occurrence Date: 0/03/2002 Weather Information WOF ID Observation Time Time Zone WOF Elevation WOF Distance From Accident Site Direction From Accident Site DTO 353 CDT 642 Ft. MSL 5 NM 300 Deg. Mag. Sky/Lowest Cloud Condition: Few 4500 Ft. AGL Condition of Light: Day Lowest Ceiling: Ft. AGL Visibility: 0 SM Altimeter: "Hg Temperature: 32 C Dew Point: 9 C Wind Direction: 0 Density Altitude: Ft. Wind Speed: 9 Gusts: 5 Weather Condtions at Accident Site: Visual Conditions Visibility (RVR): Ft. Visibility (RVV) SM Intensity of Precipitation: Restrictions to Visibility: Type of Precipitation: Accident Information Aircraft Damage: Substantial Aircraft Fire: Aircraft Explosion Classification: U.S. Registered/U.S. Soil - Injury Summary Matrix First Pilot Second Pilot Student Pilot Flight Instructor Check Pilot Flight Engineer Cabin Attendants Other Crew Passengers - TOTAL ABOARD - Other Ground - GRAND TOTAL - Fatal Serious Minor TOTAL - Page 4

8 Occurrence Date: 0/03/2002 Administrative Information Investigator-In-Charge (IIC) Aaron M. Sauer Additional Persons Participating in This Accident/Incident Investigation: Michael G Hendricks Aviation Safety Inspector Federal Aviation Administration Fort Worth, TX 7677 Mike Busch Senior Investigator Cirrus Design Duluth, MN 558 Mark Thomas Air Safety Investigator BRS, Inc. South St. Paul, MN Page 5