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| Date: | Thursday 1 September 2022 |
| Time: | 17:07 |
| Type: |  Cirrus SR22 G6 |
| Owner/operator: | Private |
| Registration: | N420SS |
| MSN: | 8750 |
| Year of manufacture: | 2022 |
| Total airframe hrs: | 20 hours |
| Engine model: | Continental IO-550-N |
| Fatalities: | Fatalities: 1 / Occupants: 3 |
| Other fatalities: | 0 |
| Aircraft damage: | Substantial |
| Category: | Accident |
| Location: | near David Wayne Hooks Memorial Airport (DWH/KDWH), Houston, TX -
 United States of America
|
| Phase: | Approach |
| Nature: | Training |
| Departure airport: | Monroe Regional Airport, LA (MLU/KMLU) |
| Houston-David Wayne Hooks Airport, TX (DWH/KDWH) | |
| Investigating agency: | NTSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
On September 1, 2022, about 1707 central daylight time, a Cirrus Aircraft SR22 airplane, N420SS, was substantially damaged when it was involved in an accident near Tomball, Texas. The flight instructor was fatally injured; the pilot and passenger sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight.
The pilot was in the process of receiving transition flight training after he accepted delivery of his factory-new airplane earlier in the week. On the morning of the accident, the pilot told his factory flight instructor that he did not feel well, and the decision was made to fly cross-country to the pilot’s homebase instead of continuing his transition training at the delivery center.
The flight approached the intended destination when about 1 minute before the accident, about 988 ft above ground level (agl) and 2.26 nautical miles (nm) from the runway displaced threshold, there was a total loss of fuel flow and subsequent loss of engine power. About 15 seconds later, 860 ft agl and 1.8 nm from the displaced threshold, the automatic flight control system (AFCS) was turned off and remained off for the remainder of the flight. With the AFCS disengaged, the flight crew continued the descent toward the runway under manual flight control and in visual meteorological conditions.
The position of the power (throttle) lever and mixture control were not recorded parameters. However, based on recorded manifold pressure indications, the throttle was decreased once and then increased twice after the total loss of engine power. The first, partial, increase of throttle occurred about 31 seconds after the loss of engine power as the airplane descended through 602 ft agl about 1.49 nm from the runway displaced threshold. This first throttle increase was likely when the pilot attempted to increase engine power to increase the airplane’s airspeed at his flight instructor’s request. The second throttle increase, likely to the full throttle position, occurred about 42 seconds after the loss of engine power as the airplane descended through 407 ft agl about 1.23 nm from the runway displaced threshold. The airplane impacted trees and terrain about 20 seconds after the second throttle increase and came to rest in a wooded mobile home neighborhood.
The second throttle increase likely was when the flight instructor became aware of the loss of engine power and assumed control of the airplane from the pilot. However, when the flight instructor advanced the throttle to full forward, the airplane was at least 200 ft below the minimum altitude threshold (600 ft agl) for a normal Cirrus Airframe Parachute System (CAPS) deployment. CAPS training documentation and pilot operating handbook (POH) guidance recommend the immediate deployment of CAPS if no other survivable alternative exists. At no point after the total loss of engine power did the airplane have sufficient altitude to glide to the runway.
Based on recorded data, there was ample fuel in both fuel tanks at the time of the accident. A postaccident examination revealed no evidence of obstructions or debris in the fuel system. The 90° elbow inlet fitting to the electric fuel pump was found separated at the accident site. Based on a laboratory analysis, the 90° elbow inlet fitting separated during ground impact and, as such, did not contribute to the sudden loss of fuel flow to the engine. Examination of the engine and related systems did not reveal any mechanical malfunctions or failures that would have precluded its normal operation.
Although residual fuel dye was observed on the external surface of the elbow fitting adjacent to its socket-side opening and suggested the possibility of a preexisting fuel leak, the laboratory examinations determined that this likely was not due to a fuel leak, but rather fuel dye that soaked into and was retained by a residual silicone film on the socket-side of the fitting postaccident. Although the silicone film covered both the tube and socket sides of the joint, the blue fuel dye was only observed on the socket-side. The lack of fuel staining on both sides of the joint further supports that the 90° elbow inlet fitting separated during ground impact.
Review of the recorded engine data did not reveal erratic engine operation typically associated with a loss of engine power due to fuel starvation or exhaustion. Postaccident flight testing revealed that when the mixture control was moved full aft to the idle cutoff position with the electric fuel pump off, the decrease in fuel flow closely matched the recorded data from the accident flight. The flight testing also revealed that if the mixture control was moved full aft to the idle cutoff position with the fuel pump on, the engine would have continued to operate but with noticeable roughness.
In the absence of any mechanical failure or obstruction of the fuel system, and with ample fuel onboard, it is likely the mixture control was inadvertently moved to idle cutoff during the descent with the electric fuel pump off, which resulted in the sudden and total loss of fuel flow to the engine.
The investigation focused on how two appropriately certificated pilots, one of which was a factory flight instructor, did not adequately identify the total loss of engine power for the nearly one minute it took from the loss of fuel flow to impact, despite being visible on the airplane cockpit instrumentation, and detectable as a decrease in airplane performance. The investigation determined it is likely that both pilots were distracted and unaware of the loss of engine power for different reasons including inexperience in the airplane make/model, illness and physiological distress, and a lack of effective communication between the pilot and the flight instructor.
The flight instructor was a new employee who had recently completed the transition training and obtained his Cirrus Standardized Instructor Pilot (CSIP) qualification. The flight instructor had no previous experience in Cirrus airplanes before he was hired as a factory flight instructor about 4 months before the accident. The consensus from all the factory 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.
The flight instructor was likely in physiological distress during the flight, which distracted him from maintaining situational awareness as the flight approached the destination. According to the pilot and the passenger, shortly after departing on the accident flight, the flight instructor stated that he had to urinate. It was the pilot’s perception that the flight instructor was in discomfort during the latter stages of their flight for this reason. Being under any sort of physiological stress would have diminished the flight instructor’s ability to perceive the environment around him and would have diverted his attention away from the task at hand. Divided or diverted attention makes it difficult to detect and correctly interpret stimuli, which in turn affects the decision-making process. Additionally, distraction can prevent a person from either identifying or properly attending to important information.
The pilot was inexperienced in the airplane and was operating under the assumption that the flight instructor was the one who was ultimately responsible for the flight, thereby shedding some of the heightened level of awareness typically required to safely fly the airplane. The pilot was also not feeling well (he was diagnosed with COVID-19 after the accident), which was the primary reason that they were returning to his homebase and not continuing his training at the delivery center. Numerous studies have been conducted on how being sick might affect cognitive performance, and how fatigue (a common side effect of being sick) affects performance. Researchers liken both to a level of impairment similar to what one might expect from being intoxicated. Common results are loss of memory, inattention, lack of alertness, and poor judgment and decision-making.
When interviewed, the pilot was not aware that there was a loss of engine power. The pilot stated that the flight instructor did not ask him to verify control positions or troubleshoot anything in the moments before the accident, nor did they discuss any anomalies with the airplane or if they should deploy the CAPS. As such, it is likely that the flight instructor was not immediately aware of a loss of engine power. The pilot stated that he believed the engine was operating at the time of the accident, but thought it was odd that he did not hear the engine “roar” with power after the flight instructor further increased the throttle. It is likely that the aural cues associated with engine operation were already diminished due to the already low engine power setting used during the approach and because they were wearing noisecanceling headsets.
For both pilots, it is highly likely that they were susceptible to the cognitive bias of plan continuation error. Once they were within proximity of their destination, their desire to achieve their goal would have directly affected their decision making and ability to maintain positive situational awareness. In addition, they would have also been susceptible to change blindness, meaning cues that were there for the senses to detect could have gone unnoticed. As a result, neither pilot noticed the loss of engine power until the airplane’s altitude and airspeed decreased noticeably and the reaction time they required to rectify the loss of engine power or deploy CAPS decreased to a critical level.
The investigation determined that the purpose for the accident flight was not effectively communicated between the flight instructor and the pilot. The pilot believed the flight instructor was the pilot-in-command (PIC) for the cross-country flight although he admitted they never had a conversation to confirm that presumption. Further, to satisfy the airplane’s insurance coverage PIC requirements, the pilot was required to complete an instrument proficiency checkride or “flight school” in the same make/model as the accident airplane, but neither of those tasks were completed before the accident flight. The pilot stated that before they departed on the flight, he and the instructor did not communicate what roles each would have should an emergency arise. The absence of a predetermined plan likely led to confusion as to who was responsible for taking that next critical step once placed in the emergency. When interviewed, most of the factory flight instructors or supervisors stated that if the customer had not completed standardization training, the factory flight instructor would act as PIC and would have ultimate responsibility for the safety of the flight (including emergency situations requiring CAPS deployment). Based on their decision to return to the pilot’s homebase due to the pilot feeling unwell (instead of remaining at the delivery center to complete his transition training), the investigation concluded that the flight instructor was acting as PIC during the accident flight and ultimately responsible for the safety of the flight.
The impact resulted in a loss of occupiable volume when the structure above the occupants was peeled away and the structure between the front crew seats and aft passenger seats was disrupted. Both the pilot and rear seat passenger remained restrained and only suffered nonlife-threatening injuries.
During the accident sequence, the front right crew seat separated from the airplane and the flight instructor was ejected from the seat. His fatal multiple blunt force injuries were consistent with impacts with trees and/or the ground. Neither of the surviving occupants could confirm whether the flight instructor was wearing his restraint properly at the time of the accident. The airbag deployed and the four-point restraint system was found intact, undamaged, and functional but unlatched. It was noted that the lap portion of his restraint had anti-rattle plugs installed in the incorrect position on the buckle side, and that the webbing routed through the buckle’s load bar was twisted. However, there were no witness marks such as rubbing, discoloration or fraying of the webbing that would indicate that the belt was pulled through the buckle rapidly. Additionally, there were no loading indicators on the webbing stitching.
The buckle functioned normally when tested after the accident. Based on the buckle examination, is unlikely that the incorrect position of the anti-rattle plugs contributed to the right front seat occupant’s injuries or death. Additionally, the investigation was unable to determine if the flight instructor’s seat restraint buckle being unlatched occurred before or during the accident sequence.
Probable Cause: 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 a 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 flight instructor about who was responsible for the safety of the flight, all of which created a situation where neither individual was adequately monitoring the engine operation during a critical phase of flight.
Accident investigation:
 |
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Sources:
https://www.click2houston.com/news/local/2022/09/01/3-transported-to-hospital-after-small-plane-crashes-in-northwest-harris-county-officials-say/
https://snbc13.com/texas-hooks-memorial-airport-plane-crash-today-2-injured-in-houston-crash/
https://springhappenings.com/breaking-news-plane-crashes-in-mobile-home-park-along-sh-99/
https://data.ntsb.gov/Docket?ProjectID=105849
https://registry.faa.gov/AircraftInquiry/Search/NNumberResult?nNumberTxt=N420SS
https://globe.adsbexchange.com/?icao=a4fd40&lat=30.086&lon=-95.556&zoom=14.0&showTrace=2022-09-01&leg=1
https://flightaware.com/live/flight/N420SS/history/20220901/2015Z/KMLU/KDWH
Location
Images:
Photo: NTSB
Media:
DPS Troopers and @HCSOTexas are at the scene of the plane crash at 8500 Monterrey Pine Place in Tomball.
— TxDPS - Southeast Texas Region (@TxDPSSoutheast) September 1, 2022
Three passengers in the plane have been transported for treatment.
PIO will brief the media at the scene this evening. #hounews pic.twitter.com/qAifGJFUNG
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 01-Sep-2022 23:24 | Geno | Added |
| 02-Sep-2022 01:33 | RobertMB | Updated [Time, Aircraft type, Registration, Cn, Operator, Total fatalities, Total occupants, Other fatalities, Location, Phase, Nature, Departure airport, Destination airport, Source, Embed code, Damage, Narrative, ] |
| 02-Sep-2022 01:39 | RobertMB | Updated [Departure airport, Embed code, Narrative, ] |
| 02-Sep-2022 05:57 | gerard57 | Updated [Total fatalities, Narrative, ] |
| 02-Sep-2022 06:39 | harro | Updated [Aircraft type, Registration, Cn, Operator, Departure airport, Source, Narrative, ] |
| 02-Sep-2022 06:46 | harro | Updated [Departure airport, Narrative, ] |
| 02-Sep-2022 06:48 | harro | Updated [Time, Narrative, ] |
| 02-Sep-2022 06:55 | RobertMB | Updated [Time, Aircraft type, Operator, Narrative, ] |
| 02-Sep-2022 07:21 | RobertMB | Updated [Time, Narrative, ] |
| 02-Sep-2022 14:59 | johnwg | Updated [Time, Source, Narrative, Category, ] |
| 02-Sep-2022 15:05 | johnwg | Updated [Source, ] |
| 23-Sep-2022 22:28 | Captain Adam | Updated [Time, Location, Source, Damage, Narrative, ] |
| 08-Sep-2024 05:51 | ASN | Updated [Narrative, Accident report, ] |
| 24-Oct-2024 20:08 | Captain Adam | Updated [Narrative, ] |
| 24-Oct-2024 20:11 | Captain Adam | Updated [Nature, Source, Photo, ] |
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