Cirrus SR22

Full Narrative

HISTORY OF FLIGHTOn February 15, 2019, about 1730 Pacific standard time, a Cirrus SR22 airplane, N917SR, was destroyed when it was involved in an accident near Ely, Nevada. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight.
The pilot and passenger departed on the cross-country flight from Craig-Moffat Airport (CAG), Craig, Colorado, about 1425, with a planned destination of Joslin Field-Magic Valley Regional Airport (TWF), Twin Falls, Idaho, about 336 nautical miles (nm) to the northwest. Visual and instrument meteorological conditions (VFR & IFR) prevailed over the route at this time, as a cold front was moving over the area. Air traffic control radar and communications information provided by the Federal Aviation Administration (FAA) revealed that the pilot contacted air traffic control shortly after departure and requested visual flight rules (VFR) flight-following services to TWF. He also stated that he would "have to go quite a ways south of direct because of convection." As the airplane proceeded west, then southwest, at an altitude of about 17,500 ft mean sea level (msl), the pilot reported to the air traffic controller that he planned to turn north upon reaching Salt Lake City, Utah. About 1552, or 1 hour and 22 minutes into the flight, and after discussing with the pilot his intent to deviate around the weather by continuing southwest, the controller suggested that the pilot proceed direct to Ely, Nevada (ELY) before continuing to TWF. At this time the airplane was about 154 nm east-northeast of ELY and about 217 nm south-southeast of TWF; TWF was about 192 nm north of ELY. The pilot replied, “I hadn't planned to go as far west as Ely but if that's what I have to do I can." About 1616, while still at an altitude of 17,700 ft msl, the pilot advised the controller that he was going north “to go under [the] deck in about 50 miles; 5 minutes later the pilot began his descent from 17,700 ft msl. This was followed about 7 minutes later when the pilot was observed having turned left to a southwest heading and descending through 12,300 ft msl. About 1632 while now descending through 10,400 ft msl and continuing on a southwest heading, the controller advised the pilot that he was going in and out of radar coverage; at 1634 radar contact was lost with the airplane while it was descending through 10,000 ft msl over mountainous terrain, with peaks over 11,000 ft msl. The controller subsequently advised the pilot that ELY was 75 miles southwest of his location and provided him with the current weather, which was wind 170° at 14 knots (kts) gusting to 22 kts, visibility 10 miles, broken ceiling at 5,000 ft and an overcast ceiling of 6,500 ft. About 1637, the pilot advised the controller that he was diverting to ELY with the intention of landing there. The controller stated that he would keep looking for the airplane on radar and provided the ELY altimeter setting, which the pilot acknowledged. Although radio communication between the controller and pilot was lost after this transmission, another airplane operating in the area established contact with the accident airplane and relayed to the pilot that radar service was terminated and to remain in VFR conditions. The relay aircraft reported to the controller that the accident pilot acknowledged the instructions. Subsequently, there were no further communications between the accident pilot and the controller, and radar contact was not reestablished.
A witness just east of ELY reported that about 1700, he heard an airplane flying low in the clouds over his residence. He stated that the weather was very bad at that time, that he could not see the house next door to him, and that the clouds were at tree-top level.
A second witness, who was about 2.6 miles north of the departure end of ELY runway 30, reported that he monitored the ELY UNICOM frequency and made unofficial visual estimates of the ceiling and visibility. He stated that, about 1719, he heard a series of 5 or 6 clicks on the frequency, which indicated that someone was attempting to activate the airport's pilot-controlled lighting. He stated that the snow was very heavy at the time and he estimated that the visibility was about 1/4 mile in snow. He then heard the following transmission, "Are the runway lights on? I can see the runway." About a minute later, he heard a second transmission of, "I'd like (or 'I'm trying') to land, but I cannot see the runway." He added that when he looked at a clock, it was 1721 or 1722. Neither transmission contained an aircraft identification number or any other identifying information; he did not hear any further communications.
The manager of a fixed-base operator at ELY reported that he was preparing to depart for the day between 1645 and 1700. Due to a fast-moving storm, the visibility had been reduced from 4 to 5 miles visibility to under 1/2 mile in just a few minutes. The witness stated that, about this time, he heard someone keying the microphone to turn on the runway lights. He added, "I was surprised that anyone was out there in the weather we were experiencing." The witness stated that he transmitted on the UNICOM frequency, and a pilot answered that he was trying to turn the runway lights on. The manager replied that the lights were on, but the visibility was "that bad." The pilot responded that if he could just see the runway, he could land. There were no further transmissions from the pilot. The witness added that the ELY Automated Surface Observing System (ASOS) had not been accurately reporting the visibility for at least 2 weeks before the accident; the problem had been reported by the ELY airport manager as well as by pilots.
Onboard non-volatile recorded data for the last 10 minutes of the flight (See Figure 1) revealed that the pilot entered the airport terminal area south of the airport on a westerly heading at an altitude of 9,000 ft msl. The pilot subsequently made a 90° right turn toward the north, followed by multiple right and left turns over the airport area at altitudes of between 7,100 ft msl to 7,800 ft msl; the ELY airport elevation is 6,259 ft msl. The pilot then proceeded toward the northeast.












Figure 1 – Overhead view of last 10 minutes of flight
AIRCRAFT INFORMATIONAccording to the manufacturer, the airplane was originally equipped with an Avidyne Multi-Functional Display (MFD), an Avidyne Primary Functional Display (PFD), an S-TEC 55X autopilot, and two Garmin GNS430 units. The airplane had also been retrofitted with an Avidyne DFC90 autopilot.
The airplane's MFD was capable of providing the pilot with a visual weather display, should the pilot elect to use it; however, the MFD was not located within the main wreckage or in the debris field. As such, it could not be determined whether the pilot was using the MFD as he approached ELY, nor was it able to be determined the level of proficiency the pilot possessed in the use the weather display.
The annual inspection entry stated that the pitot-static and transponder tests were due April 30, 2019.
The Cirrus Design SR22 Pilot Operating Handbook for the accident airplane make and model, Section 2, Limitations states, “Flight into known icing conditions is prohibited.
According to the airplane manufacturer, the accident airplane make and model cannot maintain flight at an airspeed of less than 50 knots.
METEOROLOGICAL INFORMATIONAt 1453, the ELY Automated Surface Observing System (ASOS), located about 3.4 nm southwest of the accident site, reported wind 160° at 19 kts, gusts at 25 kts, visibility 9 statute miles (sm), scattered clouds at 4,800 ft above ground level (agl), broken clouds at 7,000 ft agl, temperature 2° Celsius (C), dew point -3°C, and an altimeter setting of 29.68 inches of mercury. Remarks: snow began at 26 minutes after the hour and ended at 52 minutes after the hour.
At 1553, the ELY ASOS reported wind 170° at 14 kts, gusts 22 kts, visibility 10 sm, broken clouds at 5,000 ft agl, overcast clouds at 6,500 ft agl, temperature 2°C, dew point -4°C, and an altimeter setting 29.67 inches of mercury. Remarks: unknown precipitation began at 31 minutes after the hour and ended at 39 minutes after the hour.
At 1653, the ELY automated weather reporting system, reported wind 180° at 15 kts, gust 20 kts, visibility 10 sm, broken clouds at 4,200 ft agl, broken clouds at 5,500 ft agl, overcast clouds at 7,000 ft agl, temperature 2°C, dew point -4°C, and an altimeter setting of 29.67 inches of mercury.
At 1724, the ELY ASOS special observation reported wind 310° at 17 kts, gusts 28 kts, visibility 9 sm, light snow, broken clouds at 1,600 ft agl, light snow, broken clouds a 2,800 ft agl, overcast clouds at 3,800 ft agl, temperature -4°C, dew point -4°C, and an altimeter setting of 29.71 inches of mercury. Remarks: peak wind of 28 kts from 300° occurred at 1712, wind shift at 1710, snow began at 1702, pressure rising rapidly, trace amount of liquid equivalent precipitation since 1656.
At 1732, the ELY ASOS special observation reported wind 320 at 12 kts, visibility 9 sm, light snow, broken clouds at 1,200 ft agl, broken clouds at 2,800 ft agl, overcast clouds at 3,800 ft agl, temperature -4°C, dew point -4°C, and an altimeter setting of 29.73 inches of mercury.  Remarks: peak wind of 28 kts from 300° occurred at 1712, wind shift at 1710, snow began at 1702, pressure rising rapidly, 0.08 inches of liquid equivalent precipitation since 1656, temperature of -3.9°C and dew point temperature of -4.4°.
At 1744, the ELY ASOS special observation reported wind 310° at 6 kts, visibility 9 sm, light snow, overcast clouds at 600 ft agl, temperature -4°C, dew point -4°C, and an altimeter setting of 29.74 inches of mercury. Remarks: peak wind of 28 kts from 300° occurred at 1712, wind shift at 1710, snow began at 1702, pressure rising rapidly, 0.03 inches of liquid equivalent precipitation since 1656, temperature of -3.9°C and dew point temperature of -4.4°C.
At 1520, a Terminal Area Forecast (TAF) was issued for ELY that forecasted for the time of the accident, wind 180° at 12 kts with gusts to 22 kts, visibility 5 miles, light snow, scattered clouds at 1,500 ft agl, ceiling overcast at 2,500 ft agl, with temporary conditions between 1700 and 2100, visibility of one mile, light snow, and vertical visibility of 1,200 ft agl.
The National Weather Service (NWS) Surface Analysis Charts for 1600 and 1900 showed a cold front northwest of the accident location advancing southeast. At 1600 the chart depicted a section of the front immediately northwest of the accident location as a warm front, and a low pressure center was located immediately southwest of the accident location. By 1900 the front was southeast of the accident location, with the entire front depicted as a cold front. Continuous light snow was identified near the accident location at 1900. Overcast skies were depicted near the accident site at both times.
Calculations made by the Rawinsonde Observation Program (RAOB) for 1700 indicated the potential for clouds above 8,400 ft agl, with light and moderate icing between about 7,800 ft agl and 15,200 ft and, moderate low-level wind shear (LLWS) near the surface.
RAOB calculations for 1800 indicated the potential for clouds above about 7,200 ft with moderate icing from the surface to about 11,300 ft and light low-level wind shear (LLWS) near the surface.
Geostationary Operational Environmental Satellite (GOES)-17 infrared imagery depicted an area of relatively high clouds, which were oriented in a southwest-to-northwest fashion and advancing to the southeast and through the accident region around the accident time. Infrared cloud-top temperatures corresponded to cloud top heights of about 22,200 ft msl. Brightness temperatures in the area immediately ahead of these advancing clouds in the accident region at 1632 corresponded to cloud top heights of about 9,500 ft msl.
The Area Forecast issued at 1534 predicted light to moderate snowfall in the area of the accident site and stated that cloud ceilings and visibility at ELY would deteriorate to instrument flight rules (IFR) or low IFR conditions.
The Area Forecast issued at 1735 stated that a band of snow showers would be moving through the area of ELY with deteriorating conditions through the evening hours.
AIRMET advisories for IFR conditions, mountain obscuration, moderate turbulence below 18,000 ft msl and moderate icing between the freezing level and 18,000 ft msl were active for the accident site at the time of the accident.
According to Leidos Flight Service (LFS), neither they nor any third-party vendors using the LFS system had any contact with the accident pilot.
AIRPORT INFORMATIONAccording to the manufacturer, the airplane was originally equipped with an Avidyne Multi-Functional Display (MFD), an Avidyne Primary Functional Display (PFD), an S-TEC 55X autopilot, and two Garmin GNS430 units. The airplane had also been retrofitted with an Avidyne DFC90 autopilot.
The airplane's MFD was capable of providing the pilot with a visual weather display, should the pilot elect to use it; however, the MFD was not located within the main wreckage or in the debris field. As such, it could not be determined whether the pilot was using the MFD as he approached ELY, nor was it able to be determined the level of proficiency the pilot possessed in the use the weather display.
The annual inspection entry stated that the pitot-static and transponder tests were due April 30, 2019.
The Cirrus Design SR22 Pilot Operating Handbook for the accident airplane make and model, Section 2, Limitations states, “Flight into known icing conditions is prohibited.
According to the airplane manufacturer, the accident airplane make and model cannot maintain flight at an airspeed of less than 50 knots.
WRECKAGE AND IMPACT INFORMATIONThe airplane wreckage was consistent with the airplane impacting shallow, upsloping, snow-covered terrain in an upright and right wing low attitude at an elevation of 6,929 ft msl about 3.4 nm northeast of ELY. All major components of the airplane necessary for flight were accounted for at the accident site. The initial point of impact comprised a roughly 5-ft-wide by 12-ft-long by 6-inch-deep crater; a debris path extended about 473 ft from the crater on a magnetic heading about 065°.
The firewall and instrument panel had separated from the fuselage and exhibited impact damage. Two composite propeller blades were observed in the debris field; both blades exhibited impact damage. The propeller hub was not observed or recovered. The engine was separated from the firewall, with most of the accessories observed separated from the engine. Examination of the induction system, ignition system, fuel and oil systems, and borescope examination of the cylinders revealed no anomalies that would have precluded normal operation.
The carry-through wing spar was separated from the fuselage. The left side of the spar, torque box structure, and wing skins were present. The right side of the spar, the torque box structure, and wing skins were fragmented. Both fuel tanks were breached.
The ailerons and flaps had separated from their respective wing and exhibited impact damage. Flight control continuity was established from the cockpit through overload separations or cuts made to facilitate recovery.
The Cirrus Airframe Parachute System (CAPS) enclosure panel was located in the debris field. A fragment of the aircraft roof, which contained the CAPS activation handle and handle holder was observed in the debris field. The rocket motor remained in the launch tube with its frangible link intact. The parachute enclosure was separated from the bulkhead and the parachute was observed on the ground in the immediate vicinity and remained in a packed state.
No anomalies were noted with the CAPS system.
ADDITIONAL INFORMATIONEly Automated Surface Observing System (ASOS)The ELY ASOS was owned and maintained by the NWS Weather Forecast Office in Elko, Nevada (LKN). Review of NWS records revealed that a "trouble ticket" for the ASOS at ELY was opened on February 5, 2019. The priority 1 ticket advised of unreliable wind and visibility reporting.
On February 6, 2019, an entry in the maintenance shift log indicated that LKN technicians would have to visit the ASOS to determine visibility sensor accuracy.
On February 11, 2019, a maintenance shift log stated LKN technicians would be visiting Ely the following week to investigate the visibility reporting issue. A part was also ordered, which subsequently arrived at LKN on February 14.
On February 15, 2019, the day of the accident, a technician attempted to transport the part to Ely, but encountered adverse weather and returned to LKN.
On March 14, 2019, repairs to the visibility sensor were made.
An NWS Electronics System Analyst indicated that he believed the ELY ASOS visibility sensor was reporting erroneously on the day of the accident. According to the analyst, this would affect the snowfall intensity reporting. According to the NWS, erroneous observational elements can and do affect the issuance of automated Aviation Selected Special Weather Reports.
Non-Volatile Memory
Flight path data for the airplane revealed that from approximately 17:20:36 to 17:24:48, (see Figures 2 and 3) the indicated airspeed range was from 33 knots to 53 knots. According to the manufacturer, flight in an SR22 cannot be sustained at 50 knots, yet based on the data, the flight did continue. The airplane’s ground speed range during this time frame was from 55 kts to about 170 kts. After 17:24:48 the recorded airspeed returned to values that are in the range where flight can occur. Areas “C” and “D” represent the two areas where the airplane was maneuvering in the ELY terminal area at or below 50 kts indicated airspeed.


Figure 2 – Flight maneuvering (C & D) = 50 kts



Figure 3 – Flight parameters of last 10 minutes of flight
MEDICAL AND PATHOLOGICAL INFORMATIONThe Clark County Coroner, Las Vegas Nevada, performed an autopsy on the pilot. The cause of death was attributed to multiple blunt force injuries.
An NTSB Medical Officer reviewed the toxicological report for the pilot and reported the following: toxicology testing performed for the Clark County Coroner’s office and the FAA Forensic Sciences Laboratory detected the anti-depressant amitriptyline and its metabolite nortriptyline in liver tissue; nortriptyline was also detected in muscle tissue by the FAA laboratory. The FAA laboratory detected the psychoactive compound mitragynine, its psychoactive metabolite 7-hydroxymitragynine, and the sedating antihistamine cetirizine in the pilot’s liver and muscle tissue. Two over-the counter, non-impairing pain medications, acetaminophen (commonly marketed as Tylenol) and naproxen (commonly marketed as Aleve) were detected in liver and/or muscle tissue by the coroner’s laboratory and FAA laboratory, respectively. Toxicology performed for the Clark County Coroner’s office on the pilot’s liver tissue was positive for ethanol at 1.4 grams per hectogram (gm/hg); testing performed by the FAA laboratory was negative for ethanol in the pilot’s brain and muscle tissue.

Amitriptyline is a prescription medication used to treat depression, attention-deficit hyperactivity disorder, headaches, and panic, phobia, and eating disorders. It carries the warning that its use may impair mental and physical abilities required to perform hazardous tasks. Its metabolite is nortriptyline, which also has anti-depressant properties and carries the same warning.

Mitragynine and 7-hydroxymitraginine are the primary psychoactive compounds found in the leaves of the southeast Asian kratom tree. It has stimulant effects at low doses, such as increased alertness, physical energy, and talkativeness, and sedative effects at high doses. It is considered a drug of concern by the U.S. Drug Enforcement Administration (DEA) and the U.S. Food and Drug Administration (FDA) has asked the DEA to attempt to place the drug into Schedule I drugs with high potential for abuse and no medical value similar to heroin. The FDA has not approved mitragynine for any medical use.

Cetirizine is a second-generation antihistamine used to relieve hay fever and allergy symptoms. It is available over the counter, commonly marketed as Zyrtec. Although designed to be less sedating, cetirizine does have some sedating properties. FAA provides guidance on wait times before flying after using this medication.

Ethanol is a social drug commonly consumed by drinking beer, wine, or liquor. It acts as a central nervous system depressant: it impairs judgment, psychomotor functioning, and vigilance. Ethanol is water soluble, and after absorption it quickly and uniformly distributes throughout the body’s tissues and fluids. The distribution pattern parallels water content and blood supply of the tissue. Ethanol can be produced after death by microbial activity.