History of Flight
On July 30, 2009, at 2149 eastern daylight time, a Cirrus SR-22, N581DS, was destroyed when it impacted terrain in Ravenswood, West Virginia. The certificated airline transport pilot, the sole occupant, sustained fatal injuries. Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for a personal flight under Title 14 Code of Federal Regulations Part 91. The flight originated at York Municipal Airport (JYR), York, Nebraska, about 1840, and was bound for Eagle Creek Airpark (EYE), Indianapolis, Indiana.
The airplane was owned by an individual who did not hold any pilot certificates. He hired the accident pilot for business flights between JYR and EYE. Normally, flights from JYR to EYE were conducted at 25,000 feet to take advantage of tailwinds. On the accident day, the owner and pilot completed the outbound leg at 6,000 feet, and the pilot departed alone for the return flight. The oxygen system was not serviced before departure but was scheduled for servicing at EYE the following week.
Approximately 7 miles northeast of JYR, the pilot contacted Minneapolis Air Route Traffic Control Center and requested an IFR clearance to EYE. The airplane was incrementally cleared to 25,000 feet. Data from the Recoverable Data Module (RDM) showed the pilot activated the oxygen system at 1852, at 12,160 feet. At 1857, the airplane was cleared to climb from 22,000 to 23,000 feet. The pilot acknowledged, but the controller noted the pilot's voice had changed, acquiring a "helium/Mickey Mouse" quality.
At 1905, the controller observed the pilot climbing to the wrong altitude and "stepping all over himself." After vectors for traffic, the pilot's responses became unreadable. At 1925, the pilot requested descent to 12,000 feet, but the controller found the call sign unreadable. After verification, a clearance to descend to 24,000 feet was issued; the pilot acknowledged but did not descend. The controller remarked the pilot sounded "in distress and out of breath." At 1927, instructed to descend to 12,000 feet with altimeter setting, the pilot repeated the setting but maintained 25,000 feet. After about 6 minutes without response, at 1934 the pilot said "Go ahead." An airline pilot on frequency commented the pilot sounded "incoherent." The last transmission at 1937 was labored breathing.
At 2051, the airplane crossed directly over EYE at 25,000 feet, maintaining heading. RDM data showed cruise at 25,000 feet until 2146 when engine power and fuel flow dropped to zero. The airplane pitched nose-up, decelerated, then entered a sharp descending left turn, followed by spiraling turns until data loss. The oxygen tank was at 29 percent capacity. Ohio Air National Guard interceptors observed an unresponsive pilot who appeared unconscious. They remained until the airplane departed controlled flight and descended into terrain.
Pilot Information
The pilot, age 66, held an airline transport pilot certificate with ratings for airplane single-engine and multiengine land; a flight instructor certificate; and a commercial pilot certificate with rotorcraft and seaplane ratings. He also held a Learjet type rating. He reported 18,500 hours on his most recent FAA first-class medical application (July 14, 2009). On an insurance renewal form dated July 23, 2009, he reported 18,700 total hours, with 500 hours in the accident make and model.
Aircraft Information
The airplane was manufactured in 2008 as a single-engine, unpressurized, composite low-wing airplane with a turbo-normalized 310-horsepower Teledyne Continental Motors IO-550-N engine. It had accrued 445.6 flight hours at the accident. The most recent 100-hour inspection was July 22, 2009, at 433.5 hours. Warranty records noted an oxygen leak (December 2008) repaired by tightening a service line. Another maintenance entry on January 29, 2009, addressed oxygen fill line leaks. The most recent oxygen servicing was June 10, 2009.
Meteorological Information
At 2153, weather at Mid-Ohio Valley Regional Airport (PKB), Parkersburg, West Virginia, about 30 miles northeast of the accident site, included winds from 170 degrees at 3 knots, visibility 2.5 miles in mist, scattered clouds at 1,600 and 2,600 feet, a broken ceiling at 3,800 feet, temperature 22°C, dew point 21°C, and altimeter setting 29.93.
Wreckage and Impact Information
The airplane impacted a hill about 6 miles north of Ravenswood at 39° 2.07' N, 081° 44.30' W. All major components were accounted for. The wreckage path was oriented about 115° magnetic, about 550 feet long, widening to 150 feet. The first 200 feet were on an open pasture downslope; the rest extended down a steep wooded incline to a creek bed. Foliage browning consistent with fuel exposure was noted. The airplane was significantly fragmented. Fragments of engine, propeller blades, and flight control system were found along the path. The primary flight and multi-function displays were destroyed. The Cirrus Airframe Parachute System (CAPS) deployed due to impact forces. Recovered oxygen system components included a Precise Flight oxygen cylinder (77.1 cubic foot capacity), cannulas, masks (some with microphones), and an intact cylinder with regulator. Other components were damaged or destroyed.
Medical and Pathological Information
An autopsy by the Office of the Chief Medical Examiner, West Virginia, listed the cause of death as "multiple blunt force injuries." Toxicological testing by the FAA's Bioaeronautical Sciences Research Laboratory detected no carbon monoxide, cyanide, or drugs. No ethanol was detected in the liver; 27 mg/dl ethanol was found in muscle, noted as from sources other than ingestion.
Additional Information
The airplane had a factory-installed Precise Flight fixed oxygen system with a 77-cubic foot capacity cylinder, pressure regulator, four-place manifold, cockpit control panel, and filler port. It included a breathing station kit with flowmeters, masks (two clear, two blue with microphones), four nasal cannulas, and a pulse oximeter. All Precise Flight masks had diluter bags. The cockpit control had LED indicators for oxygen capacity (0–2,000 psi) and flashing red below 400 psi. It also had "O2 REQ'D" and "FAULT" LEDs.
On February 25, 2009, the pilot ordered a Mountain High EDS-O2D2 Pulse Demand oxygen system and installed it himself in early March. This system was battery-powered, included an on/off switch, regulator inlet, two outlets, LED indicators, static ports, audio port, two cannulas, two clear masks (without diluter bags), and adapter tubing. It was installed downstream of the existing oxygen system via an in-line regulator to ensure correct flow pressure. The O2D2 provided a burst of oxygen on inhalation rather than continuous flow.
A logbook entry for a March 12, 2009 flight on the same route stated: "EPIC!! Near Payne Stewart repeat at FL250 due to O2D2." The owner reported the pilot had experienced hypoxia symptoms on prior flights and had problems with mask fit, attempting to tighten lower straps. A friend stated the pilot mentioned the incident but gave no details, only that he learned to watch for hypoxia signs. The friend encouraged purchasing a child-sized mask due to the pilot's small face.
The owner flew with the pilot at 25,000 feet many times. They used the pulse oximeter randomly. The owner used the clear Precise Flight mask; the pilot used the blue mask with microphone. Both were aware the O2D2 pressure sensor did not work with diluter bags, so they knotted or constricted the bag with rubber bands. The O2D2 manual stated to use only Mountain High masks without dilution bags. The Precise Flight supplement warned against using other breathing equipment as it was not FAA-approved. The O2D2 modification was installed without FAA-approved data.