NTSB CAROL · Event
Event ERA13LA012
Aircraft involved
Probable cause & findings
The pilot's failure to maintain airplane control during a missed approach in instrument meteorological conditions. Contributing to the accident was the pilot's overreliance on the autopilot system and his inability to hand-fly the airplane once the autopilot was disconnected.
Factual narrative
On October 6, 2012, at 1217 central daylight time, a Cirrus SR22, N80KW, operated by a private individual, was substantially damaged during impact with terrain, after deployment of the Cirrus Airplane Parachute System (CAPS), following a loss of control during a missed approach at Birmingham International Airport (BHM), Birmingham, Alabama. The private pilot incurred minor injuries and the passenger was seriously injured. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Instrument meteorological conditions prevailed and an instrument flight rules flight plan was filed for the flight that departed Charles B Wheeler Downtown Airport (MKC), Kansas City, Missouri; destined for BHM. The pilot stated that while on the instrument landing system approach to runway 6 at BHM, he reported missed approach at 2,000 feet mean sea level (msl) to the BHM air traffic control tower. The tower controller instructed the pilot to fly the runway heading; however, the pilot reported to the controller that he was unable due to weather. The tower controller then instructed the pilot to fly a heading of 180 degrees and climb to 4,000 feet. The pilot acknowledged the instruction and during the turn, lost control of the airplane. He then observed the altimeter indicating a descent through 1,700 feet and elected to deploy the CAPS. The airplane subsequently descended via parachute and came to rest in a commercial parking lot, about 2 miles south of BHM. Review of Federal Aviation Administration (FAA) recorded radio communications between N80KW and BHM tower revealed that after the pilot declared a missed approach, the tower controller instructed the pilot to fly runway heading and climb to 4,000 feet. The pilot replied "Okay, I'm way off of runway heading…" and did not make any mention of not being able to turn due to weather. The controller then instructed the pilot twice to climb to 4,000 feet and make a left turn to 360 degrees as the airplane was approaching an antenna to the south. After a third query, the pilot replied that he was "going, trying to get around." About 20 seconds later, the pilot reported that he was "going down." Examination of the airplane by an FAA inspector revealed substantial damage to the fuselage and a puncture of the left wing near the left main landing gear. The airplane was equipped with an Avidyne primary flight display (PFD), which was forwarded to the NTSB Vehicle Recorder Laboratory, Washington, DC. The unit contained non-volatile memory, which was successfully downloaded. Review of the data revealed that the autopilot was engaged shortly after takeoff and remained on until 1215. At 1213, the autopilot approach mode was armed as the airplane was descending to 2,600 feet msl and had intercepted the localizer course. The autopilot was selected to vertical speed (VS) mode with the altitude armed, rather than the altitude mode. At 1214, the VS mode was automatically cancelled (and the autopilot automatically switched to altitude mode) as the airplane reached 2,600 feet; however, at that time the airplane was above the glideslope (GS) by 53 percent needle deflection. The airplane remained above the GS until the autopilot was disconnected at 1215 and the CAPS was deployed about 1217. According a representative from the PFD manufacturer, the autopilot would automatically arm the GS mode, provided seven criteria were met. Two of the seven criteria were altitude mode engaged and airplane no more than 10 percent needle deflection below GS (airplane above GS). Review of the data did not reveal any preimpact mechanical malfunctions with the airplane, nor did the pilot report any. The pilot reported a total flight experience of 1,944.7 hours; of which, 1,450 hours were in the same make and model as the accident airplane. He reported 17 and 75 total hours of actual and simulated instrument experience, respectively. The recorded weather at BHM, at 1153, included an overcast ceiling at 700 feet above ground level (1,350 msl). The airplane was in instrument meteorological conditions, and the pilot intended to fly an instrument landing system approach. Review of non-volatile memory data revealed that the autopilot approach mode was armed as the airplane intercepted the localizer course and was descending toward 2,600 feet mean sea level (msl). At that time, the autopilot was selected to vertical speed (VS) mode with the altitude armed rather than selected to the altitude mode, which is one of the criteria for automatically arming the glideslope (GS) mode later in the approach. About 1 minute later, the autopilot automatically cancelled the VS mode and switched to altitude mode as the airplane reached 2,600 feet msl. However, at that time the airplane was above the glideslope by 53 percent needle deflection. The autopilot will not automatically arm the GS mode unless, in addition to the altitude mode being selected, the airplane is more than 10 percent needle deflection below the glideslope. As a result, the airplane remained above the glideslope until the autopilot was disconnected about 1 minute later. The pilot then attempted to hand-fly a missed approach; however, he was unable to maintain the heading or altitude assigned by air traffic control. He subsequently lost control of the airplane during a turn and elected to deploy the airplane's parachute system. The airplane came to rest in a vacant lot. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- C Personnel issues-Action/decision-Action-Lack of action-Pilot - C
- C Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Altitude-Not attained/maintained - C
- C Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Directional control-Not attained/maintained - C
- F Personnel issues-Task performance-Use of equip/info-Use of automation-Pilot - F
- F Aircraft-Aircraft systems-Auto flight system-Autopilot system-Incorrect use/operation - F
Verbatim from NTSB's published report. Source file
NTSB_2012_ERA13LA012.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (loss of control, autopilot). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
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- arXiv 2025 · arXiv preprint
ROSplane 2.0: A Fixed-Wing Autopilot for Research
Unmanned aerial vehicle (UAV) research requires the integration of cutting-edge technology into existing autopilot frameworks.
- SKYbrary (Eurocontrol) 2024 · SKYbrary article
Loss of Control In-Flight (LOC-I) — SKYbrary Knowledge Base
SKYbrary comprehensive knowledge-base entry on Loss of Control In-Flight — definitions, contributing factors, accident case studies (Air France 447, Colgan 3407), and prevention strategies.
- arXiv 2024 · arXiv preprint
A Data-Driven Autopilot for Fixed-Wing Aircraft Based on Model Predictive Control
Autopilots for fixed-wing aircraft are typically designed based on linearized aerodynamic models consisting of stability and control derivatives obtained from wind-tunnel testing.
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