Piper PA-46 (Malibu/Meridian/Mirage/Matrix/M-Class)

At the day of the accident, the pilot, accompanied by his wife, planned to fly from Karlsruhe/Baden-Baden Airport to the Cottbus-Drewitz Special Airfield under Instrument Flight Rules (IFR) with a Piper PA 46-350P. Prior to the flight he refueled 400 liters and submitted a flight plan. According to the radar recording of the responsible air traffic control center, the airplane started at 0923 hrs1 and flew the planned route at Flight Level (FL) 190 to Cottbus-Drewitz, following the flight plan. The airplane started to descend at approx. 1044 hrs. The Initial Approach Fix (IAF) Cottbus-Drewitz NDB (DRW) was overflown in an altitude of approx. 3,900 ft AMSL with a Ground Speed (GS) of approx. 170 kt, at approx. 1104 hrs, and the descent was continued for the approach NDB-RWY-25. After flying over the intermediate approach fix in approx. 2,800 ft AMSL with a GS of approx. 190 kt, the airplane flew a turn to the left in order to intercept the final approach. The radar recording ended at 1107:34 hrs. At that time the airplane was turning into the final approach in an altitude of 2,400 ft AMSL with a GS of approx. 200 kt. According to radar recordings of the German Federal Armed Forces, the airplane was captured several more times within the turn radius: at 1107:50 hrs in an altitude of 1,200 ft AMSL, at 1108:01 hrs in an altitude of 2,700 ft AMSL, and finally in 1,700 ft AMSL and 1,000 ft AMSL. The recording ended at 1108:21 hrs in an altitude of 600 ft AMSL. The airplane crashed into a field south of the Polish city of Gubin and caught fire. Both occupants lost their lives.

The pilot reported that shortly after takeoff the engine lost power momentarily, just before losing power completely. The pilot performed an emergency landing in a nearby field. The airplane sustained substantial damage during the forced landing. The airframe, engine, and engine accessories were examined. Fuel was noted at the engine, and no anomalies were revealed that would have contributed to the accident. The cause of the loss of power could not be determined.

The pilot was conducting a cross-country flight with a certified flight instructor (CFI). During the climb-to-cruise phase of the flight, as the airplane was ascending through 16,000 feet mean sea level (msl), the pilot noticed a reduction in manifold pressure. He advanced the throttle and observed an increase of one or two inches of manifold pressure. Shortly thereafter, the pilot heard a loud bang originate from the engine followed by an immediate loss of engine power. The pilot and CFI attempted to troubleshoot the engine anomalies and noted that it seemed to respond with the low boost "on", however it began to run rough whenever the throttle was advanced more than half way. They diverted to a nearby airport and conducted an emergency descent. As the airplane approached the airport, the pilot descended through an overcast cloud layer and attempted to enter the airport traffic pattern. While on final approach to the airport, the pilot thought the airplane was high and extended the landing gear and applied flaps. Shortly thereafter, the airspeed and altitude decreased drastically and the pilot realized he was too low. The pilot applied throttle and noticed no change in engine performance. The airplane subsequently struck a fence and landed hard in an open field just short of the airport, which resulted in structural damage to the fuselage and wings. A postaccident examination of the engine revealed that the induction elbow for cylinders 1-3-5 (right side) was displaced from the throttle and metering assembly where the elbow couples with the throttle and metering assembly by an induction hose and clamp. The clamp was secure to the induction hose, however, the portion of the clamp that should have been installed
beyond the retention bead on the throttle and control assembly was observed on the inboard side of the bead on the induction elbow. Review of the aircraft maintenance logbooks revealed that cylinders 4 and 5 were recently replaced prior to the accident flight due to low compression. The replacement of these cylinders required removal of the induction system to allow for cylinder removal and installation. In addition, a manufacturer service bulletin stated that during the reinstallation of the induction system, one must slide the induction hose and clamp(s) onto one of the tubes to be joined and that the connection joint and both tube beads are to be positioned in the center of the induction hose. The clamps should be installed in a position centered between the tubing bead and end of the induction hose.

The airplane was loaded more than 500 pounds (about 12 percent) over the certificated maximum gross weight. The airplane lifted off from the 3,500-foot-long runway about one-half to two-thirds down the length of the runway. The pilot retracted the airplane's landing gear and flaps before reaching the airplane manufacturer's recommended retraction speeds. The airplane was unable to gain sufficient altitude and subsequently impacted trees and a house located beyond the departure end of the runway. A postaccident examination of the wreckage and recorded non-volatile memory revealed no evidence of any preimpact mechanical abnormalities.

The instrument-rated pilot was issued a clearance to descend to 4,000 feet for radar vectors to a non precision instrument approach in instrument meteorological conditions (IMC). The last 1 minute 23 seconds of radar data indicated the airplane leveled at 4,000 feet for about 35 seconds and then varied between 3,800 feet and 3,900 feet for the remainder of the flight for which data was available. During this timeframe, the airspeed decreased from 131 knots to 57 knots. Witnesses observed the airplane descending in a spin, and one reported hearing the engine running. Recorded engine data showed an increase in engine power near stall speed, which was likely the pilot's response to the low airspeed. The airplane damage was consistent with a low-speed impact with some rotation about the airplane's vertical axis. The pilot did not make any transmissions to air traffic control indicating any abnormalities or emergency. Post accident examination of the airplane revealed no anomalies that would have precluded normal operation. During training on the accident airplane, the instructor recommended that the pilot get 25 to 50 hours of flight in visual meteorological conditions before flying in IMC in order to gain more familiarity with the radios, switches, and navigation equipment. The pilot only had 14 hours of flight time in the accident airplane before the accident flight, however it could not determined whether this played a role in the accident.

About one minute after takeoff, the pilot reported to the air traffic controller that the airplane's control wheels were locked. The controller subsequently cleared the pilot to land on any runway. No further transmissions were received from the pilot and the airplane continued straight ahead. Witnesses observed the airplane in a slow, level descent, until it impacted wires and then the ground. During a postaccident examination of the airplane, flight control continuity was confirmed to all the flight controls. Due to the impact and post-crash fire damage, a cause for the flight control anomaly, as reported by the pilot, could not be determined; however, several unsecured cannon plugs and numerous unsecured heat damaged wire bundles were found lying across the control columns forward of the firewall. Examination of the airplane logbooks revealed the most recent maintenance to the flight controls was performed about four months prior to the accident. The airplane had flown 91 hours since then.

The airplane was on an instrument flight in night instrument meteorological conditions approaching the destination airport. The pilot contacted the approach control facility by radio and was subsequently cleared for an instrument landing system (ILS) approach to the destination airport. During the approach, the air traffic approach controller advised the pilot twice that the airplane was to the right of the approach course. The controller suggested a left turn of 5 to 7 degrees to the pilot. Once the airplane was back on the inbound course, the approach controller instructed the pilot to contact a tower controller. The pilot never contacted the tower controller, but later reestablished contact with the approach controller, who provided radar vectors for a second attempt at the ILS approach. During the second approach, the controller again advised the pilot that the airplane was to the right of the approach course and provided the pilot a low altitude alert. The airplane then started a climb and a turn back toward the inbound course. The controller advised the pilot that the airplane would intercept the inbound course at the locator outer marker (LOM) for the approach and asked if the pilot would like to abort the approach and try again. The pilot declined and responded that he would continue the approach. No further transmissions were received from the pilot. The airplane impacted a building about 0.4 nautical miles from the LOM. The building and airplane were almost completely consumed by the postimpact fire. A postaccident examination revealed no evidence of mechanical malfunction or failure. The airplane's turning ground track and the challenging visibility conditions were conducive to the onset of pilot spatial disorientation.

The pilot was established on the localizer portion of the instrument landing system approach outside the final approach fix in visual meteorological conditions above clouds. He was then given vectors away from the localizer course by an air traffic controller. The vectors were close together and included a left 90-degree turn, a descent, and a 180-degree right turn back toward the localizer course. During the right turn and descent, the airplane continued turning with increasing bank and subsequently impacted the ground. According to a pilot weather report and flight path data the pilot entered clouds as he was starting the right turn toward the localizer. The combination of descending turns while entering instrument conditions were conducive to spatial disorientation. Further, the heading changes issued by the air traffic controller were rapid, of large magnitude, and, in combination with a descent clearance, likely contributed to the pilot’s disorientation. Diphenhydramine, a drug that may impair mental and/or physical abilities, was found in the pilot’s toxicological test results. While the exact effect of the drug at the time of the accident could not be determined, it may have contributed to the development of spatial disorientation.

The pilot fueled the airplane prior to departure and flew uneventfully for approximately 30 minutes. The airplane then descended to 2,000 feet on approach to the destination airport, during night visual meteorological conditions. About 30 seconds after being cleared for a visual approach, the pilot declared an emergency to air traffic control and requested assistance to the nearest airport. The controller provided a vector to divert and distance to the nearest suitable airport. The pilot subsequently reported "engine out, engine out" and the airplane impacted wooded terrain about 4 miles northeast of runway 22 at the alternate airport. A post crash fire consumed a majority of the wreckage. Examination of the wreckage, including teardown examination of the engine, did not reveal any preimpact mechanical malfunctions; however, the fuel system and ignition system were consumed by post crash fire and could not be tested.

The aircraft departed Kamsack, on an instrument flight rules flight to Saskatoon, Saskatchewan. The pilot and three passengers were on board. At takeoff from runway 34, the aircraft began rolling to the left. The aircraft initially climbed, then descended in a steep left bank and collided with terrain 200 feet to the left of the runway. A post-impact fire ignited immediately. Two passengers survived the impact with serious injuries and evacuated from the burning wreckage. The pilot and third passenger were fatally injured. The aircraft was destroyed by impact forces and the post-impact fire. The accident occurred during evening civil twilight at 2124 Central Standard Time.