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

The pilot's failure to maintain terrain clearance during descent for undetermined reasons.

The pilot's loss of situational awareness while maneuvering in adverse weather conditions, resulting in spatial disorientation.

The pilot's failure to maintain control of the airplane during final approach for landing in night, visual meteorological conditions for undetermined reasons.

It was determined that the pilot failed to take into consideration weather conditions prior to the flight after his judgment and capabilities were impaired due to alcohol consumption. An hour and 15 minutes after the accident, a blood test revealed a blood alcohol level of 0,98‰. Investigations reported that according to wind and weather conditions, a distance of 1,300 meters was necessary for takeoff while the runway 08 is 780 meters long.

A loss of control as a result of an aerodynamic stall while completing a left turn due to an insufficient speed. During the last turn facing the setting sun, the pilot-in-command reduced the engine power excessively, possibly after suffering a loss of situational awareness. The short distance between the aircraft and the ground did not allow the crew to expect a stall recovery.

Findings as to Causes and Contributing Factors:
1. The gyro/horizon failed due to excessive wear on bearings and other components, resulting from a lack of maintenance and due to a vacuum system that was possibly not at minimum operating requirements for the instrument.
2. The gyro/horizon was reinstalled into the aircraft to complete the occurrence flight without the benefit of the recommended overhaul.
3. The autopilot became unusable when the attitude information from the gyro/horizon was disrupted.
4. The pilot had not practised partial panel instrument flying for a number of years, was not able to transition to a partial panel situation, and lost control of the aircraft while flying in instrument meteorological conditions.
5. The aircraft was loaded in excess of its certified gross weight and had a centre of gravity (C of G) that exceeded its aft limit. These two factors made the aircraft more difficult to handle due to an increase of the aircraft’s pitch control sensitivity and a reduction of longitudinal stability.
6. The structural limitations of the aircraft were exceeded during the uncontrolled descent; this resulted in the in-flight breakup.
7. There were a number of deficiencies with the company’s safety management system (SMS), in which the hazards should have been identified and the associated risks mitigated.
8. The company did not conduct an annual risk assessment as required by its SMS; this increased the risk that a hazard could go undetected.
9. The Canadian Business Aviation Association (CBAA) audit did not identify the risks in the company’s operations.
Findings as to Risk:
1. Lack of adequate instrument redundancy increases the risk of loss of control in single-pilot instrument flight rules (IFR) aircraft operations.
2. The pilot did not reduce his airspeed while attempting to maintain control of the aircraft; a lower speed would have allowed a greater margin to maximum operating speed (Vmo) while manoeuvring.
3. There were no quick-donning oxygen masks on board and the pilot was not wearing an oxygen mask at the time of the occurrence, as required by regulation.
4. If effective oversight of private operator certificate (POC) holders is not exercised by the regulator or its delegated organization, there is an increased risk that safety deficiencies will not be identified and properly addressed.
Other Finding:
1. The approved maintenance organization (AMO) that was maintaining the aircraft did not have the approval to maintain PA-46 turbine aircraft.

The pilot's failure to execute an instrument approach. Contributing to the accident was the pilot's impairment due to recent use of over-the-counter medication.

Findings as to Causes and Contributing Factors:
1. An unapproved part was installed in the alternator coupling. This resulted in debris from the coupling causing a partial blockage of oil flow to the number two connecting rod bearing. This low oil flow caused overheating and failure of the bearings, connecting rod cap bolts and nuts, and the subsequent engine failure.
2. The engine failure occurred after sunset and the low-lighting conditions in the valley would have made selecting a suitable landing area difficult.
3. The engine knocking was not reported to maintenance personnel which prevented an opportunity to discover the deteriorating engine condition.
Finding as to Risk:
1. All flights on the day of the accident were carried out without the oil filler cap in place. The absence of the oil filler cap could have resulted in the loss of engine oil.
Other Findings:
1. There were no current instrument flight rules charts or approach plates on board the aircraft for the intended flight.
2. The Teledyne Continental Motors Service Bulletin M84-5 addressed only the 520 series engines and did not include other gear-driven alternator equipped engines.