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

The private pilot was inbound to the airport, attempting to conduct a straight-in approach to runway 33. Due to the prevailing wind, traffic flow at the time of the pilot's arrival was on runway 15. Another airplane was departing the airport in the opposite direction and crossed in close proximity to the accident airplane. The departing traffic altered his course to the right to avoid the accident airplane while the accident airplane stayed on his final approach course. The two aircraft were in radio communication on the airport common traffic advisory frequency and were exercising see-and-avoid rules as required. Witnesses reported that as the airplane continued down runway 33 for landing, they heard the power increase and observed the airplane make a left-hand turn to depart the runway in an attempted go-around. The airplane entered a left bank with a nose-high attitude, failed to gain altitude, and subsequently stalled and impacted terrain. It is likely the pilot did not maintain the necessary airspeed during the attempted go-around and exceeded the airplane's critical angle of attack. The investigation did not reveal why the pilot chose to conduct the approach with opposing traffic or why he attempted a landing with a tailwind, but this likely increased the pilot's workload during a critical phase of flight.

According to the pilot, she was flying an instrument landing system approach when she noted that the glide slope was out of service. She transitioned to a localizer-only approach and continued. Night, instrument meteorological conditions prevailed with a 400-foot ceiling. She noticed that the airplane was "high and fast" on final approach, so she used speed brakes and flaps to slow the airplane and descend to the minimum descent altitude. As the airplane descended below the ceiling, she observed runway lights and attempted to land on the runway. The airplane landed long, departed the runway at the departure end, and struck an embankment before coming to rest. An inspector from the Federal Aviation Administration examined the airplane and confirmed substantial damage to the fuselage, wings, and empennage. The pilot reported no pre-impact mechanical malfunctions or failures with the airplane that would have precluded normal operation.

The pilot was departing the private, fly-in community airport on a personal flight. He was familiar with the airport/fly-in community and was instrumental in its development. Fog was present at the time, and, according to witnesses, it was "rolling up the valley," which was a frequent event at the airport. The witnesses observed the airplane lift off the runway, drift to the left, and disappear into the fog with the landing gear extended. They heard the engine running normally, with no change in sound, until the crash. They heard two distinct "booms" about 4 to 6 seconds apart. They ran down to the departure end of the runway to look for a crash site and could not see the wreckage or any smoke or fire due to the fog. The wreckage was located on elevated terrain in a heavily wooded area, about 1,500 feet north of the departure end of the runway. The elevation at the crash site was about 250 feet higher than the elevation at the departure end of runway. A swath through the treetops leading to the main wreckage was indicative of a near-level flight path at impact. An examination of the airframe and engine did not reveal any evidence of a preexisting mechanical malfunction or failure. A review of the weather by a NTSB meteorologist revealed that the departure airport was at the edge of an area of low-topped clouds. Airport remarks included "Mountainous terrain all quadrants."

The private pilot was conducting a personal flight during day, instrument flight rules (IFR) conditions. The pilot checked in with an air route traffic control center, and, after radar data showed multiple changes in altitude that were not in accordance with the assigned altitudes, an air traffic controller queried the pilot about the altitude changes. The pilot reported an autopilot problem and then later requested clearance to deviate around weather at a higher altitude. The airplane passed through several sectors and controllers, and it was understood that the pilot was aware of the adverse weather due to the deviation information in the flight strip. The air traffic controller did not provide additional adverse weather information and updates to the pilot, as required by a Federal Aviation Administration order; however, general broadcasts of this weather information were recorded on the frequency the pilot was using before the accident. Multiple weather resources showed rapidly developing multicellular to supercell-type convective activity with cloud tops near 48,000 ft. Forecasts and advisories warned of potential strong to severe thunderstorms with the potential for moderate-to-severe turbulence, hail, lightning, heavy rains, and high wind. Radar data indicated that the pilot turned into the intense weather cells instead of away from them as he had requested. The pilot declared a "mayday" and reported that he had lost visual reference and was in a spin. Damage to the airplane and witness marks on the ground were consistent with the airplane impacting in a level attitude and a flat spin. No mechanical anomalies were noted that would have precluded normal operation before the loss of control and impact with the ground. The investigation could not determine if there was an anomaly with the autopilot or if the rapidly developing thunderstorms and associated weather created a perception of an autopilot problem. The autopsy identified coronary artery disease. Although the coronary artery disease could have led to an acute coronary syndrome with symptoms such as chest pain, shortness of breath, palpitations, or fainting, it was unlikely to have impaired the pilot's judgment following a preflight weather briefing or while decision-making en route. Thus, there is no evidence that a medical condition contributed to the accident. The toxicology testing of the pilot identified zolpidem in the pilot's blood and tetrahydrocannabinol and its metabolite in the pilot's cavity blood, which indicated that he was using two potentially impairing substances in the days to hours before the accident. It is unlikely that the pilot's use of zolpidem contributed to the accident; however, the investigation could not determine whether the pilot's use of marijuana contributed to the cause of the accident.

The pilot arrived at the fixed-base operator on the morning of the accident and requested that his airplane be brought outside and prepared for an immediate departure; this occurred 1 hour 15 minutes before his scheduled departure time. Radar data showed that the airplane departed 23 minutes later. According to air traffic control data, shortly thereafter, the ground and departure controllers contacted the tower controller and asked if the airplane had departed yet; the tower controller responded, "I have no idea. We have zero visibility." Weather conditions about the time of the accident included a 200-ft overcast ceiling with about 1/4-mile visibility. Only five radar targets identified as the accident airplane were captured, and all of the targets were located over airport property. The first three radar targets began about midpoint of the 6,500-ft-long runway, and each of these targets was at an altitude of about 60 ft above ground level (agl). The final two targets showed the airplane in a shallow right turn, consistent with the published departure procedure track, at altitudes of 161 and 261 ft agl, respectively. The final radar target was about 1/2 mile from the accident site. Witnesses reported observing the airplane impact trees in a wings-level, slightly right-wing-down attitude at high speed. Examination of the wreckage revealed no preimpact mechanical malfunctions or anomalies of the airplane. The pilot's personal assistant reported that the pilot had an important meeting that required his attendance on the day of the accident flight. His early arrival to the airport and his request to have the airplane prepared for an immediate departure were actions consistent with self-induced pressure to complete the flight. Due to the poor weather conditions, which were expected to continue or worsen, he likely felt pressure to expedite his departure to ensure he was able to make it to his destination and to attend the meeting. This pressure may have further affected his ability to discern the risk associated with departing in low-visibility and low-ceiling conditions. As noted, the weather conditions were so poor that the local air traffic controller stated that he could not tell whether the airplane had departed. Such weather conditions are highly conducive to the development of spatial disorientation. Further, the altitude profile depicted by the radar data and the airplane's near wings-level attitude and high speed at impact were consistent with the pilot experiencing a form of spatial disorientation known as "somatogravic illusion," in which the pilot errantly perceives the airplane's acceleration as increasing pitch attitude, and efforts to hold the nose down or arrest the perception of increasing pitch attitude can exacerbate the situation. Such an illusion can be especially difficult to overcome because it typically occurs at low altitudes after takeoff, which provides little time for recognition and subsequent corrective inputs, particularly in very low-visibility conditions.

On 12 June 2014, at about 1530 Eastern Standard Time (EST), a Piper PA-46 aircraft, registered VH-TSV, departed Dubbo, New South Wales for a private flight to the Sunshine Coast, Queensland with a pilot and one passenger on board. The planned route was to track via Moree and Toowoomba at 13,500 ft above mean sea level (AMSL). The pilot had operated the aircraft from Sunshine Coast to Lightning Ridge, Brewarrina and Dubbo earlier that day and reported that all engine indications were normal on those flights. About 1 hour after departing Dubbo, when about 26 NM south of Narrabri, at about 13,500 ft AMSL, the pilot observed the engine manifold pressure gauge indicating 25 inches Hg, when the throttle position selected would normally have produced about 28 inches Hg. The pilot selected the alternate air1 which did not result in any increase in power. He then elected to descend to 10,000 ft, and at that power setting when normally the engine would have produced about 29 inches Hg, the gauge still indicated only about 25 inches Hg. He turned the aircraft towards Narrabri in an attempt to fly clear of the Pilliga State Forest. The pilot assessed that the aircraft had a partial engine failure and performed troubleshooting checks. As the aircraft descended through about 8,000 ft, he observed the oil pressure gauge indicating decreasing pressure. When passing about 6,500 ft, the oil pressure gauge indicated zero and the pilot heard two loud bangs and observed the cowling lift momentarily from above the engine. The passenger observed a puff of smoke emanating from the engine and momentarily a small amount of smoke in the cockpit. The pilot established the aircraft in a glide at about 90 kt, secured the engine and completed the emergency checklist. He broadcast a ‘Mayday’ 2 call on Brisbane Centre radio frequency advising of an engine failure and forced landing. The pilot looked for a clear area below in which to conduct a forced landing and also requested the passenger to assist in identifying any cleared areas suitable to land. Both only identified heavily treed areas. The pilot extended the landing gear and selected 10º of flap and, when at about 1,000 ft, the pilot shut the fuel off, deployed the emergency beacon then switched off the electrical system. As the aircraft entered the tree tops, he flared to stall3 the aircraft. On impact, the pilot was seriously injured and lost consciousness. The passenger reported the wings impacted with trees and the aircraft slid about 10 m before coming to rest. The passenger checked for any evidence of fuel leak or fire and administered basic first aid to the pilot. The aircraft sustained substantial damage.

On 22 April 2014 at approximately 0716Z the Commercial pilot accompanied by a passenger departed Cape Town International Airport (FACT) on an IFR flight to Swartwater in the Limpopo Province. Approximately 16 minutes after take-off with the aircraft climbing through an altitude of 13500 feet to 17000 feet, the Air Traffic Controller advised the pilot that the aircraft’s Mode C transponder started transmitting erroneous altitude data and indicating that the aircraft was descending whereas the pilot thought he was ascending. The pilot notified the ATC that the aircraft was not descending and attempted to rectify the problem by recycling the Mode C transponder that however didn’t resolve the problem. As the transponder information was intermittent during the IFR flight to Swartwater, the ATC requested the pilot to descent to the VFR flight level FL 135. The pilot then requested Area West for approval to ascent to flight level (FL 195) which was approved. It appears that the pilot was unaware that the pitot static tube system that supplies both pitot and static air pressure for the airspeed indicator, altimeter and triple indicator was most probably blocked by dust or sand. The aircraft exceeded the Maximum Structural Air Speed (VNO) of the aircraft and the VNE air speed of 1 hour 44 minutes and 9 minutes respectively. The VNO of 173 airspeed and VNE of 203 airspeed exceedance resulted in the catastrophic inflight breakup of the aircraft. The wreckage was found scattered in a 1.58km path in mountainous terrain. Both occupants on board the aircraft sustained fatal injuries.

According to the pilot, he applied full power, set the flaps at 10 degrees, released the brakes, and, after reaching 80 knots, he rotated the airplane. The pilot further reported that the engine subsequently lost total power when the airplane was about 150 ft above ground level. The airplane then impacted water in a nose-down, right-wing-low attitude about 300 ft from the end of the runway. The pilot reported that he thought that the runway was 1,900 ft long; however, it was only 1,300 ft long. Review of the takeoff ground roll distance charts contained in the Pilot’s Operating Handbook (POH) revealed that, with flap settings of 0 and 20 degrees, the ground roll would have been 1,700 and 1,150 ft, respectively. Takeoff ground roll distances were not provided for use of 10 degrees of flaps; however, the POH stated that 10 degrees of flaps could be used. Although the distance was not specified, it is likely that the airplane would have required more than 1,300 ft for takeoff with 10 degrees of flaps. Examination of the engine revealed saltwater corrosion throughout it; however, this was likely due to the airplane’s submersion in water after the accident. No other mechanical malfunctions or abnormalities were noted. Examination of data extracted from the multifunction display (MFD) and primary flight display (PFD) revealed that the engine parameters were performing in the normal operating range until the end of the recordings. The data also indicated that, 7 seconds before the end of the recordings, the airplane pitched up from 0 to about 17 degrees and then rolled 17 degrees left wing down while continuing to pitch up to 20 degrees. The airplane then rolled 77 degrees right wing down and pitched down about 50 degrees. The highest airspeed recorded by the MFD and PFD was about 70 knots, which occurred about 1 second before the end of the recordings. The POH stated that, depending on the landing gear position, flap setting, and bank angle, the stall speed for the airplane would be between 65 and 71 knots. Based on the evidence, it is likely that the engine did not lose power as reported by the pilot. As the airplane approached the end of the runway and the pilot realized that it was not long enough for his planned takeoff, he attempted to lift off at an insufficient airspeed and at too high of a pitch angle, which resulted in an aerodynamic stall at a low altitude. If the pilot had known the actual runway length, he might have used a flap setting of 20 degrees, which would have provided sufficient distance for the takeoff.

The single engine airplane departed Rottweil-Zepfenhan Airfield at 0847LT bound for Augsburg Airport. En route, the pilot encountered technical problems with the engine, informed ATC about his situation and activated the electrical fuel pump when the engine restarted. On final approach to Ausgburg, he re-encountered engine problems and attempted an emergency landing when the airplane hit power cables and crashed in a garden located 1,123 meters short of runway 07 threshold. The pilot was seriously injured and the aircraft was damaged beyond repair.