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

The single engine aircraft departed Kumamoto Airport runway 07 at 1711LT on a private flight to Kitakyūshū, with two persons on board: a PIC in the left seat and a passenger in the right seat. At 17:12:11, the radar of the Kumamoto aerodrome station C captured the aircraft. The pilot made a position report at 6 nm north of the airport at 2,300 feet. While climbing to the altitude of 6,500 feet, the pilot was instructed to change the frequency. About three minutes after takeoff, the aircraft collided with trees and crashed in a wooded area located on the southeast slope of Mt Yago, about 14 km northeast of Kumamoto Airport. The wreckage was found in the afternoon of the following day at an altitude of 850 metres. The aircraft was destroyed and both occupants were killed, Mr. & Mrs. Hiroshi and Hiromi Kanda.

About 20 minutes after departing on a cross-country flight, the pilot acknowledged the air traffic controller’s clearance to climb to 17,000 feet mean sea level (msl). Radar data indicated that the airplane reached a maximum altitude of 16,800 feet msl. The airplane then entered a right descending turn followed by a left descending turn. While in the left turn, the pilot informed the controller, “I lost my autopilot; I’m in an unusual attitude.” The pilot stated this same information two more times in response to transmissions by the controller. The pilot’s last transmission was that he was busy trying to recover the airplane. Witnesses heard the airplane flying overhead for several minutes, but they could not see it due to the low ceiling. A postaccident examination of the airplane did not reveal any pre accident mechanical malfunctions or failures with the engine that would have precluded normal operation. Examination of the autopilot system revealed a loose screw inside the pitch servo housing. The screw was one of two that secured the high wattage resistor to the solenoid housing. Observed corrosion within the screw threads was consistent with the threads not being engaged in a nut or other internally threaded feature. No mechanical damage or arcing was visible on the screw. The operational impact of the loose screw is unknown. The pilot’s instrument flying proficiency could not be determined. According to log records, the pilot last flew 4.5 months before the accident. The airplane was in instrument meteorological conditions when the pilot stated that he was trying to recover from the unusual attitude. The pilot did not follow prescribed procedures for an autopilot malfunction. Weather data indicates that the airplane most likely encountered turbulence and icing conditions during the flight; however, the airplane was equipped with an ice protection system. Although ethanol was found during the toxicology tests, the levels varied greatly among the tissue/fluid samples. The investigation was unable to determine if the presence of ethanol was from ingestion or from postmortem production or contamination. The detected level of diphenhydramine, an over-the-counter sedating antihistamine used to treat allergies, was above therapeutic levels and likely contributed to the pilot’s inability to recover from the unusual attitude.

About 2 hours into a cross-country flight over water, the pilot heard a noticeable change in engine noise and observed erratic engine torque readings. Moments later the airplane experienced a complete loss of engine power. After declaring an emergency, the pilot attempted to diagnose the problem and restart the engine to no avail. The airplane ditched 175 miles from land, in water over 5,000 feet deep. The airplane was not recovered and the reason for the loss of engine power could not be determined.

The instrument-rated pilot was executing a night instrument approach when the airplane impacted the water. The published approach minimums for the area navigation/global positioning system approach were 460-foot ceiling and one-mile visibility. Recorded air traffic control voice and radar data indicated that prior to the approach the pilot had turned to an approximately 180-degree heading and appeared to be heading in the direction of another airport. The controller reassigned the pilot a heading in order to intercept the final approach. The airplane was located in the water approximately 5,000 feet from the runway threshold. A postaccident examination of the airplane revealed that the left main landing gear was in the retracted position and the right main and nose landing gear were in the extended position. Examination of the left main landing gear actuator revealed no mechanical anomalies. The pilot had likely just commanded the landing gear to the down position and the landing gear was in transit. It is further possible that, as the gear was in transit, the airplane impacted the water in a left-wing and nose-down attitude and the left gear was forced to a gear-up position.

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.