Crash of a Piper PA-46-350P Malibu Mirage in Parma: 3 killed

Date & Time: Apr 23, 2008 at 1710 LT
Operator:
Registration:
D-EPOE
Flight Type:
Survivors:
No
Schedule:
Parma - Parma
MSN:
46-22180
YOM:
1995
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Copilot / Total flying hours:
705
Aircraft flight hours:
1434
Circumstances:
The single engine aircraft departed Parma-Giuseppe Verdi Airport at 1635LT on a local training flight, carrying one passenger (a PA-46 rated pilot), a pilot under supervision and one instructor. The goal of the flight was to revalidate the PA-46 licence of the pilot-in-command. Following a successful emergency landing and a touch-and-go, the crew followed a new circuit and was cleared for a new approach to runway 20 in VFR conditions. On short final, while completing a left turn to join the approach path, the aircraft stalled, collided with power lines and crashed near a roundabout located about 1,100 metres short of runway 20. The aircraft was destroyed and all three occupants were killed.
Probable cause:
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.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage near Wainwright: 5 killed

Date & Time: Mar 28, 2008 at 0811 LT
Operator:
Registration:
C-FKKH
Flight Phase:
Survivors:
No
Schedule:
Edmonton – Winnipeg
MSN:
46-22092
YOM:
1989
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The privately operated Piper PA-46-350P Jetprop DLX (registration C-FKKH, serial number 4622092) had departed from Edmonton, Alberta, at about 0733 mountain daylight time en route to Winnipeg, Manitoba, on an instrument flight rules flight plan. Shortly after the aircraft levelled off at its cleared altitude of flight level (FL) 270, the aircraft was observed on radar climbing through FL 274. When contacted by the controller, the pilot reported autopilot and gyro/horizon problems and difficulty maintaining altitude. Subsequently, he transmitted that his gyro/horizon had toppled and could no longer be relied upon for controlling the aircraft. The aircraft was observed on radar to make several heading and altitude changes, before commencing a right turn and a steep descent, after which the radar target was lost. An emergency locator transmitter signal was received by the Lloydminster, Alberta, Flight Service Station for about 1 ½ minutes before it stopped. The wreckage was found by the Royal Canadian Mounted Police about 16 nautical miles northeast of Wainwright at about 1205. None of the five people on board survived.
Probable cause:
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.
Final Report:

Crash of a Piper PA-46-500TP Malibu Meridian in San Antonio: 1 killed

Date & Time: Jan 18, 2008 at 1230 LT
Registration:
N169CA
Flight Type:
Survivors:
No
Schedule:
Waco – San Antonio
MSN:
46-97300
YOM:
2007
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1049
Captain / Total hours on type:
58.00
Aircraft flight hours:
111
Circumstances:
The pilot attempted to intercept an instrument landing system localizer three times without success. The pilot told Air Traffic Approach Control that he was having trouble performing a "coupled" approach and that he was trying to "get control" of the airplane. The airplane disappeared from radar, subsequently impacting a field and then a barn. The airplane came to rest in an upright position and a post crash fire ensued. A review of radar and voice data for the flight revealed that during the three approach attempts the pilot was able to turn to headings and climb to altitudes when assigned by air traffic control. Postmortem toxicology results were consistent with the regular use of a prescription antidepressant, and the recent use of a larger-than-maximal dose of an over-the-counter antihistamine known to cause impairment. There were no preimpact anomalies observed during the airframe and engine examinations that would have prevented normal operation.
Probable cause:
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.
Final Report:

Crash of a Piper PA-46-310P Malibu near Invermere: 3 killed

Date & Time: Oct 26, 2007 at 1912 LT
Registration:
C-GTCS
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Salem – Calgary
MSN:
46-08065
YOM:
1987
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The privately operated Piper Malibu PA-46-310P was en route from Salem, Oregon, to Springbank, Alberta, on an instrument flight rules flight plan. During the descent through 17 000 feet at approximately 55 nautical miles (nm) southwest of Calgary, the pilot declared an emergency with the Edmonton Area Control Centre, indicating that the engine had failed. The pilot attempted an emergency landing at the Fairmont Hot Springs airport in British Columbia, but crashed at night at about 1912 mountain daylight time 11 nm east of Invermere, British Columbia, in wooded terrain. The pilot and two passengers were fatally injured.
Probable cause:
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.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Sitka: 4 killed

Date & Time: Aug 6, 2007 at 1255 LT
Registration:
N35CX
Flight Type:
Survivors:
No
Schedule:
Victoria - Sitka
MSN:
46-36127
YOM:
1997
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
1800
Aircraft flight hours:
2042
Circumstances:
The private, instrument-rated pilot, was on an IFR cross-country flight, and had been cleared for a GPS approach. He reported that he was 5 minutes from landing, and said he was circling to the left, to land the opposite direction from the published approach. The traffic pattern for the approach runway was right traffic. Instrument meteorological conditions prevailed, and the weather conditions included a visibility of 3 statute miles in light rain and mist; few clouds at 400 feet, 1,000 feet overcast; temperature, 55 degrees F; dew point, 55 degrees F. The minimum descent altitude, either for a lateral navigation approach, or a circling approach, was 580 feet, and required a visibility of 1 mile. The missed approach procedure was a right climbing turn. A circling approach north of the runway was not approved. Witnesses reported that the weather included low clouds and reduced visibility due to fog and drizzle. The airplane was heard, but not seen, circling several times over the city, which was north of the runway. Witnesses saw the airplane descending in a wings level, 30-45 degree nose down attitude from the base of clouds, pitch up slightly, and then collide with several trees and an unoccupied house. A postcrash fire consumed the residence, and destroyed the airplane. A review of FAA radar data indicated that as the accident airplane flew toward the airport, its altitude slowly decreased and its flight track appeared to remain to the left side (north) of the runway. The airplane's lowest altitude was 800 feet as it neared the runway, and then climbed to 1,700 feet, where radar contact was lost, north of the runway. During the postaccident examination of the airplane, no mechanical malfunction was found. Given the lack of any mechanical deficiencies with the airplane, it is likely the pilot was either confused about the proper approach procedures, or elected to disregard them, and abandoned the instrument approach prematurely in his attempt to find the runway. It is unknown why he decided to do a circle to land approach, when the tailwind component was slight, and the shorter, simpler, straight in approach was a viable option. Likewise, it is unknown why he flew towards rising terrain on the north side of the runway, contrary to the published procedures. From the witness statements, it appears the pilot was "hunting" for the airport, and intentionally dove the airplane towards what he perceived was an area close to it. In the process, he probably saw
trees and terrain, attempted to climb, but was too low to avoid the trees.
Probable cause:
The pilot's failure to maintain altitude/distance from obstacles during an IFR circling approach, and his failure to follow the instrument approach procedure. Contributing to the accident was clouds.
Final Report:

Crash of a Piper PA-46-310P Malibu in Wangerooge

Date & Time: Jun 30, 2007 at 1558 LT
Operator:
Registration:
D-EJHF
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Wangerooge - Bremen
MSN:
46-08081
YOM:
1987
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
993
Captain / Total hours on type:
76.00
Aircraft flight hours:
1396
Circumstances:
The single engine aircraft departed Wangerooge Island Airport on a private flight to Bremen, carrying four passengers and one pilot. Following a takeoff roll of about 300 metres from runway 28, the aircraft lifted off and entered a high angle of attack. It rolled to the left and crashed in a drainage ditch located about 340 metres from the departure point. All five occupants were injured and the aircraft was destroyed. Both people seating in the cockpit were seriously injured as the cockpit was destroyed by impact forces.
Probable cause:
The exact cause of the accident could not be determined with certainty due to the degree of destruction of the cockpit and because the aircraft was not fitted with CVR or DFDR systems. It was reported that the airplane took off after a course of 300 metres with flaps down to 10°. No technical anomalies were found on the aircraft and its equipments.
Final Report:

Crash of a Piper PA-46-500TP Meridian in Wellsville: 3 killed

Date & Time: Jun 28, 2007 at 0815 LT
Registration:
N477MD
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Saint Louis - Buffalo
MSN:
46-97264
YOM:
2006
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1000
Aircraft flight hours:
201
Circumstances:
On June 28, 2007, about 0815 central daylight time, a Piper PA-46-500TP, N477MD, was destroyed on impact with terrain following an in-flight breakup near Wellsville, Missouri. The personal flight was operating under Title 14, Code of Federal Regulations Part 91. Visual meteorological surface conditions prevailed in the area at the time of the accident. An instrument flight rules (IFR) flight plan was on file and was activated. The pilot and two passengers sustained fatal injuries. The flight originated from the Spirit of St Louis Airport, near Chesterfield, Missouri, about 0750, and was destined for the Buffalo Municipal Airport, near Buffalo, Minnesota. About 0711, a person representing N477MD contacted Kankakee Automated Flight Service Station (AFSS) to file an IFR flight plan and obtain an abbreviated weather update. During the abbreviated weather update, the AFSS briefer advised the pilot that there was heavy rain and thunderstorm activity in Missouri along the aircraft's planned route of flight. The pilot stated that he had onboard radar for weather avoidance. About 0750, N477MD departed SUS, contacted Federal Aviation Administration (FAA) air traffic controller (ATC) on the St. Louis (Gateway) Departure frequency about 0752, and was initially cleared to climb to 4,000 feet. The Gateway controller advised of light to moderate precipitation three miles ahead of the aircraft. The pilot requested a northerly course deviation for weather avoidance, which was approved. About 0753, N477MD was cleared to climb to 10,000 feet. The controller then advised of additional areas of moderate and heavy precipitation ahead of the airplane, gave the pilot information on the location and extent of the weather areas, and suggested a track that would avoid it. The pilot responded that he saw the same areas on his onboard radar and concurred with the controller's assessment. Radar data showed that the airplane flew northwest bound, and then turned toward the west. About 0757, N477MD was instructed to resume the Ozark 3 departure procedure, and the pilot acknowledged. About 0758, the pilot was cleared again to proceed direct to Macon, Missouri (MCM) VHF omnidirectional range distance measuring equipment (VOR/DME), and two minutes later, was instructed to contact Kansas City Center (ZKC). The pilot contacted the ZKC R53 controller at 0800:47, and, after a discussion about the final requested altitude, was cleared to climb and maintain flight level 230. At 0801:42, a position relief briefing occurred and the R53 controller was replaced. The new R53 controller made no transmissions to N477MD, and was replaced by a third controller at 0806:27. The next transmission to N477MD occurred at 0812:26, when the R53 controller asked the pilot if he had been given a clearance to deviate. The flight's radar track showed that the airplane turned to the left. The pilot responded, "mike delta we've got problems uh..." The controller responded by asking the pilot if he was declaring an emergency, and made several other attempts to contact N477MD. The pilot did not respond to any of these calls, and radar contact was lost. None of the three ZKC controllers had given the pilot any weather information during the time he was controlled by ZKC. The plane crashed in an open field near Wellsville and was destroyed upon impact. All three occupants have been killed.
Probable cause:
The pilot's failure to activate the pitot heat as per the checklist, resulting in erroneous airspeed information due to pitot tube icing, and his subsequent failure to maintain aircraft control. Contributing to the accident was the pilot's continued flight in an area of known adverse
weather.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage off Ibiza

Date & Time: Apr 30, 2007 at 1735 LT
Operator:
Registration:
EC-IQX
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Madrid - Ibiza
MSN:
46-22181
YOM:
1995
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
600
Captain / Total hours on type:
480.00
Circumstances:
The single engine aircraft departed Madrid-Cuatro Vientos Airport at 1617LT with 3 passengers and one pilot on board. Following a flight at FL230, the pilot contacted Palma ARTCC and was cleared to descend to FL130. Few minutes later, the engine torque dropped while the temperature of the turbine increased. The pilot tried several times to troubleshoot the fuel supply system and checked the fuel selector as well, but the situation did not change. While descending to 9,000 feet, the IAS was 80 knots only. At 1722LT, the pilot contacted ATC and declared an emergency before continuing the descent. As he realized he could not reach Palma Airport, the pilot attempted to ditch the aircraft in the Mediterranean Sea. The aircraft landed in the sea about 27,7 km north of the Ibiza Island and came to rest. All four occupants were quickly rescued and were uninjured while the aircraft sank and was lost.
Probable cause:
Due to the lack of evidences as the wreckage was not found, the exact cause of the accident could not be determined with certainty. However, the assumption that the loss of power/engine failure was the consequence of a technical failure of the fuel supply system was not ruled out.
Final Report:

Crash of a Piper PA-46-310P Malibu off Bird Cay: 2 killed

Date & Time: Apr 10, 2007 at 1703 LT
Registration:
N444JH
Flight Phase:
Survivors:
No
Schedule:
Fort Lauderdale – Nassau
MSN:
46-8608014
YOM:
1986
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
9818
Aircraft flight hours:
6912
Circumstances:
The pilot obtained two data user access terminal service (DUATS) preflight weather briefings for the intended flight from the U.S. to Nassau, Bahamas; the briefings included information that thunderstorms were forecasted. The pilot did not request a weather briefing with DUATS or Lockheed Martin flight service station before departure on the return accident flight. Although there was no way to tell whether he received a preflight weather briefing with Nassau Flight Service Station before departure on the accident flight, thunderstorms with associated severe turbulence were forecasted for the accident area well in advance of the aircraft's departure, and would have been available had the pilot requested/obtained a preflight weather briefing. After takeoff, and while in contact with Nassau terminal radar approach control, which had inoperative primary radar, the flight climbed to approximately 8,000 feet mean sea level and proceeded on a northwesterly heading with little deviation. The airplane, which was equipped with color weather radar and a stormscope, penetrated level 6 radar returns with numerous lightning strikes in the area, and began a steep descent. Prior to that there was no request by the pilot to air traffic control for weather avoidance assistance or weather deviation. Radar and radio communications were lost, and the wreckage and occupants were not recovered.
Probable cause:
The pilot's poor in-flight weather evaluation, which resulted in flight into a level 6 thunderstorm.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Concord: 4 killed

Date & Time: Dec 21, 2006 at 1101 LT
Registration:
N1AM
Flight Type:
Survivors:
No
Schedule:
San Diego – Concord
MSN:
46-22061
YOM:
1989
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3628
Captain / Total hours on type:
25.00
Aircraft flight hours:
2470
Circumstances:
While on an instrument approach for landing, the local tower air traffic controller observed on the BRITE radar repeater scope that the airplane passed the outer marker (OM), 600 feet below the permissible crossing altitude. The controller issued a low altitude alert to the pilot and cleared him to land. The controller also reminded the pilot that the minimum descent altitude for the Localizer Directional Aid (LDA) approach was 440 feet, and provided instructions for the missed approach. At that point the pilot reported that he had the airport in sight and acknowledged the landing instructions. The controller again cleared the pilot to land on the prescribed runway for the instrument approach, and the pilot acknowledged the landing clearance. Shortly thereafter the controller instructed the pilot to execute the missed approach as the radar track showed that the airplane was off course. The pilot was instructed to initiate a climbing left turn to the VOR. The pilot said he had the airport in sight and that he saw one of the cross runways and wanted to land. The controller told the pilot that circling to that runway was not an authorized procedure for the LDA approach and again instructed the pilot to perform the missed approach. A witness stated that he was working on a storage container, about 50 feet in height, when the airplane passed overhead. He estimated the airplane to be about 50 feet higher than the storage container. The airplane made a turn westbound and the witness looked away for a second. When he looked back the airplane was in a nose and left wing down attitude and then it impacted the ground. Another witness located on the airport's north-northeast corner also observed the airplane flying toward the airport. He reported simultaneously hearing the engine power up and observed the left wing stall prior to it impacting the ground. Both witnesses reported that they did not hear anything wrong with the engine. Examination of the airframe, power plant, and propeller revealed no mechanical anomalies that would have precluded normal operation. Internal damage signatures in the engine and propeller were consistent with the production of significant power at the time of impact. A review of the weather in the area revealed that while light rain and mist were occurring near the accident site, no meteorological phenomena existed that would have adversely affected the flight. The pilot and two passengers were killed while a third passenger, a boy aged 12, was seriously injured. He died from his injuries few hours later.
Probable cause:
Failure of the pilot to follow the prescribed instrument approach procedures and to maintain an adequate airspeed while maneuvering in the airport environment that led to a stall.
Final Report: