Alberta

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.

Findings as to Causes and Contributing Factors:
1. The pilot lost situational awareness most likely believing he was over lower terrain.
2. The aircraft was very likely flown into cloud during a day VFR flight, which prevented the pilot from seeing and avoiding the terrain.
Findings as to Risk:
1. The aircraft was not required by regulation to have terrain avoidance equipment installed, leaving the pilot with no last defence for determining the aircraft's position relative to the terrain. This is a risk for all aircraft operated in similar conditions.
Other Findings:
1. The flight plan was prematurely closed by NAV CANADA, which caused the early stoppage of SAR activities and delayed the recommencement of those searches by two hours.

Double engine failure on final approach due to a fuel exhaustion.

An unstabilized approach resulted in a heavy landing because the captain changed the configuration of the aircraft, and the high rate of descent that resulted was not arrested before contact was made with the runway surface. Contributing to the high rate of descent were the reduction of engine power to flight idle, airframe ice, and the time available for the final descent. Contributing to the damage on landing was the left to right movement of the aircraft.

The aircraft was inadvertently flown into trees and the ground, in controlled flight and dark ambient conditions, during a night departure because a positive rate of climb was not maintained after take off. Factors contributing to the accident were the pilot’s concentrating on blue line speed rather than maintaining a positive rate of climb, the dark ambient conditions, a departure profile into rising terrain, an overweight aircraft, and crew resource mismanagement.