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

On final approach to Saltillo-Plan de Guadalupe Airport Runway 35, the single engine airplane entered a sudden left turn, impacted the ground and crashed in an open field. The wreckage was found about 200 metres short of runway threshold. The airplane was destroyed upon impact and all four occupants were killed.

The single engine airplane departed from runway 32 at Lake Norman Airpark (14A), Mooresville, North Carolina, about 1152LT and climbed to an altitude of about 3,000 feet MSL on a northwest ground track, following the Catawba River for about 30 NM. The data showed that, at 1202LT, the airplane turned left then flew a direct course back toward 14A. The airplane’s ground speed was about 200 knots for the entire flight until about 1210LT, when it decreased, and the airplane began a descent. The airplane’s last ADS-B position was recorded at 1213LT. It showed that the airplane was at an altitude of 850 feet MSL, which was about 60 feet agl. The accident site was about 488 feet southeast of the last ADS-B position, which was about 3/4 nm from the threshold of runway 14. A witness located near the accident site reported hearing no engine noise from the airplane before the impact. A security camera located at a private residence captured both video and audio of the accident airplane. The airplane was visible for 9 seconds as it traveled from right to left across the camera’s field of view, then the sound of impact occurred about 3 seconds later. When the airplane entered the camera’s field of view, it showed minor roll oscillations, its propeller was turning, then it started to bank to the right and lose altitude before it exited the field of view. A sound spectrum study performed on the captured audio calculated that the propeller rotation was about 1,100 rpm, which was consistent with the propeller windmilling. The airplane was destroyed and the pilot, sole on board, was killed.

The airplane had just departed for a cross-country flight when witnesses observed it flying nose-high but descending. The airplane’s nose pitched downward before the airplane rolled sharply left, consistent with an aerodynamic stall, and collided with trees. Examination of the airframe and engine found no preimpact anomalies. Flight data from the airplane’s onboard engine monitoring system showed that several engine parameters advanced normally for the takeoff portion but then gradually reduced during the takeoff roll and continued to decrease as the airplane began to climb away from the runway. The data stopped seconds before the accident. Estimated weight and balance calculations for the accident flight showed that the airplane was being operated about 550 pounds over its maximum gross weight and 0.5 inches outside of its aft center of gravity (cg) limit. The airplane’s throttle quadrant friction lock was found in the full aft position (disengaged) after the accident. The throttle and condition levers appeared full forward and the propeller level was near mid-travel. Pilot-rated friends who had flown with the pilot reported that he would “ease into the power and not go to full torque.” Accordingly, although the recorded gradual reduction in power was consistent with the engine controls moving during takeoff and rotation, which commanded a reduction in engine power, the reason for the airplane’s reduction in power could not be determined. Toxicology results indicated that the pilot had used the sedating medication zolpidem and may have been experiencing some associated impairing effects at the time of the accident. However, the timing and dosage of the pilot’s last zolpidem use, whether he may have been impaired by it, or whether he may have been experiencing impairing effects from an underlying sleep disturbance that was being treated with zolpidem could not be determined. The pilot’s decision to take off with the airplane loaded about 550 lbs over its maximum gross weight, and outside of its aft cg limit, combined with the gradual reduction in engine power, would have significantly degraded the airplane’s controllability. The pilot subsequently exceeded the airplane’s critical angle of attack during the initial climb, resulting in an aerodynamic stall from which he could not recover.

The pilot reported that before takeoff on the cross-country flight, the airplane contained 100 gallons of fuel, with 11 gallons in the header fuel tank, and the airplane’s automatic fuel transfer system was configured as per the checklist. No anomalies were noted during the engine start, takeoff, and initial climb. About 7 minutes into the flight and climbing through 12,000 ft mean sea level (msl), the engine sustained an abrupt loss of power that was confirmed by the loss of torque and engine compressor turbine rpm (Ng) speed. The pilot noted no cockpit warning or abnormal indications before the loss of engine power. The pilot declared an emergency and then executed a 180° turn back to the departure airport. The pilot attempted two engine restarts, and both were unsuccessful. Unable to make it back to the airport, the pilot executed an off airport forced landing. During the forced landing, the airplane sustained substantial damage to the fuselage and both wings. A postaccident examination of the airframe, fuel system components, and functional engine test revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The fuel transfer pump switch was found in the manual position. The engine’s fuel was provided by the airframe header tank. Avionics data indicated that during the short flight, the header fuel tank quantity consistently decreased, and the airplane’s automatic fuel system did not continually resupply fuel to the header tank. Based on the available data, a functional engine test, and functional testing of the airplane’s fuel system, it is likely the pilot improperly configured the airplane’s fuel transfer system, which prevented the header fuel tank from automatically refilling during the flight and resulted in fuel starvation and total loss of engine power. Although the pilot reported that he had configured the airplane’s automatic fuel transfer system per the checklist, it is likely that the fuel transfer switch was in the manual or OFF position during the flight. In addition, the pilot did not properly monitor the header tank’s fuel quantity.

While climbing the airplane to cruise altitude after takeoff, the pilot observed an increase in engine oil temperature above the normal range and requested to return to the departure airport. While receiving vectors for an instrument approach, the pilot saw smoke in the cabin and the engine lost total power. Unable to glide to any runway, the pilot selected a field for the forced landing, during which the airplane sustained substantial damage to the wings and fuselage. Postaccident examination revealed that about 2 quarts of oil remained in the engine, and the recovered oil displayed evidence of metal contamination. There was evidence of an oil leak in the engine compartment and along the lower fuselage. There was evidence of a crankcase fracture near the oil dip stick port; however, a laboratory examination determined the fracture to be consistent with overload and likely due to impact-related damage. The engine exhibited no evidence of any loose or disconnected oil lines. The oil filter was removed, and the filter material was found to be saturated with metallic particles. The oil suction screen plug, located on the oil sump, was not secured with safety wire as required per the manufacturer’s maintenance manual. There was no evidence that the plug or required safety wire was damaged by other objects. The oil suction screen plug was found to be loose, with engine oil observed below the oil suction screen plug. The crush washer behind the oil screen plug was intact and exhibited no damage. Laboratory analysis of the metallic debris recovered from the oil suction screen was consistent with connecting rod material as well as steel from fittings, fasteners, and brackets. The metallic debris found in the recovered oil, oil filter, and oil suction screen was likely due to mechanical damage associated with oil starvation. Eleven days before the accident flight, the pilot observed decreased engine manifold pressure and a partial loss of engine power. He diverted to an airport, where he had the turbocharger replaced by an aviation mechanic. In addition to replacing the turbocharger, the mechanic also drained and replaced the engine oil, which included removal and reinstallation of the oil suction screen plug. The loss of engine power was likely due to a loss of oil during the flight that led to oil starvation within the engine. The loose oil suction screen plug, the absence of safety wire on the plug, and the evidence of an oil leak beneath the plug were consistent with the mechanic’s failure to properly secure the oil suction screen plug during recent maintenance.

The pilot reported that the airplane did not gain sufficient airspeed during the takeoff roll. He stated that, to avoid overrunning the runway onto a busy road he lifted the airplane off the runway when it reached rotation speed near the end of the runway. He was able to clear the highway, but the airplane contacted trees on the far side of the highway. The airplane descended to the ground and postimpact fire ensued. Witnesses who heard and saw the airplane taking off reported the engine sounded strong, as if it was running at full power. One witness observed the airplane pitch up into a steep nose-up attitude, climb to an estimated altitude of 100 ft, then start settling, barely clearing the streetlights along the side of a road. The airplane then began a slight roll to the left and struck trees. A large fireball erupted almost immediately upon impact with the trees. The climb and impact sequence were later verified by review of airport security camera video. The pilot contacted air traffic control (ATC) and requested to take off from a runway that was 2,700 ft in length, had an uphill gradient, and obstacles off the departure end. In addition, the pilot did not use the entire runway for the takeoff; instead, he initiated the takeoff with 2,301 ft of runway available. The requested runway also resulted in him departing with a tailwind component of about 3 knots, and an 11-knot crosswind component. The primary runway in use was 8,001 ft long and would have resulted in the airplane taking off downhill, with a headwind and no obstacles off the departure end. The runway selected by the pilot was closer to his hangar than the available longer runway. Examination of the wreckage did not reveal any evidence of preimpact failure of the engine or airplane that would have precluded normal operation. As the postimpact fire consumed many of the items onboard, the investigation was unable to establish the actual weight of the items that were loaded onto the airplane. However, the weights of the recovered cargo, in addition to the weights of the occupants (the pilot, his wife, and their dog), and the fuel onboard, indicated that at a minimum the total weight was in excess of the airplane’s maximum takeoff weight by about 14 pounds and the center of gravity (CG) was outside of the forward limit of the operating envelope. Based on this information, it is most likely that the overweight condition and exceedance of the CG limitations resulted in performance degradation that prevented the pilot from gaining sufficient airspeed and altitude to clear the trees off the end of the runway. The performance degradation was compounded by the pilot’s runway selection, which resulted in a takeoff tailwind component and obstacles.

The airplane sustained substantial damage when it was involved in an accident near Thedford, Nebraska. The pilot and passenger were uninjured. The airplane was being operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that during landing, when the nose wheel made contact with the runway, the airplane began to veer right. He attempted to use left rudder and brake to keep the airplane on the runway, but as the airspeed decreased, directional control became harder to maintain and the airplane subsequently departed the right side of the runway. During the runway excursion, the airplane impacted a runway light, spun left and the landing gear collapsed. During a post accident examination, it was determined that the airplane sustained substantial damage to the left wing.

The pilot reported, and airport security video confirmed, that during a takeoff attempt, the right wing contacted the runway and the pilot pulled back excessively on the yoke. The airplane pitched up, stalled, and descended back on to the runway. It subsequently traveled off the end of the runway and impacted trees, before coming to rest on its side. The pilot added that in retrospect, he should have rejected the takeoff when the right wing contacted the runway. Examination of the wreckage by a Federal Aviation Administration inspector did not reveal any preimpact mechanical malfunctions, nor did the pilot report any. The inspector noted that both wings separated, and the fuselage was substantially damaged.

A review of air traffic control (ATC) data showed that the airplane departed with an instrument flight rules (IFR) clearance for the destination airport. The pilot requested and was cleared for an RNAV (GPS) approach into the destination airport. When the airplane was descending through 3,500 ft msl , the controller instructed the pilot to report cancelling the IFR clearance and approved a radio frequency change. There was no further communication from the pilot; the ATC facility reported that radar contact was lost when the airplane reached 2,000 ft msl, which was normal for the approach. The sole surviving passenger reported the airplane was off course during the approach, and the pilot was struggling with the airplane to get it back on course. The passenger remembered hearing a warning alarm several times and the airplane “aggressively pitching up” with more warning alarms and then “aggressively pitching down.” He observed the pilot pulling hard on the yoke and he believed he heard the copilot calling for the pilot to try and get the nose of the airplane up and straightened out. He said that he couldn’t see anything out of the windows due to the clouds and fog until right before the airplane impacted the ground. The airplane came to rest in an open pasture about 1.5 miles from the destination airport. Low IFR (LIFR) conditions were forecast for the area of the accident site and the destination airport. The National Weather Service (NWS) forecasts were consistent with the weather conditions encountered by the pilot on the approach. Data recovered from the airplane’s autopilot indicate that the pilot began the approach with the autopilot engaged. When the airplane was about 1 mile from the runway and 500 ft above the airport elevation, the pilot initiated a right climbing turn and disconnected the autopilot. This action was consistent with the initiation of the missed approach procedure. Autopilot datas indicate that the airplane’s pitch then increased as high as +20° and roll to +47° (right) during the climbing right turn. These angles suggest that the pilot likely had difficulty controlling the airplane. The pilot then engaged the autopilot’s unusual attitude recovery mode. The autopilot made inputs to return to a level flight attitude; however, autopilot data indicate that the pilot made conflicting flight control inputs. As a result, the airplane entered a brief descent, followed by a rapid climb. Indicated airspeed at the top of the climb was 16 knots, well below the airplane’s stall speed for any flap configuration. Thus, the airplane likely entered an aerodynamic stall followed by a rapid descent to impact with the terrain. The airplane impacted an open field at a shallow pitch angle, which suggests that the pilot may have attempted a stall recovery maneuver. However, altitude was insufficient for a full recovery. Postaccident examination revealed no anomalies with the airframe, engine, or autopilot. Toxicology testing showed trace levels of pheniramine, naltrexone, naltrexol, and CBD in the pilot’s system. Although postmortem toxicological testing indicates that the pilot had used these substances, his performance was not likely impaired by effects of those substances at the time of the accident. Based on the level of meclizine detected in the copilot’s heart blood, it is reasonably likely he was experiencing some effects of this medication at the time of the accident. However, whether such effects impaired his performance in a way that contributed to the accident is unknown, particularly considering his uncertain role on the flight and the presence of the other pilot. The copilot’s toxicology testing also indicated he had used cetirizine, but this medication was not detected in his blood, so it was not likely causing impairing effects at the time of the accident. The pilot’s difficulty in controlling the airplane when initiating the climbing turn in instrument conditions, along with the activation of the autopilot’s unusual attitude recovery mode, and his continued inappropriate control inputs suggest that pilot was experiencing spatial disorientation during the missed approach procedure.