Background
On the morning of the accident, a Piper PA-46-350P Jetprop DLX (registration C-FKKH, serial number 4622092) departed Edmonton, Alberta, at about 0733 mountain daylight time on an instrument flight rules flight plan to Winnipeg, Manitoba. The aircraft was privately operated.
Accident Sequence
Shortly after leveling at its cleared altitude of flight level (FL) 270, radar showed the aircraft climbing through FL 274. The controller contacted the pilot, who reported autopilot and gyro/horizon problems and difficulty maintaining altitude. Subsequently, the pilot transmitted that the gyro/horizon had toppled and could no longer be relied upon. Radar observed several heading and altitude changes, then a right turn and 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 1½ minutes. The wreckage was located by the Royal Canadian Mounted Police about 16 nautical miles northeast of Wainwright at about 1205. None of the five occupants survived.
Findings
Causes and Contributing Factors
The investigation determined that the gyro/horizon failed due to excessive wear on bearings and other components, resulting from a lack of maintenance and a vacuum system possibly not meeting minimum operating requirements. The gyro/horizon was reinstalled before the occurrence flight without the recommended overhaul. When attitude information from the gyro/horizon was disrupted, the autopilot became unusable. The pilot had not practiced partial panel instrument flying for several years, could not transition to a partial panel situation, and lost control in instrument meteorological conditions. The aircraft was loaded above its certified gross weight and had an aft center-of-gravity exceeding limits, increasing pitch sensitivity and reducing longitudinal stability. During the uncontrolled descent, structural limitations were exceeded, leading to an in-flight breakup. Additionally, deficiencies existed in the company's safety management system (SMS), including failure to conduct an annual risk assessment; the Canadian Business Aviation Association audit did not identify operational risks.
Risks Identified
The investigation noted that lack of adequate instrument redundancy increases loss-of-control risk in single-pilot IFR operations. The pilot did not reduce airspeed while attempting to maintain control; a lower speed would have allowed a greater margin to maximum operating speed. No quick-donning oxygen masks were on board, and the pilot was not wearing an oxygen mask as required. Ineffective oversight of private operator certificate holders by the regulator or its delegated organization increases the risk that safety deficiencies remain unaddressed.
Other Finding
The approved maintenance organization maintaining the aircraft did not have approval to maintain PA-46 turbine aircraft.