2 fatalities

2019-02-28: Piper PA-46 (Malibu/Meridian/Mirage/Matrix/M-Class) (N428CD) — Lennard Properties — Shreveport-Downtown, United States of America

Shreveport-Downtown, United States of AmericaTakeoff (climb)

On February 28, 2019, a Piper PA-46 (Malibu/Meridian/Mirage/Matrix/M-Class) (registration N428CD) operated by Lennard Properties was involved in an aviation accident near Shreveport-Downtown, United States of America during takeoff. 2 people were killed. Investigators recorded the probable cause as: The pilot's conduct of a departure into instrument meteorological conditions (IMC), which resulted in spatial disorientation and subsequent loss of airplane control. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A); 8 related events involving the same aircraft type or operator are linked below.

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781191092Data APIEditorial standards

A private pilot departed overweight into low clouds with an unresolved autopilot issue, then lost control after likely experiencing spatial disorientation. The instrument-rated pilot and passenger were on board.

Departure into IMC

The instrument-rated private pilot and a passenger departed into instrument meteorological conditions with a 600-ft cloud ceiling. The airplane was about 550 lbs over its maximum gross weight. Air traffic control data showed the airplane making a climbing left turn that continued beyond the assigned heading.

Erratic Flight Path

After reaching 1,400 ft mean sea level, the airplane continued turning left while its altitude and speed began to vary. It then entered a left spiral, completing more than two full circles. Subsequently, the airplane decelerated in a right turn and rapidly descended until impact with terrain.

Aircraft and Autopilot Examination

Examination of the flight control system revealed no evidence of mechanical malfunctions. Downloaded engine data indicated normal engine operation. Data from the autopilot system showed three in-flight error codes. The first error code, which likely occurred about 1 minute after takeoff, would have resulted in the autopilot disengaging if it was engaged at that time. The subsequent error codes likely occurred during the erratic flight profile, with the autopilot disengaged.

Pilot Background and Toxicology

Before the accident flight, the pilot had informed a mechanic (who is also a pilot) of intermittent issues with the autopilot system and that these issues were unresolved. The mechanic had flown with the accident pilot previously and assessed his instrument flying skills as weak. The flight instructor who provided initial flight training for the turbine engine transition stated the pilot's instrument flying proficiency was poor when hand-flying the airplane.

Toxicology testing revealed that the pilot had used marijuana. His girlfriend stated the pilot would take a marijuana gummy before bedtime to sleep more soundly. However, given that no psychoactive compounds were found in blood specimens, it is unlikely that the pilot was impaired at the time of the accident.

Conclusion from Investigation

The instrument conditions at the time of the accident, the airplane's erratic flightpath, and the pilot's reported lack of instrument proficiency when flying by hand support the likelihood that the pilot experienced spatial disorientation sometime after takeoff. In addition, given the reports of the intermittently malfunctioning autopilot that had not been fixed, it is likely the pilot experienced an increased workload during a critical phase of flight that, in combination with spatial disorientation, led to the pilot's loss of airplane control.

Probable cause

The pilot's conduct of a departure into instrument meteorological conditions (IMC), which resulted in spatial disorientation and subsequent loss of airplane control. Contributing to the accident was the pilot's poor instrument flying skills and his decision to depart into IMC with an unresolved autopilot maintenance issue.