Accident Details
Probable Cause and Findings
An in-flight loss of control following an encounter with supercooled large droplet icing conditions, which ultimately resulted in an uncontrolled descent and subsequent inflight breakup. Also causal was the pilot’s failure to maintain an appropriate airspeed for flight in icing conditions.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHTOn December 20, 2018, about 0904 eastern standard time, a Piper PA-46-350P, N307JM, was destroyed when it was involved in an accident near Mayport, Florida. The private pilot and pilot-rated passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.
According to Federal Aviation Administration (FAA) air traffic control and radar information, after takeoff, the pilot established contact with Orlando Approach and remained in contact with that facility for about 17 minutes before it was transitioned to Jacksonville Air Route Traffic Control Center (ZJX ARTCC).
The pilot was incrementally cleared to climb to 19,000 ft, where he leveled the airplane for about 5 minutes before being cleared to climb to 23,000 ft msl. About 0859, the controller informed the pilot of “…moderate and some heavy precipitation extending along your route of flight for the next two zero zero miles.” One of the pilots acknowledged and advised that they would be watching the weather. Review of weather radar information indicated that, about 0859, the airplane was located in an area of light to moderate echoes of 20 to 30 decibels (dBZ). Data from the onboard portable GPS receiver revealed slight deviations of the airplane’s flightpath about this time, but the airplane continued in a northerly direction. About 0902, the controller broadcast on the frequency that AIRMETs Tango and Zulu (for turbulence and icing, respectively) were available.
About this time, while flying within an area of base reflectivity returns of 10 to 30 dBZ (light precipitation) at the airplane’s altitude and composite reflectivity of 35 to 50 dBZ (classified as heavy precipitation), the airplane began a right turn. Between 0902:03 and 0902:28, the airplane continued the right turn, descending from 23,000 ft to 22,100 ft; between 0902:28 and 0903:12, the airplane continued descending to 14,700 ft msl.
At 0903:08, while at 14,700 ft msl, the controller attempted to contact the airplane, but there was no reply. The controller continued to communicate with the flight, and at 0903:27, in response to one attempt, while about 12,200 ft msl, an occupant advised, “we’re not ok we need help.” The controller asked the pilot if he was declaring an emergency, to which the occupant immediately replied, “I’m not sure whats happening,” followed by “I have anti-ice…everything.” At 0903:40, with the airplane at an altitude of 10,400 ft msl, the controller asked if they could maintain altitude, and an occupant responded that they could not. The controller provided vectors to a nearby airport, but there was no reply from the airplane. At 0904:31, while at about 3,300 ft msl, an occupant advised the controller that the airplane was inverted and asked for assistance. Radar contact was lost shortly thereafter. Air and water searches for the airplane were performed by multiple U.S. Coast Guard aircraft and vessels, but the wreckage was not located. The search was suspended on December 22, 2018.
PERSONNEL INFORMATIONFAA records indicated that, on January 2, 2018, the pilot received notice of disapproval of application for the flight portion of his instrument rating practical test. The FAA designated examiner indicated that he failed to maintain altitude within 100 ft during level flight and failed to maintain airspeed within 10 knots during a precision approach. On June 20, 2018, the pilot completed the practical test, which comprised 1.8 hours flight in a Piper PA-32-301 airplane. At that time, he reported 289 total hours of flight experience, of which 70 were instrument.
The pilot obtained ground and flight training in the accident airplane between December 10, 2018, and December 14, 2018, to meet an insurance requirement of 25 hours of dual flight instruction. The training was performed by a flight instructor who was an FAA designated pilot examiner (DPE). During that training, the pilot received endorsements for a flight review and instrument proficiency. A review of the training records revealed that the pilot received training in operating within icing conditions and the use of the airplane’s ice protection system.
According to notes from the flight instructor/DPE, the accident pilot needed to review the missed approach procedure and work on his instrument flight rules phraseology, but was “good” with autopilot use. The instructor stated that, as part of his ground training, he discussed cumuliform and cumulonimbus cloud types, the amount of precipitation that would occur in each, and the icing hazards associated with each. He also discussed and trained what airspeed (130 to 140 knots) to maintain during climb and cruise when operating in icing conditions to avoid ice accumulating on the bottom of wing.
According to the report submitted by the pilot’s attorney, at the time of the accident, the pilot had a total flight experience of 390 hours, of which 290 were as pilot-in-command, and his total time in the accident airplane make and model was 30 hours.
AIRCRAFT INFORMATIONThe airplane was equipped with an enhanced digital display indicator, annunciator panel, a portable Garmin 496 GPS map receiver, vertical profile weather radar system, and stormscope.
The ice protection system was designed and tested to allow for continuous maximum and intermittent maximum icing specified in 14 CFR Part 25, Appendix C. The system comprised pneumatic wing and empennage boots, a wing ice detection light, electrothermal propeller deice pads installed on each propeller blade, an electrically heated windshield, heated lift detector, heated pitot head, two operating alternators, two vacuum pumps and the alternate static source. The surface deice system was manually engaged by a switch on the environmental/deice switch panel, which provided power to the solid-state timer.
According to the manufacturer of the solid-state timer, it was not possible to determine positional information such as where it was in a cycle, nor did it contain any non-volatile memory.
Although the enhanced digital display indicator was retained, no attempt was made to download any nonvolatile memory. The environmental/deice switch panel was examined by NTSB Materials Laboratory personnel, but the internal mechanisms of the switch panel were too damaged to determine switch position at impact.
METEOROLOGICAL INFORMATIONThe pilot received a preflight weather briefing at 0717, which included a convective SIGMET “outlook” valid for the accident site area, which implied the possibility for severe or greater turbulence, severe icing, and low-level wind shear if a convective SIGMET was subsequently issued. He did not request the current icing potential (CIP) or forecast icing potential (FIP). The CIP issued about 9 minutes before the pilot requested weather information and again at 0808 revealed that, in the airplane’s last location at 22,000 to 23,000 ft, the icing probability, icing severity, and potential for supercooled large droplets (SLD) were 0% to 10%, light, and unknown, respectively.
The briefing information provided to the pilot also included icing AIRMET Zulu update 1, which specified moderate ice between the freezing level (between 11,000 ft msl and 14,000 ft msl) and 27,000 ft, which was valid for the route of flight. The airplane was operating within clouds/precipitation above 14,000 ft msl from about 0842 until the departure from controlled flight about 0902.
Center weather advisory (CWA) 201 issued at 0822 and valid until 0922 for the area of the accident site warned of a developing area of thunderstorms moving from 200° at 40 knots. Thunderstorm tops were to 30,000 ft with heavy rainfall and an increasing trend.
The FIP issued at 0900, indicated higher FIP icing values associated with the abundant cumuliform precipitation along the route of flight and between a 10% to 40% probability of light to moderate icing at 19,000 to 23,000 ft above the airplane’s last radar return. The FIP did not indicate any probability of SLD over the area around the accident time.
At the accident airplane’s altitude before descent, the temperature was about -16ºC. The Geostationary Operational Environmental Satellite (GOES) visible imagery indicated an extensive layer of cumuliform cloud cover in the area of the airplane’s last radar return, with the cloud cover moving from southwest to northeast. Based on the brightness temperatures above the accident site and the vertical temperature profile about the time of the loss of control, the approximate cloud-top heights were 33,000 ft.
AIRPORT INFORMATIONThe airplane was equipped with an enhanced digital display indicator, annunciator panel, a portable Garmin 496 GPS map receiver, vertical profile weather radar system, and stormscope.
The ice protection system was designed and tested to allow for continuous maximum and intermittent maximum icing specified in 14 CFR Part 25, Appendix C. The system comprised pneumatic wing and empennage boots, a wing ice detection light, electrothermal propeller deice pads installed on each propeller blade, an electrically heated windshield, heated lift detector, heated pitot head, two operating alternators, two vacuum pumps and the alternate static source. The surface deice system was manually engaged by a switch on the environmental/deice switch panel, which provided power to the solid-state timer.
According to the manufacturer of the solid-state timer, it was not possible to determine positional information such as where it was in a cycle, nor did it contain any non-volatile memory.
Although the enhanced digital display indicator was retained, no attempt was made to download any nonvolatile memory. The environmental/deice switch panel was examined by NTSB Materials Laboratory personnel, but the internal mechanisms of the switch panel were too damaged to determine switch position at impact.
WRECKAGE AND IMPACT INFORMATIONA second search located the wreckage on Febru...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA19LA072