Aircraft Accident Report AAR 1/2020 - Piper PA-46-310P Malibu, N264DB, 21 January 2019
Aircraft lost 22 nm north-north-west of Guernsey, 21 January 2019.
Summary
The Air Accidents Investigation Branch (AAIB) became aware on 21 January 2019 at 2122 hrs that the aircraft had gone missing at approximately 2016 hrs. The search for survivors, coordinated by the authorities in Guernsey, was called off at 1515 hrs on 24 January 2019.
The aircraft was lost in international waters and, in such circumstances, Annex 13 to the Convention on International Civil Aviation places a responsibility on the State of Registration of the aircraft, in this case the USA as represented by the National Transportation Safety Board (NTSB), to commence an investigation. However, the State of Registration may, by mutual agreement, delegate the investigation to another State. On 22 January 2019, in anticipation that an accident investigation would be required, the NTSB delegated responsibility for the investigation to the State of the Operator, in this case the UK as represented by the AAIB.
In exercise of his powers, the Chief Inspector of Air Accidents ordered an investigation to be carried out in accordance with the provisions of Regulation (EU) 996/2010 and the UK Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 2018. The sole objective of the investigation of an accident or incident under these Regulations is the prevention of accidents and incidents. It shall not be the purpose of such an investigation to apportion blame or liability.
In accordance with established international arrangements, both the NTSB, representing the State of Design and Manufacture of the aircraft, and the Bureau d’Enquêtes et d’Analyses pour la Sécurité de l’Aviation Civile (BEA) in France, which had been supporting search activities, appointed Accredited Representatives to the investigation. The Junta de Investigación de Accidentes de Aviación Civil (JIAAC) in Argentina, representing the State of Nationality of the passenger, appointed an Expert. The European Union Aviation Safety Agency (EASA) and UK Civil Aviation Authority (CAA) assisted the investigation, and the NTSB was assisted by Advisors from the aircraft and engine manufacturers.
Prior to this Final Report, the AAIB published Special Bulletins on 25 February 2019 and 14 August 2019.
The investigation established that the aircraft departed from Nantes Airport, France, at 1906 hrs on 21 January 2019 carrying a passenger on a commercial basis to Cardiff Airport in the UK. At 2016 hrs, probably while manoeuvring to avoid poor weather, the aircraft was lost from radar and struck the sea 22 nm north-north-west of Guernsey. Neither the pilot nor aircraft had the required licences or permissions to operate commercially.
The investigation identified the following causal factors:
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The pilot lost control of the aircraft during a manually-flown turn, which was probably initiated to remain in or regain Visual Meteorological Conditions (VMC).
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The aircraft subsequently suffered an in-flight break-up while manoeuvring at an airspeed significantly in excess of its design manoeuvring speed.
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The pilot was probably affected by carbon monoxide (CO) poisoning.
The investigation identified the following contributory factors:
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A loss of control was made more likely because the flight was not conducted in accordance with safety standards applicable to commercial operations. This manifested itself in the flight being operated under Visual Flight Rules (VFR) at night in poor weather conditions despite the pilot having no training in night flying and a lack of recent practice in instrument flying.
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In-service inspections of exhaust systems do not eliminate the risk of CO poisoning.
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There was no CO detector with an active warning in the aircraft which might have alerted the pilot to the presence of CO in time for him to take mitigating action.
Safety action was taken to: raise awareness of the risk associated with unlicensed charter flights; and improve the guidance given to personnel undertaking inspections of exhaust systems.
Five Safety Recommendations have been made in this report concerning: flight crew licensing records; the carriage of CO detectors; and additional in-service inspections of exhaust systems.
Corrections
Prior to publication a correction was issued concerning this report and can be downloaded below.
In April 2021, a correction was issued concerning this report and can be downloaded below:
In February 2022, a correction was issued concerning this report and can be downloaded below.
Download Report
The above corrections have been incorporated into the final report below:
Download Bulletin Summary
Special Bulletins
Special Bulletin S1/2019
This Special Bulletin was published on 25 February 2019. It contains preliminary factual information on the investigation and general information about how aircraft registered in the USA may be operated between the UK and France.
Read Special Bulletin S1/2019.
Special Bulletin S2/2019
This Special Bulletin was published on 14 August 2019. It contains medical information relevant to the accident to highlight the implications of that information to the General Aviation community.
Read Special Bulletin S2/2019.
Anniversary Statement
On 21 January 2020 published a statement concerning the accident.
Safety Recommendation document