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AIRCRAFT ACCIDENT REPORT 1/2020 AIRCRAFT ACCIDENT REPORT 1/2020 Aair Accidentsa Investigationib �Ranch AIRCRAFT ACCIDENT REPORT 1/2020 AIRCRAFT ACCIDENT REPORT 1/2020 AIRCRAFT AAir AccidentsA InvestigationIB ranch Report on the accident to Piper PA-46-310P Malibu, N264DB 22 nm north-north-west of Guernsey on 21 January 2019 N264DB Aircraft Accident Report 1/2020 Report on the accident to Piper PA-46-310P Malibu, N264DB 22 nm north-north-west of Guernsey on 21 January 2019 Unless otherwise indicated, recommendations in this report are addressed to the appropriate regulatory authorities having responsibility for the matters with which the recommendation is concerned. It is for those authorities to decide what action is taken. In the United Kingdom the responsible authority is the Civil Aviation Authority, Westferry Circus, Canary Wharf, London, E14 4HD or the European Union Aviation Safety Agency, Postfach 10 12 53, D-50452 Koeln, Germany. AIRCRAFT ACCIDENT REPORT 1/2020 Air Accidents Investigation Branch Report on the accident to Piper PA-46-310P Malibu, N264DB 22 nm north-north-west of Guernsey on 21 January 2019 This investigation has been conducted in accordance with Annex 13 to the ICAO Convention on International Civil Aviation, EU Regulation No 996/2010 and The 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 future accidents and incidents. It is not the purpose of such an investigation to apportion blame or liability. Accordingly, it is inappropriate that AAIB reports should be used to assign fault or blame or determine liability, since neither the investigation nor the reporting process has been undertaken for that purpose. © Crown Copyright 2020 This report contains facts which have been determined up to the time of publication. This information is published to inform the aviation industry and the public of the general circumstances of accidents and serious incidents. Extracts may be published without specific permission providing that the source is duly acknowledged, the material is reproduced accurately and it is not used in a derogatory manner or in a misleading context. Published 13 March 2020 Printed in the United Kingdom for the Air Accidents Investigation Branch ii Aircraft Accident Report: 1/2020 N264DB EW/C2019/01/03 Contents Summary .......................................................................................................................... 1 1. Factual information ................................................................................................ 5 1.1 History of the flight .......................................................................................... 5 Contents 1.2 Injuries to persons ........................................................................................... 7 1.3 Damage to the aircraft .................................................................................... 7 1.4 Other damage ................................................................................................. 7 1.5 Personnel information ..................................................................................... 8 1.5.1 Pilot ................................................................................................... 8 1.5.2 Pilot’s licence .................................................................................... 8 1.5.3 Colour vision deficiency .................................................................... 9 1.5.4 Pilot’s recent flying experience.......................................................... 9 1.6 Aircraft information ........................................................................................ 10 1.6.1 Leading particulars .......................................................................... 10 1.6.2 General description of the aircraft ................................................... 10 1.6.3 Engine information ...........................................................................11 1.6.3.1 General description of the engine .................................11 1.6.3.2 Engine history ............................................................... 14 1.6.4 Previous failures of turbocharger turbines ...................................... 14 1.6.5 Minimum equipment list (MEL) ....................................................... 14 1.6.6 Limitations ....................................................................................... 15 1.6.7 Safety equipment ............................................................................ 15 1.6.8 Ice protection system ...................................................................... 16 1.6.9 Autopilot .......................................................................................... 16 1.6.10 Nosewheel steering ........................................................................ 17 1.6.11 Wheel brakes .................................................................................. 18 1.6.12 Audio warnings ............................................................................... 18 1.6.13 Cabin environmental system ........................................................... 18 1.6.13.1 General description ...................................................... 18 1.6.13.2 Pressurised operation................................................... 19 1.6.13.3 Unpressurised operation .............................................. 20 1.6.13.4 Cabin air distribution ..................................................... 22 1.6.14 Maintenance and fault history ......................................................... 22 1.6.14.1 Registration and recent maintenance ........................... 22 1.6.14.2 Annual inspection and 100-hour maintenance ............. 22 1.6.14.3 Inspection of the engine exhaust system ..................... 23 1.6.14.4 Recent fault history ....................................................... 24 1.6.14.5 Faults arising during the flight to Nantes ...................... 25 1.6.15 Weight and balance ........................................................................ 27 © Crown Copyright 2020 iii Contents Aircraft Accident Report: 1/2020 N264DB EW/C2019/01/03 1.7 Meteorological information ............................................................................ 27 Contents 1.8 Aids to navigation .......................................................................................... 28 1.9 Communications ........................................................................................... 29 1.9.1 Flight plan ....................................................................................... 29 1.10 Aerodrome information ................................................................................. 29 1.11 Recorded information .................................................................................... 29 1.11.1 Sources of recorded information ..................................................... 29 1.11.2 Passenger’s voice mail message .................................................... 30 1.11.3 The flight from takeoff until approximately 2005 hrs ....................... 30 1.11.4 The flight after 2012 hrs .................................................................. 31 1.11.5 Mode C altitude validity ................................................................... 32 1.12 Wreckage and impact information ................................................................ 33 1.12.1 General information on wreckage ................................................... 33 1.12.2 Initial survey .................................................................................... 33 1.12.3 Specific damage ............................................................................ 33 1.13 Medical and pathological information ............................................................ 38 1.13.1 Post-mortem examination result .................................................... 38 1.13.2 Toxicology ....................................................................................... 38 1.14 Fire ................................................................................................................ 39 1.15 Survival aspects ............................................................................................ 40 1.16 Tests and research ........................................................................................ 40 1.16.1 Simulation of the final manoeuvres ................................................. 40 1.16.2 NTSB investigations into in-flight structural failures of PA-46 aircraft .................................................................................. 43 1.17 Organisational and management information ............................................... 44 1.17.1 Airworthiness requirements for operating a US-registered aircraft in the UK ......................................................................................... 44 1.17.1.1 Applicable regulation .................................................... 44 1.17.1.2 Inspection and maintenance - general ......................... 45 1.17.1.3 Inspection and maintenance – Aircraft Maintenance Manual .......................................................................... 45 1.17.1.4 Inspection and maintenance – Engine Manuals and Service Documents ...................................................... 46 1.17.1.5 Ownership and responsibility for airworthiness ............ 47 1.17.1.6 Airworthiness oversight ...............................................
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