CEN11FA133

The pilot did not recover from an unusual attitude while operating in instrument meteorological conditions following a disconnect of the autopilot system for undetermined reasons. Contributing to the accident were the pilot’s lack of recent flight experience and impairment due to diphenhydramine.

About 20 minutes after departing on a cross-country flight, the pilot acknowledged the air traffic controller’s clearance to climb to 17,000 feet mean sea level (msl). Radar data indicated that the airplane reached a maximum altitude of 16,800 feet msl. The airplane then entered a right descending turn followed by a left descending turn. While in the left turn, the pilot informed the controller, “I lost my autopilot; I’m in an unusual attitude.” The pilot stated this same information two more times in response to transmissions by the controller. The pilot’s last transmission was that he was busy trying to recover the airplane. Witnesses heard the airplane flying overhead for several minutes, but they could not see it due to the low ceiling. A postaccident examination of the airplane did not reveal any preaccident mechanical malfunctions or failures with the engine that would have precluded normal operation. Examination of the autopilot system revealed a loose screw inside the pitch servo housing. The screw was one of two that secured the high wattage resistor to the solenoid housing. Observed corrosion within the screw threads was consistent with the threads not being engaged in a nut or other internally threaded feature. No mechanical damage or arcing was visible on the screw. The operational impact of the loose screw is unknown. The pilot’s instrument flying proficiency could not be determined. According to log records, the pilot last flew 4.5 months before the accident. The airplane was in instrument meteorological conditions when the pilot stated that he was trying to recover from the unusual attitude. The pilot did not follow prescribed procedures for an autopilot malfunction. Weather data indicates that the airplane most likely encountered turbulence and icing conditions during the flight; however, the airplane was equipped with an ice protection system. Although ethanol was found during the toxicology tests, the levels varied greatly among the tissue/fluid samples. The investigation was unable to determine if the presence of ethanol was from ingestion or from postmortem production or contamination. The detected level of diphenhydramine, an over-the-counter sedating antihistamine used to treat allergies, was above therapeutic levels and likely contributed to the pilot’s inability to recover from the unusual attitude.

HISTORY OF FLIGHT On December 30, 2010, at 0958 central standard time, a Piper PA-46-310P, N9103N, collided with the terrain in Milaca, Minnesota, after the pilot reported the autopilot was no longer functioning and he was trying to recover from an unusual attitude. The private pilot, passenger, and a dog on board were fatally injured. The airplane was substantially damaged. The 14 Code of Federal Regulations Part 91 personal flight was operating in instrument meteorological conditions. The pilot had filed and activated an instrument flight rules (IFR) flight plan. The flight departed from the Aitkin Municipal Airport (AIT), Aitkin, Minnesota, about 0930, and was en route to the Beaumont Municipal Airport (BMT), Beaumont, Texas. The pilot contacted the Minneapolis Air Route Traffic Control Center at 0928 requesting an IFR clearance to BMT. The pilot was cleared direct to BMT and given an initial departure altitude of 5,000 feet. Five minutes later, the pilot reported to air traffic control that he was passing through 2,200 feet climbing to 5,000 feet. The pilot was instructed to climb and maintain 8,000 feet. The pilot acknowledged the clearance and at this time radar showed the airplane was about eight miles south of AIT. The pilot was then issued a frequency change. The pilot checked-in on the new frequency reporting he was at 4,000 feet climbing to 8,000 feet. The air traffic controller instructed the pilot to climb and maintain 22,000 feet (flight level [FL] 220). The pilot acknowledged this clearance. At 0950, the controller instructed the pilot to maintain 17,000 feet. Once again, the pilot acknowledged this instruction. According to radar data, at 0950:44, upon reaching 16,800 feet, the airplane entered a descending right turn. The airplane completed a 360 degree right turn followed by a 360 degree left turn. Approximately two minutes later, the controller instructed the pilot to climb and maintain FL190. The pilot responded, “I lost my autopilot I’m in an unusual attitude.” When the controller asked the pilot to repeat what he had said, the pilot replied, “I’ve lost my autopilot and in an unusual attitude.” The controller stated to the pilot that he did not understand what he had said, and again the pilot replied that he had “lost” the autopilot and he was trying to recover from an unusual attitude. Approximately one minute later, the controller asked the pilot if he needed assistance. The pilot replied that he was busy trying to recover the airplane. This was the last transmission from the pilot. The last radar data containing mode C altitude information was recorded at 0951:24. At this time the airplane was in a left turn and the altitude was reported as 16,000 feet. The last radar contact with the airplane was at 0955. The location of this radar data was nearly over the accident site. There were no eye witnesses to the accident. Ear witnesses reported hearing the airplane overhead and the engine sounds varying. One witness, who holds a pilot certificate, stated he first heard the airplane engine "winding up which I assumed it was in a spiral." He stated it then sounded as if the pilot got out of the spiral and the airplane was coasting as it traveled north. He stated he heard the airplane travel back over his house with the engine sounding as if the throttle was still pulled back. He believed the airplane then turned and headed back north as he did not hear any engine sounds for a minute or two. He then heard the airplane heading back to the south, southeast toward his house. He stated he could hear the engine running, but it sounded like it was at idle. He then heard the engine sounds “wind up” and he thought the airplane was in a spiral. He did not hear an impact, but the engine sounds eventually ceased. The witness contacted the local authorities and went looking for the airplane which he located in a field near his residence. PERSONNEL INFORMATION The pilot, age 65, held a private pilot certificate with airplane single-engine land, instrument airplane, and glider ratings. He held a third-class airman medical certificate issued June 9, 2009. The medical certificate contained a limitation that the pilot must wear corrective lenses. The pilot reported having 2,000 hours of flight time on the application for the medical certificate. The pilot’s family provided two pilot logbooks for review. The first logbook contained entries between August 5, 1997, and August 13, 2005. The flight time logged in this book totaled 949 hours, of which 34 hours were in the accident airplane. The second log book contained entries which totaled about 45 hours of flight time, of which approximately 43 hours were in the accident airplane. It could not be determined in what year some of the flights were flown. An aircraft flight log page was found in the wreckage. The log contained flights for the accident airplane dated between May 1, 2009, and December 30, 2010. The second to last flight on the log was dated August 12, 2010. The date, departure airport, and destination airport of the last entry matched the accident flight. The flight times on this log totaled 90.5 hours, not including the accident flight. The pilot’s last flight review and instrument proficiency check were conducted on October 2, 2009. The instructor who provided the flight review and instrument proficiency check stated that he provided flight training for the pilot in 2007, 2008, and on October 2, 2009. He stated that the pilot had training scheduled with him in October 2010. The pilot called him about a week before the training stating he had to cancel because he had a landing mishap in the airplane and it was being repaired. The pilot told him he was going to call and reschedule when the airplane was repaired, but the instructor never heard back from the pilot. The instructor stated that most PA-46 pilots fly using the autopilot and that the accident pilot was no exception. He stated that during the training he provides, he has pilots hand-fly the airplane. Although not documented in the pilot’s records, the instructor stated that unusual attitude recovery is typically a part of the flight training he provides. He described the accident pilot as being an average to below average pilot compared to other pilots that he trains. Federal Aviation Regulations, 14 Code of Federal Regulations Part 61, state that in order to act as pilot in command under IFR a pilot must perform and log at least six instrument approaches, holding procedures and tasks, and intercepting and tracking courses through the use of navigational electronic systems within the preceding six calendar months. The pilot’s logbook did not indicate that he met this requirement. AIRCRAFT INFORMATION The six-seat, low-wing, pressurized, retractable-gear airplane, serial number 4608021, was manufactured in 1986. The airplane was registered to a company which was owned by the pilot. The airplane was powered by a Continental TSIO-550-C(1) engine, serial number 814578R. The engine and propeller, a Hartzell PHC-G3YF-1E/7890K were installed on the airplane in accordance with Supplemental Type Certificate number SA01770CH. Based on the hobbs meter, legible records, and the aircraft flight log, the aircraft total time at the time of the accident was estimated to be 2,465.5 hours. The hobbs time at the time of the accident was 727.5 hours. A review of the maintenance records revealed the last aircraft annual inspection was completed on March 15, 2010, at a total aircraft time of 2,438.7 hours. The last maintenance recorded for the airplane was dated September 13, 2010, at a hobbs time of 726 hours. The last static altimeter transponder certification inspection was performed on February 2, 2010. The zero-time factory rebuilt engine was installed in the airplane on March 15, 2006, at a total aircraft time of 1,778.2 hours. According to the engine logbook, the