Piper Aircraft Corporation, Pa-46 Malibu/Mirage Accidents/Incident, May 31, 1989 to March 17, 1991

Between May 31, 1989, and March 17, 1991, Piper PA-46 series Mallibu and Mirage airplanes were involved in seven fatal accidents in the United States, Mexico, and Japan following  departures from controlled flight. In addition to the seven accidents, another PA-46 airplane was involved in an incident that included  substantial departures from controlled flight.

In July 1990, following the fourth U.S. fatal accident, the Safety Board initiated a special investigation of the facts, conditions, and circumstances that led to the loss of the four Malibu/Mirage airplanes in the U.S. As other accidents occured, they were included in the special investigation. Two of the seven fatal accidents occurred in Japan and Mexico, and the available information on the accidents was included in the special investigation. The special investigation included a review of the relevant design features of the Malibu and Mirage airplanes, including structural integrity, flight control systems, and operating limitations. The investigation also focused on the flight experience and training of the pilots of the airplanes, particularly as these factors related to flying the Malibu/Mirage airplanes in instrument meteorological conditions (IMC) at and above the freezing level with relatively sophisticated integrated flight guidance and control systems.

Finally, as a consequence of the accidents, the Federal Aviation Administration, with the Safety Board's encouragement, conducted a special certification review of the airplanes, and the results are included in the report.

The probable causes of the five fatal accidents that occurred in the United States are included in the report. The investigation and analysis of the relevant data indicate that the causes of the accidents involved failure to use pilot heat freezing IMC, possible misuse of the integrated flight guidance and control systems, loss of control, and in-flight airframe failures due to loads and stresses that substatially exceeded design limits. Factors related to the accidents included the lack of an appropriate checklist item for pilot heat in the pilot's handbook, and inadequate pilot training in the integrated flight guidance and control systems.

As a result of the special investigation, the Safety Board made safety recommendations concerning modifications to the PA-46 airplane flight manual, the pilot training needed to operate small pressurized airplanes, the addition of a pilot heat operating light, additional training requirements for the use of integrated flight guidance and control systems in small pressurized  airplanes, and the provision of training supplements by manufactures of integrated flight guidance and control systems.