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The aircraft was observed on radar proceeding direct toward OBVUP, then making a 360 degree right turn in about 20 seconds, with radar returns at 4000, 2600 and 1900 feet asl before it was lost off radar. The radar track and the descent rate of the aircraft are indicative of a spiral dive.

The following TSB Laboratory reports were completed:

LP115/2010 – Radar /ATC Synchronization LP153/2010 - Route Map

Analysis

The two occupants of the aircraft did not survive the accident. There were no witnesses to the final moments of the flight and there were no onboard recording devices to assist investigators. The aircraft impacted the water in a near vertical attitude, suggesting an in-flight loss of control. This analysis therefore focuses on possible scenarios explaining why the aircraft departed controlled flight and collided with the water.

Although the aircraft was extensively damaged by the impact, there was no evidence suggesting a problem with the flight controls or engines. All historic technical records were carried on the occurrence aircraft; only the most recent maintenance records could be reviewed as copies were retained by the facilities in Buttonville. This practice impeded the determination of the aircraft’s maintenance history since new. The investigation ruled out turbulence as a factor for loss of control because there were no significant weather conditions in the area that could cause turbulence.

The PIC was communicating on the radio up until 1 minute before the loss of control. During these communications, the PIC did not indicate any medical concerns or display any signs of impairment. This, coupled with the fact that the heater was recently overhauled and tested serviceable just days before the occurrence flight, allowed the investigation to rule out carbon monoxide poisoning. Pilot incapacitation was therefore not considered a contributing factor.

The PIC was in an unfamiliar aircraft, was flying in conditions which he did not like (night, inclement weather), and was operating into an unfamiliar airport. These factors would have contributed to the degradation of the PIC’s conscious attention management capability. Simple tasks such as re-programming the GPS would have become difficult and may have taken attention away from flying for several minutes. Important steps were omitted such as reducing the airspeed or changing altitude when repeatedly instructed to do so. Additionally, the pilot turned to the left when instructed to turn right, and declined the offer for radar vectorswhich would have reduced pilot workload.

The owner had received limited experience flying a multi-engine aircraft 2 years earlier, had limited instrument flight experience and had not received any training on the occurrence a i r c r a f t o r i t s s y s t e m s . T h e s e f a c t o r s w o u l d h a v e c o n t r i b u t e d t o t h e d e g r a d a t i o n o f t h e o w n e r conscious attention management capability. s

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