In February, when the NTSB published its final report on the January 2023 fatal crash of a Piper PA-46-350P JetProp in Yoakum, Texas, the core problem identified—pilot error—did not come as a surprise to anyone in the industry. There have been many “déjà vu” fatal crashes due to pilot error in these popular six-seat high-performance single-engine aircraft over the years. Yet this accident—which killed four of the five people onboard, including the pilot—may have been the tipping point for a new slate of industry-leading safety improvements in the PA-46 (also known as the Piper M-Class) sector.
“We made the decision that we have to change the way things are done in our community,” says Mike Nichols, CEO of the Piper M-Class Owners and Pilots Association (PMOPA), the “type” club for the PA-46 . PMOPA members own and operate about half of the worldwide fleet of approximately 2,000 PA-46 aircraft, which include the six-seat JetProp turbine conversion and eight other piston- and turbine-powered models. Nichols became CEO in 2022 after retiring as the senior vice president for strategy and innovation at the National Business Aviation Association. “The problem is with how pilots are flying the airplane, and largely, it has to do with poor decision-making and risk management,” he says.
Integral to aeronautical decision-making (ADM) and safety risk management (SRM) are training and proficiency, both of which were nonoptimal in the Yoakum JetProp accident. The NTSB’s probable cause for the crash was the pilot’s spatial disorientation, which led to an aerodynamic stall during a missed approach to the Yoakum Municipal Airport in Texas in low instrument meteorological conditions (IMC). The 64-year-old commercially rated pilot, his 33-year-old certified flight instructor co-pilot, and two passengers in the cabin died in the crash. A third passenger in the rear of the aircraft survived with serious injuries.
In 2022, two fatal PA-46 fatal accidents preceding the Yoakum crash occurred in IMC after pilots in both accidents experienced spatial disorientation, according to the NTSB.
There have been six fatal PA-46 accidents worldwide since the Yoakum accident. Among the potential root causes the PMOPA identified are shortfalls in ADM, SRM, proficiency and training. The NTSB has not yet published final reports.
The déjà vu goes back decades. The NTSB in 1992 published a special investigation report on seven fatal PA-46 Malibu/Mirage accidents—including five in the U.S. that killed 12 people—between May 1989 and March 1991. Common themes included loss of control, possible misuse of integrated flight guidance and control systems, and inflight structural failures due to overstressing the airframe.
PMOPA’s earliest forerunner, the Malibu Coalition, formed in 1990 to participate with the NTSB in the investigation. The four owner-operators worked with the agency to develop several safety recommendations, including changes to the flight manual and improvements in initial pilot training. Once the report was issued, the coalition disbanded and the community launched a new advocacy organization, the Malibu Mirage Owners and Pilots Association (MMOPA). This organization was rebranded as the PMOPA in September 2023.
Master Aviator
In an effort to boost pilot proficiency, the MMOPA in 2018 created a Master Aviator program to encourage pilots to participate in advanced training activities above and beyond yearly insurance company requirements. Activities at the time included flying a minimum of 100 hours per year, getting a tailwheel endorsement (to help with landing issues) and taking upset prevention and recovery training (to help with loss-of-control problems). The initiative has been successful for 20-30 pilots per year who have achieved the Master Pilot distinction.
“Not a single person who’s reached the Master Aviator top level has had a fatal accident,” says Nichols. “If you look at where there’s a higher number of accidents, it’s the people who do the bare minimums and don’t pursue additional training.”
To get more pilots to participate in the program, PMOPA has replaced the tailwheel and upset training requirements with other safety activities, including flight data monitoring. Nichols says 54 pilots took part in the program in 2024.
The Yoakum pilot had not participated in the Master Aviator program, and the NTSB does not discuss what (if any) training above minimum currency requirements he may have had.
Morning of Crash
On the morning of Jan. 17, 2023, the pilot was cleared for the RNAV (GPS) Runway 31 approach to Yoakum. All seemed well as the aircraft descended and controllers, as expected for the area, lost radar coverage at 2,000 ft. There were no further communications. When flying the RNAV (GPS) 31 approach, pilots can descend as low as 840 ft. mean sea level (477 ft. above ground level), but they must be able to see the runway environment to land or otherwise initiate a missed approach.
Yoakum Municipal Airport does not have weather information, but area advisories from the National Weather Service called for low instrument flight rules (IFR) conditions through noon that Tuesday. Before takeoff from Memphis International Airport at 7:48 a.m., the pilot received through his ForeFlight app Center Weather Advisory (CWA) 102, which called for low IFR conditions until 9 a.m. That advisory was updated to CWA 103 while the aircraft was en route, extending the low IFR time until 11 a.m., about 30 min. after the expected arrival in Yoakum. The NTSB found that the controller did not inform the pilot of the update.
The landowner at the accident site noticed “a lot of fog” at the time, and the operator of an air medical helicopter dispatched to the crash site cancelled its flight due to heavy fog.
Flightpath data showed the aircraft descending and maintaining the charted minimum descent altitude, but there may have been issues with the automation. The surviving passenger told investigators that the aircraft was off course as it approached Yoakum, and the pilot “was struggling with the airplane to get it back on course.” The NTSB report did not comment on whether issues with flight control were related to how the aircraft was loaded with respect to the center of gravity.
Based on his actions, the pilot could not see the runway at the minimum descent altitude and initiated a climbing right turn earlier than the charted missed approach (see Figure 1), with the autopilot turned off. Under manual control, the aircraft began a series of pitch and roll excursions that the surviving passenger described as “aggressive” pitching up and down. He remembered hearing the co-pilot call for the pilot to try to get the PA-46’s nose “up and straightened out.” At some point during that process, one of the pilots engaged the autopilot’s Unusual Attitude Recovery mode, a feature designed to return the aircraft to straight and level flight. However, this mode was turned off shortly after being engaged.
The NTSB found that the aircraft had logged more than 122 hr. since its most recent annual inspection in May 2022, so the pilot/owner was likely fully current by general aviation standards. Flight hours, however, may not be a good indicator of proficiency, particularly when it comes to missed approach procedures, which pilots are not obligated to practice as part of the FAA’s instrument currency requirements.
“I have pilots that come to me for recurrent training, who have just spent a year flying the airplane for 100-200 hr., and they didn't do a single missed approach that entire time,” says Joe Casey, a longtime PA-46 instructor pilot. “I find that when I do recurrent training events, one of the most frequently fumbled events is the missed approach. This is not just in the PA-46 world; this is broadscale.”
Learn From Others
When assessing potential ADM and SRM upgrades beyond the Master Aviator program in the summer of 2023, PMOPA reached out to people like Casey as well as experts from other owner and pilot organizations that overcame similar déjà vu pilot performance and fatal crash issues—including the American Bonanza Society (ABS) and the Cirrus Owners and Pilots Association (COPA).
ABS was founded in 1967 by two men in upstate New York who owned V-tail Bonanzas and wanted to share techniques for instrument flight procedures. “There wasn’t a lot of education oriented specifically toward high-performance aircraft operations and IFR, so they started sharing information,” says Thomas Turner, executive director of the ABS Air Safety Foundation, the education and training arm of the ABS. At the time, the pilot-error-induced fatal accident rate for the V-tail Bonanza (Model 35), first introduced in 1947, was very high compared to other aircraft, earning the model the dubious title of “fork-tailed doctor killer.”
Today, ABS membership includes more than 10,000 owners of the approximately 12,000 flyable Bonanza, Debonair, Baron and Travel Air aircraft models, and Beechcraft accident rates are comparable to other high-performance singles. “Eventually, the training community caught up with the flying community,” says Turner. Among other training and educational benefits, ABS provides members with opportunities for type-specific training through the Beechcraft Pilot Proficiency Program.
Turner also launched a “train the trainer” program, given the daunting logistics of providing hands-on training to more than 10,000 members. “In our best years, we might have seen 5% of our membership in ABS training,” says Turner. To get more ABS flight training out to the masses, he created the ABS Flight Instructor Academy. “My thrust has been to train flight instructors on how to provide type-specific training in these airplanes, and oriented toward the pilot who is never going to take another FAA check ride in his life,” he explains.
In the early 2000s, when Cirrus and its aircraft owners started experiencing a higher fatal accident rate than expected for the new line of SR20 and SR22 high-performance composite singles, COPA naturally looked at what ABS had done. Like ABS, they found that training was an issue, in part because there were no factory-trained instructors. Any single-engine certified flight instructor could instruct in a Cirrus. Together, Cirrus and COPA captured best practices and put in place a training system that includes Cirrus Standardized Instructor Pilots (CSIP) and COPA University, where pilots and mechanics hone their skills, both on aircraft and in simulators. Jim Ratliff, a platinum-level CSIP and chief flight instructor for Houston-based Cirrus training provider Tidal Aviation, says the SR series fatal accident rate has improved greatly.
In August 2023, Nichols brought Turner and Ratliff together with a cadre of PMOPA members and flight instructors to help the group develop a comprehensive new approach to PA-46 type-club training. “I like to think that Tom and I helped them in that first session, because we both were saying the same thing: ‘Go for the low hanging fruit—ADM and stabilized approaches,’” says Ratliff. “You can teach those two areas in any airframe and build on that.”
The program that emerged in 2024, under the auspices of the PMOPA Safety and Education Foundation, did that and more. It has two main components—one for pilots and one for instructors. The pilot training curriculum, called M-Class Elevate, focuses first on SRM and ADM, followed by aeronautical knowledge and systems, avionics and flight instruments, and flight procedures. “A lot of people have these incredible avionics, and about all they know how to do is press ‘direct to,’” says Nichols.
The M-Class Standardized Instructor Pilots (MSIP) program is designed to bring instructors who provide standardized training into the PA-46 community.
“Like any new product, it’s going to take a while until we have early adopters and climb the product life cycle, until it’s fully embraced by the community,” says Nichols, adding that getting insurance underwriters on board could greatly help accelerate adoption. “The sooner they require that instructors are under our program, then I think the faster we’ll get to full market adoption and really make a difference with our safety record,” he says.
While it is too soon to know the effects of the new training paradigm, Nichols is confident that adopting best practices and continuing to collaborate with other industry leaders who have “been there and done that” will lead to positive change. “If something works in one group, there’s a good chance it’s going to work with another group,” he says.
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