ANC18FA007

The pilot's improper decision to perform aggressive, low-altitude maneuvers due to his impairment from the use of multiple psychoactive substances, which resulted in a loss of control.

The private pilot was conducting a personal flight over water in his light sport amphibious airplane. Recorded flight data indicated that the pilot performed a series of maneuvers near the shoreline at low altitudes. During the final maneuver, the airplane pitched up from about 210 ft, the throttle was moved almost to the idle position, the load factor increased to about 2 Gs, and the angle of attack increased steadily to 15° as the airplane reached 358 ft and banked more than 50° to the right. Immediately afterward, the airplane descended nose low and wings level and impacted the water. Multiple witnesses observed the airplane maneuvering between 5 and 300 ft over vessels in the water and close to houses along the shoreline. The recovered flight data indicated no exceedances of design maneuvering limits during the accident sequence. Even though the data indicated that the airplane might have experienced a momentary aerodynamic stall, the lack of reliable end-of-flight data precluded this determination.  Postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operations. The airplane performance study for this accident and the engine control unit data showed that the reduction in engine power before impact was a result of the pilot moving the throttle lever. Although bird feathers were found within the wreckage, no avian DNA was found, and there was no damage that could be attributed to a bird impact in the areas where the feathers were found. The airplane's flight track and orientation at impact were consistent with a loss of control. The Icon Aircraft A5 pilot operating handbook stated that the emergency procedure for a loss of control was to pull the handle for the complete aircraft parachute (CAP) system. As part of the After Cockpit Entry checklist, the pilot was to remove and stow the CAP system safety pin in case the system needed to be activated. Because the pilot did not remove the safety pin from the handle before flight, he would not have been able to deploy the parachute system to arrest the descent before impact. Although the airplane's altitude and attitude were not consistent with optimal CAP system actuation, the handbook indicated no restrictions on the use of the CAP system.   Postaccident toxicology testing indicated that the pilot had used multiple psychoactive substances before the accident, including amphetamine, zolpidem, morphine, fluoxetine, and baclofen. Although the effects of these five substances have not been studied in combination, each of the substances is impairing or potentially impairing by itself. Some of these substances might undergo postmortem redistribution, and the measured levels might therefore not represent the antemortem levels. However, all of the substances were at or above the levels that affect the central nervous system functions, including judgment, executive functioning, alertness, attention, and psychomotor skills. The substances that were simultaneously present in the pilot's system at the time of the accident most likely resulted in significant impairment that contributed to the pilot's decision to perform high-risk maneuvers. Further, the pilot's actions were consistent with sensation-seeking and a willingness to take risks. The pilot's risk-taking behavior was also demonstrated by his statement on social media (7 days before the accident) that flying the Icon A5 over water was "like flying a fighter jet" and his documented flight under a local bridge (12 days before the accident). In summary, the circumstances of the accident were consistent with the pilot's failure to maintain control of the airplane while performing aggressive maneuvers at a low altitude and a nose-high attitude, which resulted in the airplane's low energy state. The pilot's decision-making ability and psychomotor skills were significantly impaired by the combination of substances that were present in his system at the time of the accident.

The Office of the Medical Examiner, District Six, Pasco and Pinellas Counties, Florida, performed an autopsy of the pilot. His cause of death was blunt trauma, and drowning was a contributory condition. Toxicology testing performed at the Federal Aviation Administration (FAA) Forensic Sciences Laboratory identified the following drugs in the pilot's specimens: Zolpidem was identified in the pilot's cardiac blood (0.088 µg/ml) and urine. Zolpidem is a sleep aid available by prescription as a schedule IV controlled substance that is often sold with the name Ambien. The drug information states the following: Complex behaviors such as 'sleep-driving' (i.e., driving while not fully awake after ingestion of a sedative-hypnotic, with amnesia for the event) have been reported with sedative-hypnotics, including zolpidem. These events can occur in sedative-hypnotic-naive as well as in sedative-hypnotic-experienced persons. Although behaviors such as ''sleep-driving' may occur with zolpidem tartrate alone at therapeutic doses, the use of alcohol and other CNS [central nervous system] depressants with zolpidem tartrate appears to increase the risk of such behaviors. Amphetamine was identified in the pilot's cardiac blood (2.2 µg/ml) and urine. Amphetamine is a schedule II controlled substance that stimulates the central nervous system. It is available by prescription for the treatment of attention deficit disorder and narcolepsy. It carries a boxed warning about its potential for abuse and has warnings about an increased risk of sudden death and the potential for mental health and behavioral changes. In some preparations, the prescription drug is metabolized to amphetamine; commonly marketed names in this category include Adderall, Dexedrine, and Vyvanse. After a single 30-mg oral dose, early blood levels averaged 0.111 µg/ml, and average blood levels in adults using the long-acting prescription orally for a week were about 0.065 µg/ml. Amphetamine is also prepared and used as a street drug that can be snorted, inhaled, or injected. Generally, levels above 0.2 µg/ml indicate amphetamine misuse to maximize the drug's psychoactive effects. Morphine was identified in the pilot's cardiac blood (0.192 µg/ml) and urine. Morphine is a powerful opioid pain medication available as an injection, a tablet, or a capsule and is identified as a schedule II controlled substance. Ranges for therapeutic levels are typically determined by giving novice users one or two doses and measuring their blood levels; such ranges are 0.010 to 0.100 µg/ml. With regular opioid use, brain physiology changes, leading to tolerance for both the desired analgesic and sedative effects and resulting in increased dosing. Chronic users may need the drug to feel and act "normally"; thus, a chronic user may appear to function normally at levels that could be toxic or even fatal to a first-time user. Fluoxetine and its metabolite norfluoxetine were identified in the pilot's cardiac blood (0.984 and 1.569 µg/ml, respectively) and urine. Fluoxetine is an antidepressant available by prescription. It carries the following warning: As with any CNS-active drug, fluoxetine has the potential to impair judgment, thinking, or motor skills. Patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that the drug treatment does not affect them adversely. However, major depression itself is associated with significant cognitive degradation, particularly in executive functioning. The cognitive degradation may not improve even with remission of the depressed episode, and patients with severe disease are more significantly affected than those with fewer symptoms or episodes. Baclofen was identified in the pilot's cardiac blood (0.72 µg/ml) and urine. Baclofen is a muscle relaxant available by prescription. It carries the following warning: Because of the possibility of sedation, patients should be cautioned regarding the operation of automobiles or other dangerous machinery, and activities made hazardous by decreased alertness. Patients should also be cautioned that the central nervous system effects of baclofen may be additive to those of alcohol and other CNS depressants. Hydromorphone was found in the pilot's urine. Hydromorphone is an opioid pain medication available by prescription as a schedule II controlled substance. Other common names are Dilaudid and Exalgo. Hydromorphone is also a relatively uncommon active metabolite of morphine and a common metabolite of hydrocodone, which is not a metabolite of morphine. Hydromorphone carries the following warning: Hydromorphone and other Schedule II opioid agonists, including morphine, oxymorphone, oxycodone, fentanyl, and methadone, have the highest potential for abuse and risk of producing respiratory depression. Alcohol, other opioids and central nervous system depressants (sedative-hypnotics) potentiate the respiratory depressant effects of hydromorphone, increasing the risk of respiratory depression that might result in death. Ibuprofen was found in the pilot's urine. Ibuprofen is an over-the-counter pain medication commonly sold as Motrin and Advil. It is not considered impairing. No ethanol was detected in the pilot's vitreous specimens. Review of the available personal medical records for the pilot indicated a history of substance abuse requiring inpatient rehabilitation twice between 2013 and early 2015 and diagnoses of chronic back pain, insomnia, and depression, which were treated with various prescribed medications. The pilot's personal medical records for 2016 and 2017 were not available. The pilot had 14.5 hours of total flight experience in the accident airplane. The pilot made an entry into his logbook indicating that, while en route from the Peter O. Knight Airport in Tampa, Florida, to his home, he flew under the Skyway Bridge; the bridge has a 180-ft vertical clearance over the water. Recovered GPS data showed that the pilot flew under the bridge on October 26, 2017. A few days later, the pilot stated on social media, "flying the Icon A5 over the water is like flying a fighter jet!" The airplane came to rest inverted in about 4 ft of water and was oriented on a 192° heading, as shown in figure 4. The empennage was separated and displaced forward of the wings. All major airplane components were located at the accident scene. The front fuselage and cockpit were highly fragmented, with pieces scattered within a 300-ft radius of the main wreckage. Figure 4. Airplane wreckage at the accident scene. The CAP system was not deployed, and the CAP cockpit handle pin was in its installed position. The fuselage canopy was located about 50 ft west of the wreckage with about 50% of the plexiglass fractured and missing. The left (pilot's) seat was separated from the fuselage. The pilot's three-point harness system was anchored securely to the left wall with the inertia reel intact, secure, and fully operable. The webbing exhibited fraying about 12 inches from the reel. The seatbelt buckle operated normally and locked in place when the tab was inserted. The wings, wing tips, and nose section exhibited symmetrical fragmentation consistent with a wings-level impact. Both wings were attached and secured in the locked position. Control continuity was established from the cockpit controls to the elevator, which exhibited full movement between stops. The torque tube was bent about 10° near the center; the forward pulley was intact with the bracket separated at the bond. The cables were traced through the system with no fractures. Secondary elevator stops were observed in place near the forward bellcrank. The pitch trim actuator rod remained intact. The pitch trim electrical connector remained attached to the torque tube, and all contact pins were intact. Control continuity was established from the cockpit to the rudder through