CEN15FA400

The noninstrument-rated pilot's improper judgment and his failure to maintain situational awareness, which resulted in the flight's encounter with instrument meteorological conditions and controlled flight into terrain during cruise flight.

The airplane owner, who was a noninstrument-rated private pilot and did not hold a multiengine airplane rating, was conducting a visual flight rules (VFR), personal cross-county flight in the multiengine airplane. Before the accident flight, the pilot flew the airplane to an intermediate airport to refuel. A review of air traffic control (ATC) radio transmissions between the pilot and an air traffic controller between 0911 and 0938 showed that, during the approach for landing, the pilot misidentified in every transmission the make and model airplane he was flying, referring to his airplane as a Piper Comanche instead of a Cessna 310. Further, he did not provide correct responses to the controller's instructions (for example, he reported he was set up for the left base leg instead of right base leg as instructed), and he provided inaccurate information about the airplane's position, including its distance and direction from the airport. A witness stated that, after the airplane landed and while it was taxiing, it almost hit another airplane and golf carts, and it was taxied close enough to the fuel pumps that it "knocked" a ladder with one of its propellers. The witness said that the pilot was not "observant about his surroundings." While at the intermediate airport, the pilot requested an abbreviated weather briefing for a VFR flight from that airport to the destination airport. However, the pilot incorrectly identified the destination airport as "L51," which was depicted on the VFR sectional chart for the Amarillo area but referred to the maximum runway length available at the destination airport not the airport itself. L51 was an airport identifier assigned to an airport in another state and located north of the accident location and in a direction consistent with the airplane's direction of travel at the time of the acident. During the  departure for the accident flight, the pilot taxied to and attempted to take off from an active runway without any radio communications with or clearance from ATC, which resulted in a runway incursion of an air carrier flight on final approach for landing to the runway. The air carrier initiated a missed approach and landed without further incident. The controller reported that the runway incursion was due to the accident pilot's loss of "situational awareness." Radar data showed that, after the airplane departed, it turned northward and away from a course to the intended destination airport. The northward turn and track was consistent with a course to an airport in another state. According to meteorological information, as the flight progressed northward, it likely encountered instrument meteorological conditions (IMC) while flying into rain showers. The wreckage was found in rising mountainous terrain, and the accident wreckage distribution was consistent with a low-angle, high-speed impact. Given that postaccident examination of the airplane revealed no mechanical anomalies that would have precluded normal operation, it is likely that the noninstrument-rated pilot did not see the rising mountainous terrain given the IMC and flew directly into it.  The pilot had told person(s) that he flew F-4 Phantoms, but a military identification card showed that the pilot was a retired Marine lance corporal. Although the pilot's logbook showed that he had accumulated 150 hours of multiengine airplane flight time, there was no record of the actual flights showing the accumulation of 150 multiengine airplane hours or any record that he had flown military aircraft. The logbook did not show that the pilot had received any flight training in the accident airplane. The logbooks also showed that he had flown numerous flights in the airplane with passengers without proper certification and that he had not had a recent flight review as required by Federal Aviation Regulations (FARs). The pilot's logbook showed that he had once made low-altitude (10 ft above the ground) passes over a parade in the same airplane. The airplane had not received an annual inspection for continued airworthiness as required by FARs. The pilot's noncompliance with FARs and the logbook entries indicate that he had a history of poor decision-making and piloting errors, which was reflected in his behavior and actions while landing at the intermediate airport and during the taxi and takeoff phases of the accident flight. Although the pilot had a number of medical problems that potentially could have interfered with his ability to safely operate the airplane, including spinal cord injuries, diabetes, and psychiatric issues, and was taking medications to treat them, these conditions and medications likely would not have interfered with his navigational skills and his ability to communicate on the radio or affected his decision-making. Although the available medical information was limited by the degree of damage to the body, there was no evidence of a medical condition or effects of a medication that contributed to this accident. Although ethanol was detected in the pilot's tissues, it likely resulted from postmortem production.

The NTSB's Chief Medical Officer reviewed the pilot's and pilot-rated passenger's FAA medical case reviews, toxicology results, autopsy reports, the investigator's reports, and the audio tapes of the ATC conversations in Flagstaff. The pilot/airplane owner's personal medical records were obtained and reviewed. Pilot/Airplane Owner The pilot's last aviation medical examination was dated December 17, 2013. According to the records, he was 70 inches tall, weighed 165 pounds, and had reported no chronic medical conditions and no medications to the FAA. He had reported a number of previous surgical procedures and a disability related to a military gunshot wound but the aviation medical examiner noted "no residual." Rocky Mountain Forensic Services, PLLC, performed an autopsy of the pilot. The autopsy report noted the cause of death was "multiple injuries" and the manner of death was "accident." Examination of the body for natural disease was limited by the severity of the pilot's injuries; no organs were available for evaluation. The FAA's Bioaeronautical Research Laboratory performed toxicology testing on the only available specimen, which was muscle, from the pilot. The testing identified ethanol at 0.015 gm/dl as well as citalopram and its metabolite N-desmethylcitalopram. Federal Aviation Regulations, Section 91.17 (a), prohibits any person from acting or attempting to act as a crewmember of a civil aircraft while having 0.040 gm/dl or more ethanol in the blood. Detected ethanol may be to the result of ingestion or microbial activity in the body after death. Citalopram is an antidepressant that carries a warning: "May impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery)." However, it has not been shown to degrade performance in psychological testing experiments using healthy volunteers. According to records obtained from the pilot's Veteran's Administration Hospital, in January 2013, he was documented as having multiple chronic medical conditions including spinal stenosis, hypothyroidism, depressive disorder, posttraumatic stress disorder, panic disorder, gastroesophageal reflux disease, esophageal stricture, chronic neck pain, paraplegia, peptic ulcer disease, type 2 diabetes, and emphysema. In a single note from an outside physician, the pilot's paraplegia was documented as relating to a motor vehicle accident in 1996. The Veterans Administration records show that, in January 2015, the pilot was hospitalized for being unable to swallow. Eventually, he had a gastrostomy tube placed for feeding. He was admitted for a rotator cuff repair in March, 2015, and remained in the hospital for rehabilitation until May 2015. During that time, the feeding tube was removed. His active medications as of July 2015 included albuterol, formoterol, citalopram, hydromorphone (4mg tab every 4 active hours), aspart insulin (short acting), glargine insulin (long acting), levothyroxine, lidocaine patch, prazosin, and zolpidem. Albuterol and formoterol are beta-agonists available as inhaled medication for the short-term treatment of wheezing and the longer term prevention of wheezing, respectively. Hydromorphone is an opioid analgesic Schedule II controlled substance available by prescription that is commonly marketed with the name Dilaudid and carries a warning about central nervous system depression so severe it may cause respiratory failure. The pilot was on two forms of injected insulin: aspart, which is short acting, and glargine, which is long acting. Their common names are Novolog and Lantus, respectively. Levothyroxine is a replacement thyroid hormone typically used to treat hypothyroidism; it is commonly marketed with the name Synthroid. Lidocaine is a local anesthetic available in patch format to treat localized pain. Prazosin is a blood pressure medication commonly marketed with the name Minipress. Zolpidem is a short-acting sleep aid commonly marketed with the name Ambien and carries a warning about sedation and changes in judgment or behavior. Finally, in a visit from September 1, 2015, the pilot was described as having a T12 spinal cord injury, "in a wheelchair but able to transfer." Pilot-Rated Passenger The pilot-rated passsenger's last aviation medical exam was dated May 28, 2015. At that time, he was 67 inches tall and weighed 255 pounds. He had previously reported high blood pressure to the FAA and reported using atenolol and naproxen as medications. Rocky Mountain Forensic Services, PLLC, performed an autopsy Rocky Mountain Forensic Services, PLLC. The autopsy reported the cause of death was "multiple injuries" and the manner of death was "accident." Examination of the body for natural disease was limited by the severity of the pilot's injuries; no organs were available for evaluation. The FAA's Bioaeronautical Research Laboratory performed toxicology testing on the only available specimen from the pilot-rated passenger, which was muscle. The testing identified ethanol at 0.043 gm/dl, as well as atenolol, diphenhydramine, and D-methamphetamine. Atenolol is a medication used to treat high blood pressure and prevent recurrent heart attacks. It is commonly marketed with the name Tenorman. Diphenhydramine is a sedating antihistamine used to treat allergy symptoms and as a sleep aid. It is available over the counter under the trade names Benadryl and Unisom. Diphenhydramine carries the following Federal Drug Administration warning: "may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery). Compared to other antihistamines, diphenhydramine causes marked sedation; it is also classed as a CNS depressant and this is the rationale for its use as a sleep aid. Altered mood and impaired cognitive and psychomotor performance may also be observed. In fact, in a driving simulator study, a single dose of diphenhydramine impaired driving ability more than a blood alcohol concentration of 0.100%." Methamphetamine is a Schedule II controlled substance and is available in low doses by prescription to treat attention deficit hyperactivity disorder, attention deficit disorder, obesity, and narcolepsy. It is also commonly available as a street drug. Even in prescription form, methamphetamine can cause a host of physiological and psychoactive effects. Astronomical Data The astronomical data obtained from the United States Naval Observatory for the accident site on the day of the accident indicated that civil twilight began 0618, sunrise was 0645, sun transit was 1310, sunset was 1935, and civil twilight ended 2001. Weather Information Telluride Regional Airport (TEX), located 12 miles north-northwest of the accident site at an elevation of 9,070 ft mean sea level (msl) was the closest official weather station to the accident site. TEX had an Automated Weather Observing System, and its reports were not supplemented. At 1415, TEX reported wind from 190 degrees at 5 knots, 10 miles visibility, present weather thunderstorms in the vicinity, sky condition scattered clouds at 4,700 ft above ground level (agl), broken ceiling at 6,000 ft agl, broken skies at 7,000 ft agl, temperature of 17° C, dew point temperature of 7° C, and an altimeter setting of 30.34 inches of mercury. Remarks: automated station with a precipitation discriminator, lightning distant northwest, temperature 17.4° C, dew point temperature 6.6° C. Closer to the accident site, observations from the nonofficial surface stations within 12 miles of the accident site reported gusting wind between 8 and 39 mph. The strongest wind was at the nonofficial surface stations closest to the accident site altitude and near the tops of the mountains between 10,000 and 12,000 ft. In addition, these stations reported rain showers in the vicinity and had relative humidity values greater than 8