CEN23FA369

The pilot’s failure to maintain control of the airplane after landing on a grass taxiway with a tailwind, which resulted in a nose over.

The 78-year-old pilot had flown his airplane to the destination airport where an annual inspection was to be performed. The airplane did not have a current annual inspection and did not have a ferry permit for the accident flight. No record of a current flight review for the pilot was found. In addition, the pilot did not possess current FAA medical certification or BasicMed qualifications. Recorded GPS device data showed the airplane made several turns around the airport and then proceeded in the direction of and onto a grass taxiway with a prevailing tailwind, where it was found nosed over. There were no witnesses to the accident. There were no indications of ground scars or rotational features on the propeller and spinner indicative of engine power production. Although the airplane’s right front brake master cylinder arm had a bungee cord tied around it that connected to the pilot seat frame, the brakes actuated and released without anomaly. Examination of the airplane revealed no useable fuel aboard; however, the airplane’s flight path indicated that it circled the airport multiple times before landing, indicating that the flight had adequate fuel to reach and land at the airport. No mechanical anomalies were found that would have precluded normal operation. Although the pilot’s cardiovascular disease placed him at increased risk of an impairing or incapacitating medical event such as heart attack, arrhythmia, or stroke, there was no autopsy evidence that such an event occurred, and such an event does not reliably leave autopsy evidence if it occurs just before death. Toxicology results indicated that the pilot had used the opioid pain medication tramadol and likely was experiencing some effects of tramadol at the time of the accident. Although details of the pilot’s tramadol use are unknown, there is no specific evidence that this use was significantly different from the pilot’s baseline use of tramadol, which had begun years previously. Toxicology results also indicated that the pilot had used venlafaxine and a cannabis product. The measured postmortem levels of the substances in the pilot’s system at the time of the accident neither exclude nor specifically predict any impairing effects, especially in combination with one another and considering the pilot’s age and medical conditions. Based on the evidence, the pilot likely did not maintain control of the airplane after landing on a grass taxiway with a tailwind. Whether the impairing effects of the pilot’s substance use and medical conditions contributed to the accident could not be determined.

No pilot logbook records showing the pilot had a current flight review were found. The pilot’s wife indicated that she did not know how much flight time the pilot had accumulated in the 30 and 90 days before the accident and that he no longer kept a pilot logbook because he believed that he was “beyond that.” She also said that he no longer flew with a flight instructor. The FAA performed a medical case review of the 78-year-old male pilot’s medical history, which included high blood pressure, a coronary artery bypass graft (CABG) performed in 2005, paroxysmal atrial fibrillation, bilateral knee replacement, decreased vision in his left eye, chronic obstructive pulmonary disease, acid reflux, and arthritis. The FAA had granted the pilot a Statement of Demonstrated Ability for his left eye condition and had granted several Authorizations for Special Issuance of medical certification for coronary artery disease, CABG, high blood pressure, and acid reflux. In 2009, the FAA had temporarily withdrawn the pilot’s medical certificate because he had been using the narcotic pain medication tramadol to treat arthritis pain. The pilot’s last FAA aviation medical examination was in November 2010. At that time, he was issued a third-class medical certificate by Special Issuance, limited by a requirement to wear corrective lenses; this certificate expired in 2011. He subsequently completed certain requirements for operations under BasicMed, but these requirements were not current as of the accident date. At the time of the accident, the pilot did not possess current FAA medical certification or BasicMed qualifications. The pilot’s wife reported that the pilot had a stent redone about 8-12 weeks before the accident. She said the pilot wore a heart monitor after that and received a clean bill of health. Photographed among the pilot’s belongings at the crash site was a typed medication list on a sheet of paper. “[Pilot’s name] meds 12/7/2022” was typed at the top of the sheet of paper. Listed medications were rivaroxaban, clopidogrel, furosemide, spironolactone, metoprolol, terazosin, simvastatin, tramadol, venlafaxine, metformin, allopurinol, cetirizine, and fluticasone. The Waupaca County Medical Examiner’s Office performed the pilot’s autopsy and death investigation. According autopsy report, the pilot’s cause of death was blunt force trauma to his chest and the manner of death was accident. The pilot’s autopsy identified an enlarged heart with dilated chambers. There was severe narrowing of the native coronary arteries by calcified plaque. Three coronary artery bypass grafts were identified and were not blocked. The autopsy report did not document coronary artery stent presence. Visual examination of the heart muscle did not identify other significant natural disease. Microscopic examination of heart muscle showed mild cell enlargement without other significant identified abnormalities. There was severe, calcified, ulcerated plaque in the pilot’s aorta, and mild calcified plaque in the blood vessels of his brain. He was noted to have obesity and fatty liver. His kidney tissue showed changes consistent with chronic high blood pressure. NMS Labs performed toxicological testing of postmortem femoral blood from the pilot. Tramadol was detected at 420 ng/mL. O-desmethyltramadol was detected at 96 ng/mL. Venlafaxine was detected at 220 ng/mL. O-desmethylvenlafaxine was detected at 460 ng/mL. Delta-9-tetrahydrocannabinol (delta-9-THC) was detected at 2.4 ng/mL. 11-hydroxy-delta-9-THC was detected at 1.3 ng/mL. Carboxy-delta-9-THC was detected at 11 ng/mL. Caffeine was presumptively detected. The FAA Forensic Sciences Laboratory also performed toxicological testing of postmortem specimens from the pilot. Tramadol was detected at 547 ng/mL in heart blood and at 12,860 ng/mL in urine. O-desmethyltramadol was detected at 144 ng/mL in heart blood and at 2,043 ng/mL in urine. N-desmethyltramadol testing in heart blood was inconclusive; n-desmethyltramadol was detected at 317 ng/mL in urine. Venlafaxine was detected at 418 ng/mL in heart blood and at 3,885 ng/mL in urine. O-desmethylvenlafaxine was detected at 835 ng/mL in heart blood and at 8,388 ng/mL in urine. 11-hydroxy-tetrahydrocannabinol (11-hydroxy-THC) was detected at 1.7 ng/mL in heart blood and at 11.3 ng/mL in urine. Carboxy-delta-9-THC was detected at 27.4 ng/mL in heart blood and at 11.5 ng/mL in urine. Norchlorcyclizine was detected at 11 ng/mL in heart blood and at 11 ng/mL in urine. Metformin was detected in heart blood and urine. Glucose was not detected (normal result) in urine or vitreous fluid. Rivaroxaban, furosemide, metoprolol, losartan, terazosin, trimethoprim, and tetrahydrozoline were detected in heart blood and urine. On August 19, 2023, about 1254 central daylight time, a Piper J5A, N35417, was involved in an accident near Iola, Wisconsin. The airplane sustained substantial damage, and the pilot was fatally injured. The airplane was operated under Title 14 Code of Federal Regulations Part 91 as a personal flight. The pilot flew the airplane to Central County Airport (68C), Iola, Wisconsin, from Escanaba, Michigan, so that an annual inspection of the airplane could be performed at 68C by a mechanic. The mechanic stated that the pilot had driven twice and flown once before to 68C. The mechanic talked to the pilot about 1-2 days before the accident, when the pilot told him he would like to fly the airplane to 68C during a “weather window.” The mechanic told the pilot to tie down the airplane if he arrived on the weekend since he was going to be away. There was no record that the pilot received a ferry permit for the flight since the last annual inspection of the airframe and engine had expired; the airplane’s annual inspection was due in September 2022, about 11 months before the accident. A friend of the pilot drove to 68C to pick up the pilot; when the friend arrived at the airport, he did not see the airplane. The friend looked around the airport and found the airplane nosed over at the end of a taxiway. The friend then drove to a store and called 911. There were no witnesses to the accident. The airplane was nosed over near the northern end of a north/south grass taxiway at the airport. The airplane was near the middle of the taxiway and was oriented (nose to tail) approximately parallel to the taxiway (about 1,500 ft by 100 ft), which had a heading of about 030°. The taxiway was mowed and had a grass height of about 3 inches, which was the approximate grass height of the airport runways. The airport had a wind direction indicator and a windsock. The windsock was located about 500 ft down, relative to the southern end, and off the west side of the taxiway. A ground scar that preceded the airplane and was in line with the airplane nose extended about 16 ft from the airplane’s nose. The wing leading edges did not have impact damage. The propeller spinner and the underside cowl aft of the spinner had longitude scoring. The spinner had no rotational scoring/scratches. The propeller blades did not exhibit S-shaped bends/twists consistent with torsion due to engine power. Examination of the flight controls confirmed continuity from the control surfaces to the cockpit. Engine control continuity from the engine to the cockpit was confirmed. The fuel selector handle was in the left fuel tank position. Fuel selector detents were present when the fuel selector handle was moved through the off, left, and right positions. There was no fuel smell or evidence of fuel spillage at the accident site. There was no evidence of fuel leakage of the airplane fuel system. Both wing fuel caps were attached and secure. There were no placards relating to fuel type, quantity, and fueling instructions on the airplane. The header tank gascolator, which had a clear bowl, was approximately half full. The left and right wing tank fuel sight gauges were empty while