ERA14FA073

The pilot's failure to maintain airplane control while maneuvering the airplane in the traffic pattern at night. Contributing to the accident was the pilot's impairment from the use of illicit drugs.

The pilot and passenger departed on a night personal flight. A review of the cockpit voice recorder (CVR) transcript revealed that, immediately after departure, the passenger asked the pilot if he had turned on the heat. The pilot subsequently informed the tower air traffic controller that he needed to return to the airport. The controller then cleared the airplane to land and asked the pilot if he needed assistance. The pilot replied "negative" and did not declare an emergency. The pilot acknowledged to the passenger that it was hot in the cabin. The CVR recorded the enhanced ground proximity warning system (EGPWS) issue 11 warnings, including obstacle, terrain, and stall warnings; these warnings occurred while the airplane was on the downwind leg for the airport. The airplane subsequently impacted trees and terrain and was consumed by postimpact fire. Postaccident examination of the airplane revealed no malfunctions or anomalies that would have precluded normal operation. During the attempted return to the airport, possibly to resolve a cabin heat problem, the pilot was operating in a high workload environment due to, in part, his maneuvering visually at low altitude in the traffic pattern at night, acquiring inbound traffic, and being distracted by the reported high cabin temperature and multiple EGPWS alerts. The passenger was seated in the right front seat and in the immediate vicinity of the flight controls, but no evidence was found indicating that she was operating the flight controls during the flight. Although the pilot had a history of coronary artery disease, the autopsy found no evidence of a recent cardiac event, and an analysis of the CVR data revealed that the pilot was awake, speaking, and not complaining of chest pain or shortness of breath; therefore, it is unlikely that the pilot's cardiac condition contributed to the accident. Toxicological testing detected several prescription medications in the pilot's blood, lung, and liver, including one to treat his heart disease; however, it is unlikely that any of these medications resulted in impairment. Although the testing revealed that the pilot had used marijuana at some time before the accident, insufficient evidence existed to determine whether the pilot was impaired by its use at the time of the accident. Toxicology testing also detected methylone in the pilot's blood. Methylone is a stimulant similar to cocaine and Ecstasy, and its effects can include relaxation, euphoria, and excited calm, and it can cause acute changes in cognitive performance and impair information processing. Given the level of methylone (0.34 ug/ml) detected in the pilot's blood, it is likely that the pilot was impaired at the time of the accident. The pilot's drug impairment likely contributed to his failure to maintain control of the airplane.

Cockpit Voice Recorder (CVR) The CVR was forwarded to the NTSB Vehicle Recorders Laboratory in Washington, DC for readout. The CVR was a L-3 Fairchild FA-2100-1010; however, the serial number could not be determined. The thirty-minute digital recording consisted of four channels of audio information. Excellent quality audio information was recorded from both occupants' microphones and cabin/PA and good quality audio information was recorded from the cockpit area microphone. The exterior of the unit exhibited extensive heat and structural damage. Removal of the outer case revealed the interior crash-protected case did not exhibit any heat or structural damage. The memory ribbon cable that connected the memory to the external electronics was burned and not useable. A new ribbon cable was soldered to the accident memory, the memory boards were disassembled, cleaned and examined for damage, with no damage noted. The digital audio was successfully downloaded from the memory board. A CVR group was convened and a transcript was developed and is located in the public docket for this accident. The entire recording was transcribed and the recording began at an unknown time and ran approximately one minute with no one in the cockpit of the aircraft. Electrical power was cycled and the verbatim transcript began at 18:55:07. The recording contained events from startup, taxi, takeoff, climb, and the accident sequence. The airplane started to taxi at 1903:22 to the departure runway and remained short of the runway from 1908:54 to 1919:24 while the pilot addressed some aircraft system issues. During the flight the pilot received several obstacle, terrain , and bank angle warnings from the enhanced onboard ground proximity warning system. The pilot also received several stall warnings from the aircraft during the flight. The recording ended at 1924:02. Enhanced Ground Proximity Warning System (EGPWS) The EGPWS was a Honeywell MK V EGPWS and an exterior examination revealed the unit had sustained heat exposure with charring to the unit's housing. An interior inspection revealed no heat or impact damage to the circuit boards and the data was extracted by the NTSB Recorders Laboratory. The unit was designed to record events triggered by exceeding preset limits in 7 different modes, 3 of the modes required urgent attention by the flight crew. Once a limit was exceeded, a new event would be recorded at one sample per second that included 20 seconds before and 10 seconds after the exceedance. The accident flight data recording was triggered by 13 EGPWS alerts over two separate periods of time. The first period of time contained one, "Too Low Terrain" alert during the accident flight's takeoff. The second period of time contained 12 alerts spanning a time of about 50 seconds. The initial alert, during the second period of time, was a "Caution Obstacle" alert that was triggered by a smokestack, located 3 miles to the northeast of the airport and about 1,200 feet laterally from the airplane's recorded flight path. Two subsequent "Obstacle Pull-Up" warnings were recorded 4 and 15 seconds following the initial warning. For more detailed information on the EGPWS, please refer to the "EGPWS Factual Report" located in the public docket for this accident. Flight Management Computer (FMC) The FMC was a Rockwell Collins FMC-3000, Part No. 822-0883-701. An exterior examination of the unit revealed impact and thermal damage and an interior examination revealed the condition of the circuit board was acceptable to be placed into a test fixture. After being loaded into the test fixture, the unit failed to power up, and additional troubleshooting revealed the circuit board had damage consistent with impact damage. The damaged parts were replaced and the data was partially recovered. Some of the data was determined to be corrupted; however, an Angle of Attack (AOA) fault was displayed on the Cockpit Display Unit (CDU) prior to the accident flight's takeoff. Further research revealed that had the source of the AOA fault come from the flight management system, the FMC would have logged the fault in the data. For more detailed information on the FMC, please refer to the "Flight Management Computer Factual Report" located in the public docket for this accident. Maintenance Data Computer (MDC) The MDC was a Rockwell Collins MDC -3000, Part No. 822-1139-021. An exterior examination of the unit revealed impact and thermal damage to the casing and an interior examination revealed the primary circuit board contained flexure damage. The circuit board sustained damage that prohibited directly inserting it into a test fixture. Special connectors were utilized to connect the board to a test bench, and the data was downloaded successfully. The accident flight was identified as two faults were logged at 1921. The faults logged were "FMC 2 – NO BUS TO IOC" and a fault for the TCAS (Traffic Collision Advisory System). The FMC fault could be concluded as a nuisance fault when generated by the aircraft with only one FMC installed, as was with the accident airplane. The TCAS fault was also likely a nuisance fault and was reported as "fairly common" during the startup sequence and timing within the system. For more detailed information on the MDC please refer to the "Maintenance Data Computer Factual Report" located in the public docket for this accident. Air Data Computer (ADC) The airplane was equipped with two ADC units. Both units were manufactured by Rockwell Collins as the ADC-3000, Part No 822-1109-016. The Serial No. on the units were 12WYB and 13TVC. Exterior examination revealed impact damage to the housing and foreign object debris from impact. The memory chip on the unit with Serial No. 12WYB was damaged and data could not be recovered. The circuit board from the unit with Serial No. 13TVC was removed and data was successfully recovered. The recovered data included 44 flights and revealed only normal weight on wheel transition in the log and no failures were logged. The ADC indicated that the unit was shut down and powered up twice on the ground prior to the event flight. The unit further recorded the last weight on wheels transition (take-off) 25 minutes after having been powered up and no record of returning to "on-ground." The airport in a publically owned airport and at the time of the accident had an FAA operating control tower. The airport was equipped with three runways designated as runway 8/26, 9/27, and 14/32. Runway 8/26 was reported as "in good condition" and runway 9/27 and 14/32 was reported as "in fair condition." Runway 8/26 was 5,797-foot-long by 100-foot-wide, runway 9/27 was 2,801-foot-long by 60-foot-wide, and runway 14/32 was 4,158 -foot-long by 100-foot-wide. The airport was surveyed at 841.1 feet above mean sea level. An autopsy was performed on the pilot on December 18, 2013, by the Fulton County Medical Examiner, Atlanta, Georgia. The autopsy findings included Atherosclerotic cardiovascular disease, post mortem thermal burns, and "multiple blunt force injuries." The report listed the specific injuries. The cause of death was reported as "multiple blunt force injuries of the head, torso and extremities." Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated no carbon monoxide nor ethanol was detected in the blood (Cavity). The report listed the following drugs being detected: • Atenolol detected in Blood (Cavity) • Atenolol detected in Liver • Sildenafil detected in Blood (Cavity) • Sildenafil detected in Liver • Desmethylsildenafil detected in Blood (Cavity) • Desmethylsildenafil detected in Liver • Tadalafil detected in Blood (Cavity) • Tadalafil detected in Liver • 0.34 (ug/ml, ug/g) Methylone detected in Blood (Cavity • Methylone detected in Liver • 0.0021 (ug/ml, ug/g) Tetrahydrocannab