ERA15FA352

The student pilot's improper decision to intentionally maneuver at low altitude while waving to people on the ground, which led to the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall.

The student pilot was conducting a local flight that consisted of traffic pattern work and landings and then several orbits in the area. After completing the orbits, the student flew near a friend's house, where he executed a left, 360° turn while flying at a low altitude despite being counseled against doing so by his flight instructor and the instructor's son, who was also a pilot. The instructor reported that the student had a habit of "making low passes." The student's friend waved to him, and he waved back, and then the friend and another witness noticed the airplane's bank angle increase while the airspeed was slowing. According to GPS data, while the airplane was flying about 58 mph, which is about the stall speed with the airplane at gross weight with the flaps retracted and a bank angle of about 20°, its nose pitched down, consistent with a stall/mush. Witnesses reported hearing the engine rev-up, hesitate briefly, then respond during the uncontrolled descent, but they reported it was "too late." The airplane impacted a wooded area, and its propeller cut some trees, consistent with the engine developing power at the time of impact. Examination of the airplane revealed that the flaps were retracted, and there was no evidence of preimpact failure or malfunction of the flight controls for roll, pitch, or yaw. It is likely that the student, while maneuvering and turning the airplane while waving, which would have increased his workload, was unable to appropriately divide and prioritize his attention and allowed the airplane to exceed its critical angle of attack near its stall speed at too low of an altitude to recover. Although toxicological evidence indicated that the pilot had used three sedating and/or impairing substances (amitriptyline, tetrahydrocannabinol, and diphenhydramine, the last two of which were at very low levels), the investigation could not determine whether they contributed to the accident or affected the student's aeronautical decision-making.

The Gloucester County Medical Examiner's Office performed a postmortem examination of the pilot. The cause of death was reported to be "multiple injuries." The only finding of natural disease was a 3/8-inch scar in the midsection posterior wall of the left ventricle. NMS Labs, Willow Grove, Pennsylvania, conducted forensic toxicology testing of specimens from the pilot, and no positive findings were reported. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, also performed forensic toxicology testing on specimens from the pilot. According to the FAA toxicology report, the results were negative for carbon monoxide and volatiles; testing for cyanide was not performed. Unquantified amounts of amitriptyline, diphenhydramine, nortriptyline, tetrahydrocannabinol (THC/marijuana) and tetrahydrocannabinol carboxylic acid (marijuana) were detected in the liver specimen. An unquantified amount of diphenhydramine was detected in the blood below the lower end of the therapeutic range. The blood also contained 0.126 ug/ml or ug/g amitriptyline, 0.065 ug/ml or ug/g nortriptyline, and 0.046 ug/ml tetrahydrocannabinol carboxylic acid. No THC was detected in the blood. Amitriptyline is a tricyclic antidepressant that causes sedation, which is more pronounced when initiating the drug or increasing the dose. Commonly marketed with the name Elavil, its usual therapeutic levels are between 0.0050 and 0.2000 ug/ml. Nortriptyline is an active metabolite also available by prescription with the trade name Pamelor. These medications may also be used to treat insomnia and as adjunct medications in the treatment of chronic pain. Diphenhydramine is a sedating antihistamine used to treat allergy symptoms and as a sleep aid. It is available over the counter with 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; 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%." Tetrahydrocannabinol carboxylic acid is the major metabolite of THC, the active component in marijuana. Both diphenhydramine and THC may have hangover effects when their levels in the blood are very low or undetectable. At 1154, South Jersey Regional Airport, Mount Holly, New Jersey, which was located about 10 nautical miles north of the accident site, reported wind variable at 6 knots, visibility 10 statute miles, few clouds at 2,600 ft, scattered clouds at 3,800 ft, broken clouds at 11,000 ft, temperature 25°, dew point 19° C, and altimeter setting 29.79 inches of mercury. The student pilot, age 65, was issued third-class medical and student pilot certificates in March 2010, April 2012, and July 3, 2014; all three certificates contained a limitation to wear corrective lenses. On the application for his last certificate, he listed a total flight time of 115 hours. His last solo signoff in a Cessna 150 airplane was dated August 1, 2015. A review of the pilot's logbook revealed two entries in 1998. The next entry was dated March 8, 2010, which was 2 days after he purchased the airplane. The pilot flew consistently in 2010, but he only flew three times in 2011 and once in December 2012. The next logged flight was on August 1, 2015, which was a 0.9-hour-long dual flight in the accident airplane, and it was the only logged flight for 2015. The pilot logged a total flight time of about 69 hours, about 67 hours of which were in the accident airplane. Additional flight time was logged in a black notebook located in the wreckage, but some pages of the notebook were missing. The first logged flight was February 25, 2013, and ended with a tachometer time of 6,159.3 hours, and the last logged flight was September 5, 2015, and ended with a tachometer time of 6,206.0 hours. Between these dates, the pilot accrued 46.7 hours. In the last 90 and 30 days, he logged 5.4 and 2.2 hours, respectively, all of which were in the accident airplane. Based on the time provided on his medical application (115 hours) and the student pilot's subsequent logged time (15.3 hours), the student pilot's estimated total flight time was 130.3 hours, 128.3 hours of which were in the accident airplane. The student pilot's friend reported flying with the pilot in the accident airplane. The friend reported that, during one flight, the pilot performed a low pass over the same area where the accident occurred, although he could not recall the altitude. He reported that the pilot orbited twice and then returned to 19N. According to the student pilot's instructor, who was formerly a Federal Aviation Administration (FAA) designated pilot examiner (DPE), he conducted the pilot's last 90-day flight check on August 1, 2015. During that flight, the pilot only performed traffic pattern work. He also indicated that he knew that the pilot had a habit of "making low passes" and, being a former DPE, he had numerous talks with the pilot about the hazards of performing low passes. He indicated that his son, who is a pilot for a major US airline, also had a discussion with the pilot about his tendency to perform low passes and maneuver at low altitudes. The instructor indicated that he had not contacted an FAA flight standards district office about the low-pass issue and that he had last discussed the issue with pilot about 1 month before the accident. The wreckage was moved from the accident site with FAA approval but without NTSB consultation on the day of the accident and taken to 19N where it was secured. The recovery involved mechanically cutting the airplane to allow it to be loaded into a trailer. The airplane crashed in a wooded area behind and near residences at an elevation of 116 ft and damaged several trees. Damage to a tree was noted about 44 ft agl. Closer examination of the tree trunk, which was 9 inches in diameter, revealed gray colored paint transfer marks on the smooth cut surface oriented on about an 18° angle from vertical. A second tree, located about 21 ft from the base of the first tree, exhibited damage about 22 ft agl. Further examination of the tree revealed scars along its trunk to ground level and black-colored transfer marks on the smooth cut surface. The airplane's resting position was oriented on a magnetic heading of 328°. Following removal of the wreckage from the recovery trailer, extensive structural damage either by impact or during the recovery process was noted. The engine remained attached to the engine, and the propeller remained attached to the engine. Examination of the fragmented cockpit revealed that both seats were separated from the seat tracks, but both seats were recovered. The pilot's lapbelt was found unbuckled, and both ends remained attached to the structure, but the webbings of the dual shoulder harness, which was unbuckled, were cut. Impact damage was noted to the pilot's seat, and damage was noted to the seat pin locking hole that was sixth from the front. An aft seat stop was in place on the outboard seat track. The fuel selector was positioned to "on," and the airspeed indicator was indicating 110 knots. Examination of the pilot's control yoke revealed that the GPS mount was attached, and the left grip was fractured. The throttle was extended about 1/4 inch, and the mixture, carburetor heat, and primer controls were full in. The flap selector was in the middle position, and the ignition switch was in the right position; the key was bent right. The oil temperature was off-scale low, the oil pressure was 0, and tachometer indicated 0 rpm. Examination of b