ERA15FA361

The pilot's failure to maintain a stabilized instrument approach, which resulted in a loss of control.

The commercial pilot departed in his amphibious, single-engine airplane on an instrument flight rules (IFR) flight plan for his home seaplane base. When the pilot arrived near his destination, he cancelled his flight plan with air traffic control (ATC), then circled in the area before requesting another IFR clearance to an airport that was equipped with an instrument approach. ATC cleared the pilot for the approach. A review of radar data indicated that the approach was normal until the airplane passed over the final approach fix; it then went off course and entered a steep descent into a residential neighborhood. Postaccident examination of the airframe, engine, and data downloaded from the electronic engine monitor revealed no mechanical deficiencies that would have precluded normal operation before impact. The pilot's logbook revealed that he had been actively training for his flight instructor certificate for instrument airplane and had recent IFR experience. The pilot's toxicology testing was positive for metabolites of cocaine; however, it could not be determined if he was impaired at the time of the accident. The pilot was also under investigation by the Federal Aviation Administration (FAA) for not reporting his past use of illegal drugs and suicidal thoughts. The FAA had conducted two psychological evaluations and a review was in process regarding the status of his medical certificate at the time of the accident. However, the investigation could not determine whether any underlying psychiatric or psychological conditions contributed to the pilot's behavior at the time of the accident.

An autopsy was conducted on the pilot by the Florida Medical Examiner's Office - District 5, Leesburg, Florida. The cause of death was multiple blunt force injuries. Toxicology findings from the FAA's Bioaeronautical Research Sciences Laboratory were positive for the following metabolites of cocaine: Anhydroecgonine Methyl Ester detected in the liver and cavity blood. Benzoylecgonine and ecgonine methyl ester detected in cavity blood. The 56-year-old pilot had a history of illegal drug use and suicidal thoughts. At the time of the accident, he was under investigation by the FAA for not reporting this past history on his application for a medical certificate. As a result of these findings, the NTSB's Chief Medical Officer conducted a postaccident review of the pilot's FAA Medical File and Medical Case Review. According to the NTSB Medical Factual Report, the pilot initially applied for and received an FAA medical certificate and student pilot certificate in 2006. Records in the FAA file indicated that the pilot was pulled over for reckless driving on September 15, 2007, and, after a search of his vehicle, he was arrested and later convicted for possession of 6 grams of marijuana and related paraphernalia. He completed 6 weeks of drug treatment and probation as a result of this conviction, and when the FAA became aware of this event, they reviewed pertinent records pertaining to the conviction. In 2009, the FAA determined that the pilot was eligible for a third-class medical certificate. On August 11, 2014, the FAA issued the pilot a second-class medical certificate with a limitation for corrective lenses. At that time, he reported the use of testosterone and vitamin B12 on the medical application. On September 15, 2014, a call was made to the FAA's Hotline regarding the pilot's mental status and behavior, including the fact that the pilot had recently sued his homeowner's association and neighbors over complaints they had made about his flying. On September 25, 2014, the FAA began its investigation into the allegations and required the pilot to provide information regarding an incident in June 2007, where the pilot had been committed to a psychiatric ward at the request of the police. According to a copy of the police report obtained separately from the FAA medical file, this was the result of an episode where he had been using cocaine, had made comments to friends and family about suicide, and had been shooting guns inside his residence. According to friends and family, he was threatening to commit suicide using the firearm in his hand at the time. As part of the ongoing FAA investigation to determine the pilot's eligibility for a medical certificate, complete psychiatric and psychological evaluations were requested in February 2015. The reports from these evaluations are contained in his FAA file; in each, the pilot denied the use of any illicit substance and reported only the occasional use of alcohol. No psychiatric or psychological diagnosis was made by either practitioner who examined the pilot. These reports were provided to the FAA in a letter dated April 16, 2015. On August 10, 2015, the FAA referred all of the medical files on the pilot to the FAA's psychology consultant, requesting an evaluation and determination of the pilot's eligibility for a medical certificate. No final determination had been made at the time of the accident. The weather conditions reported at BKV at 0853, included wind from 030° at 6 knots, visibility 10 statute miles, overcast ceiling 500 ft (variable between 400 and 800 ft), temperature 24° C, dew point 22° C, and an altimeter setting of 29.84 inches of Hg. The pilot held a commercial pilot certificate with ratings for airplane single-engine land, single-engine sea, and instrument airplane. His most recent FAA second-class medical certificate was issued on August 11, 2014. A review of the pilot's logbook revealed that as of September 17, 2015, he had accrued a total of 559 flight hours, of which 320.7 hours were in the accident airplane make and model. He also had 55.5 hours of simulated instrument time, and 15.8 hours of actual instrument experience. In the 6 months preceding the accident, the pilot logged 3.0 hours of actual instrument time, of which 1.8 hours were logged two days before the accident while receiving instruction for his instrument flight instructor rating. The instruction included holding procedures and six instrument approaches. He also logged 5.8 hours of simulated instrument time in the 6 months preceding the accident, which included navigation and standard terminal arrival routes. The airplane came to rest in the backyard of a private residence. All major components of the airplane were accounted for at the site, and there was no postimpact fire. The point of initial impact was a stand of trees that were about 80 ft tall. The airplane then collided with a fence and the ground before coming to rest about 75 ft from the initial impact point. Severed tree limbs, the left elevator, the left elevator tip fairing, a tire, and a propeller blade were scattered along the wreckage path. The main wreckage included the propeller, engine, fuselage, tail section, and both pontoons. Several of the severed tree limbs exhibited flat, 45° cut surfaces with black paint transfer. Examination of the main wreckage revealed it was twisted, crushed, and partially lying on its right side. Flight control continuity was established for all major flight control surfaces. The flaps were fully retracted and the wheels were extended. The elevator trim tab was in the 10° down position. The left wing remained attached to the fuselage and sustained impact damage. The fuel tank was breached, and first responders reported fuel draining from the wing upon their arrival at the scene. The right wing also sustained impact damage and had separated from the fuselage at the wing root. First responders reported fuel draining from the right wing's tank; in addition, about 5 gallons of 100LL fuel were drained during the recovery process. The two header tanks appeared to be undamaged. The fuel selector valve was selected to the right tank. The firewall fuel strainer remained attached to the firewall and the bowl was full of fuel. Some fuel was also found in the engine-driven fuel pump and fuel manifold valve. No evidence of water or contamination was observed. According to a fuel provider at FMY, the airplane was topped off with 36.5 gallons of 100LL fuel the day before the accident. The engine remained partially attached to the airframe by control cables, and the three-bladed propeller had separated from the engine at its hub. The spinner exhibited rotational damage. One blade had separated from the propeller hub and was found in the initial impact crater. The blade was bent forward. The other two blades remained in the hub, which was located about 4-ft from the fuselage. The second and third blades were twisted. The engine crankcase sustained impact damage to the lower forward area and was leaking oil. The top spark plugs were removed and exhibited normal wear as per the Champion Check-A-Plug chart. The rocker covers were removed and the engine was manually rotated. Compression and valve train continuity was established on all but the No. 6 cylinder. Further examination revealed the push rod and push rod tube for the No. 6 cylinder was impact-damaged. The left magneto remained attached to the engine; however, the right had separated from its mounting pad and remained attached via the ignition leads. When the engine was rotated, spark was produced to each of the left magneto's ignition leads. An electric drill was used to spin the right magneto, and spark was produced to each ignition lead. The fuel manifold valve was removed from the engine and disassembled. A small amount of fuel was in the valve and the diaphragm was intact. The fuel screen was absent of debris. Although the No. 1 i