ERA16FA035

The pilot’s loss of airplane control due to spatial disorientation. Also causal to the accident was the pilot’s impairment by the combined effects of multiple medications and drugs.

The purpose of the flight was for the commercial pilot/owner to pick up passengers at the destination airport and return to the departure airport. The airplane was 33 miles from its destination in cruise flight at 3,300 ft mean sea level (msl) and above a solid cloud layer when the pilot declared to air traffic control (ATC) that he had the destination airport "in sight" and cancelled his instrument flight rules (IFR) clearance. During the 13 minutes after cancellation of the IFR clearance, the airplane's radar track made an erratic sequence of left, right, and 360° turns that moved the airplane away from the destination airport in a westerly direction. The altitudes varied between about 4,000 and 900 ft msl. Later, the pilot reestablished communication with ATC, reported he had lost visual contact with the airport, and requested an instrument approach to the destination airport. The controller then provided a sequence of heading and altitude assignments to vector the airplane onto the approach, but the pilot did not maintain these assignments, and the controller provided several corrections. The pilot expressed his inability to identify the initial approach fix (IAF) and asked the controller for the correct spelling. The radar target then climbed and subsequently entered a descending right turn at 2,500 ft msl and 180 knots groundspeed near the IAF, before radar contact with the airplane was lost. Although a review of airplane maintenance records revealed that the airplane was overdue for several required inspections, examination of the wreckage revealed signatures consistent with both engines being at high power at impact, and no evidence of any preimpact mechanical anomalies were found that would have precluded normal operation. Examination of the airplane's panel-mounted GPS, which the pilot was using to navigate the flight, revealed that the navigation and obstruction databases were expired. During a weather briefing before the flight, the pilot was warned of low ceilings and visibility. The weather conditions reported neara the destination airport about the time of the accident also included low ceilings and visibilities. The restricted visibility conditions and the high likelihood of inadvertent entry into instrument meteorological conditions were conducive to the development of spatial disorientation. The flight's erratic track, which included altitude and directional changes inconsistent with progress toward the airport, were likely the result of spatial disorientation. After reestablishing contact with ATC and being cleared to conduct an instrument approach to the destination, the airplane's flight track indicated that the pilot was not adequately prepared to execute the controller's instructions. The pilot's subsequent loss of control was likely the result of spatial disorientation due to his increased workload and operational distractions associated with his attempts to configure his navigation radios or reference charts. Postaccident toxicological testing of samples obtained from the pilot revealed the presence of ethanol; however, it could not be determined what percentage was ingested or produced postmortem. The testing also revealed the presence of amphetamine, an opioid painkiller, two sedating antihistamines, and marijuana. Although blood level quantifications of these medications and drugs could not be made from the samples provided, their combined effects would have directly impacted the pilot's decision-making and ability to fly the airplane, even if each individual substance was only present in small amounts. Based on the reported weather conditions at the time the pilot reported the airport in sight and canceled his IFR clearance, he likely was not in a position to have seen the destination airport even though he may have been flying between cloud layers or may have momentarily observed the ground. His decision to cancel his IFR clearance so far from the destination, in an area characterized by widespread low ceilings and reduced visibility, increased the pilot's exposure to the hazards those conditions posed to the successful completion of his flight. The pilot showed other lapses in judgment associated with conducting this flight at the operational, aircraft, and the personal level. For example, 1) the pilot did not appear to recognize the significance of widespread low ceilings and visibility along his route of flight and at his destination (nor did he file an alternate airport even though conditions warranted); 2) the accident airplane was being operated beyond mandatory inspection intervals; and 3) toxicological testing showed the pilot had taken a combination of multiple medications and drugs that would have likely been impairing and contraindicated for the safe operation of an airplane. The pilot's decision-making was likely affected by the medications and drugs.

The Division of Forensic Sciences, Georgia Bureau of Investigation, performed an autopsy on the pilot. The autopsy report stated that the cause of death was "blunt force injuries." The FAA Bioaeronautical Research Sciences Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens from the pilot. The testing identified 0.203 gm/dl of ethanol, N-propanol, amphetamine, 0.6 ug/g of tramadol, and its active metabolite O-desmethyltramadol in the muscle tissue. In addition, tetrahydrocannabinol (THC), the active compound in marijuana, and its metabolite, tetrahydrocannabinol carboxylic acid (THC-COOH) were found in the lung tissue. Cetirizine and THC-COOH were identified in the kidney tissue. Finally, 0.044 gm/dl of ethanol, doxylamine, 1.976 ug/g of tramadol, O-desmethyltramadol, and THC-COOH were found in the liver tissue. Ethanol may be detected due to ingestion, or it may be produced in body tissues by postmortem microbial activity. Ethanol significantly impairs pilots' performance even at very low levels. Federal Aviation Administration regulations 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. N-propanol is another type of alcohol that is produced in body tissues after death. Amphetamine is a prescription medication used to treat attention deficit/hyperactivity disorder and narcolepsy. It is often marketed with the name Adderall. It carries a warning regarding the high likelihood for abuse. Tramadol is an opioid analgesic available by prescription, commonly marketed with the name Ultram. O-desmethyltramadol is created in the body by the metabolism of tramadol and has psychoactive effects. Cetirizine and doxylamine are both sedating antihistamines available in several over-the-counter products. Doxylamine is so sedating, it is primarily used as a sleep aid. Tramadol, cetirizine, and doxylamine all carry warnings regarding sleepiness and hazards to driving safety. Medical, pharmacy, and drug rehabilitation records were requested from three different law firms handling affairs for the pilot and his estate and none were provided. The 1015 weather observation at Decatur County Industrial Airpark (BGE), 8 miles west of the accident site, included wind from 050°at 10 knots, an overcast ceiling at 400 ft, 2 miles visibility in fog, temperature 16°C, dew point was 15°C, and an altimeter setting of 30.04 inches of mercury. Weather observations at airports surrounding the accident site reported cloud ceilings between 200 and 800 ft above ground level (agl). Photographs taken a few minutes before the accident by a passenger waiting at the destination airport showed a ceiling estimated to be between 200 and 250 ft agl with mist and fog in the treetops. The pilot received an official weather briefing from Lockheed Martin Flight Service (LMFS) by phone at 0830. During his weather briefing, the pilot and the briefer discussed how the pilot had "looked up" the latest weather conditions, a SIGMET along his route of flight, a center weather advisory for rain, embedded thunderstorms, and low IMC. The LMFS weather briefer told the accident pilot that "it's pretty bad out there." The pilot then requested the closest terminal area forecast and mentioned that he might "give it an hour before taking off, as it sounds like things are clearing out." Instead, the pilot departed about 30 minutes later. The pilot did not file an alternate airport in his flight plan. A center weather advisory for IFR conditions was in effect for the area surrounding the destination airport at the time of the accident, and upper air balloon data showed a solid cloud layer that reached about 2,500 ft msl over the southeastern United States. Clouds above that layer were likely between 5,000 and 12,000 ft msl. The pilot/owner held a commercial pilot certificate with ratings for airplane single-engine land, multiengine land, rotorcraft helicopter, and instrument airplane. His most recent FAA third-class medical certificate was issued on May 30, 2013. At that time, the pilot reported 1,150 total hours of flight experience. The pilot-rated passenger held a commercial pilot certificate with ratings for airplane single-engine land, multiengine land, rotorcraft helicopter, and instrument airplane and helicopter. His most recent FAA second-class medical certificate was issued on December 4, 2014. At that time, he reported 9,500 total hours of flight experience. The wreckage was examined at the accident site on November 10, 2015. There was a strong odor of fuel, and all major components of the airplane were accounted for at the scene. The wreckage path was oriented along a magnetic heading of about 175° and was about 150 ft long and about 45 ft wide. The initial impact point was in a 60-ft-tall tree, and the airplane impacted several other trees before impacting the ground about 24 ft beyond the first tree strike. Several pieces of angularly cut wood were found throughout the length of the debris field. The airplane was fragmented and scattered along the length of the wreckage path. Control continuity to the wings, rudder, and elevator was confirmed through the control cables and bellcranks to the cockpit area. The cockpit, cabin area, and empennage were destroyed by impact forces and postcrash fire and were found entangled about 48 ft down the wreckage path. The engines and their respective propeller assemblies were entangled with the main wreckage and were severely damaged by impact and fire. All four propeller blades exhibited similar twisting, bending, leading and trailing edge gouging, and chordwise scratching. The tips of each blade on one propeller system were melted away by fire. One propeller blade tip was fractured and found 215 ft southeast of the main wreckage. The compressor and power turbine sections of both engines were exposed, and the compressor tips were all bent opposite the direction of rotation. Metal spray deposits were observed on the suction side of the third-stage stator vanes. According to FAA and maintenance records, the airplane was manufactured in 1980 and was equipped with two 715-horsepower Garrett Research TPE331-8-402S turboprop engines. The most recent phase inspections were completed on April 25, 2014, at 18,422.8 total aircraft hours. The airframe logbook entry documenting those phase inspections noted that 3 subsequent phase inspections were due in September 2014, with an additional phase inspection due in September 2015. No additional phase inspections had been logged. The final airframe logbook entry dated September 22, 2015, indicated that the airplane had accrued 18,513.7 total aircraft hours. An aircraft maintenance facility at the pilot's home airport (LAL) maintained the accident airplane, the other airplanes in the pilot's fleet, and their collective maintenance records. The owner and president of the maintenance company, an airframe and powerplant mechanic, provided a detailed maintenance and event history on the accident airplane and the rest of the pilot's fleet. The airplane was purchased from Australia, and the engines were on an approved operator's maintenance program there. Once purchased and brought to the United States, the airplane's engines were due for overhaul. They were subsequently removed at LAL, overhauled in Ohio, then reinstalled at LAL. The engine overhauls were not completed at the same time, so the pilot/owner requested that the overhauled engine be installed along with a rental engine. On the first flight after installation, the pilot aborted the first takeoff, closed the throttles, feathered the propellers, and then attempted an engine restart. The pilot's actions were contrary to the checklist and resulted in damage to the compressor section of the overhauled engine. In June 2014, new, metal, four-bladed propellers were installed on the airplane at the owner's request. No one w