ERA23FA048

The pilot’s visual flight rules flight into instrument meteorological conditions during an approach to land at an airport in mountainous terrain, which resulted in controlled flight into terrain. Contributing to the accident was the pilot’s hazardous anti-authority attitude.

The pilot was a physician, and the purpose of flight was to attend to his patients for scheduled appointments at a medical office near the destination airport. He had frequently flown into the airport, which was located in mountainous terrain. Review of flight track data found that the flight followed a route that was consistent with what the pilot had entered into a flight planning application shortly before flight. Upon arrival in the destination airport area, the pilot announced over the airport’s common traffic advisory frequency that he would circle to land. There were no further communications recorded from the pilot. Flight track data revealed that the airplane completed a total of three approaches to the runway. The weather conditions reported at the time of the approaches were low instrument flight rule (IFR) conditions. Based upon hourly weather observations at the airport, surveillance video, and a pilot-rated witness located at the airport, visibility was likely restricted to 200-300 ft due to fog and low clouds. Based upon a witness statement and flight track data, it is likely that on each approach the pilot descended to a lower altitude in search of the runway environment. On the third and final approach, the airplane impacted a ravine and steep rock wall about 50 ft below the runway elevation and 375 ft short of the runway threshold (the runway sat atop of rising terrain, with a valley below). Based on this information, it is likely that the pilot descended below the runway elevation on final approach, which resulted in the pilot’s controlled flight into terrain while searching for the runway environment. The pilot did not file a flight plan, nor communicate with air traffic control during the flight after departing under visual flight rules (VFR). The airport had one published GPS circling instrument approach procedure. The airplane’s flight path and altitude were not consistent with this approach, and the weather conditions were far below published visibility and cloud ceiling minimums for the approach. Additionally, a few weeks before the accident, the airport had issued a Notice to Air Mission, which advised that the runway end identifier lights, and all airport lights, were out of service. Due to the extremely low visibility and clouds, it is unlikely that the runway lights would have aided the pilot’s search for the runway environment. Review of the pilot’s past flights into the accident airport found that he routinely conducted teardrop circling maneuvers to land in poor weather. Within the 90 days before the accident, a total of four flights were identified in which the pilot was able to land by circling over the airport under IFR or low IFR weather conditions. The approaches were likely conducted under VFR and into instrument meteorological conditions (IMC), given that the altitudes and flight track flown were not consistent with the published instrument approach procedure. There was one additional flight located in the pilot’s logbook, about four years before the accident, where remarks noted that he attempted an approach to the accident airport to check the low IFR conditions. The remarks noted that the low IFR conditions were confirmed during an approach, and he subsequently diverted to a nearby airport that he also frequently flew to. This nearby airport’s weather reporting station, around the time of the accident, reported similar low IFR conditions to the accident airport. There was no record that the pilot received a weather briefing before the flight, and it is not known what information he reviewed. Had he checked the weather, he would have seen that the destination airport was reporting low IFR conditions, as well as the other nearby airport that he had diverted two on the flight four years prior. While the pilot had logged several hours of actual instrument flight experience in the preceding 90 days before the accident, he did not possess instrument currency for the accident flight (nor had he filed an IFR flight plan). The investigation found that the pilot routinely flew VFR to the accident airport and conducted circling maneuvers to land into IMC. The pilot’s repeated VFR flight into IMC, his decision to fly an approach that was not consistent with the instrument approach procedure published for the airport, and lack of instrument currency demonstrated an anti-authority hazardous attitude, in which he repeatedly disregarded regulations and demonstrated poor judgement. It is possible that the pilot’s decision to conduct the flight was in-part influenced by his scheduled appointments with his patients, which would have increased the external pressures to complete the approach to landing. Toxicology testing revealed that the pilot had used phentermine, a stimulant and anorectic medication used to treat obesity. The drug also has a possible side benefit of increased alertness. Methamphetamine was also detected at low levels in some of the pilot’s tissue specimens; methamphetamine is also a central nervous stimulant and can be medically indicated to treat obesity. Due to extensive injuries, no blood specimens were available for toxicological testing, so whether these medications were at therapeutic levels could not be determined. The pilot’s use of prohibited substances, in addition to his decisions to habitually fly to the airport under VFR and into IMC, is a further example of poor judgment and an anti-authority hazardous attitude. The detection of these medications was more emblematic of his disregard of safety and rules than of impairment. Thus, while stimulants were detected in the pilot’s tissues, it is unlikely that the effects of the pilot’s use of phentermine and methamphetamine contributed to this accident. The sedating antihistamine chlorpheniramine was also detected in the pilot’s liver and muscle tissue, which is commonly taken to treat colds. Due to the lack of specimens available for toxicology testing, it is unknown whether the pilot had experienced side effects or if chlorpheniramine was at therapeutic levels. Thus, it could not be determined if the effects from the pilot’s use of chlorpheniramine was a factor in this accident.

Review of the pilot’s electronic logbook found that his most recent flight review and instrument proficiency check (IPC) was completed on March 30, 2021. In the past six months, the pilot logged three instrument approaches. The last flight logged was on October 28, 2022. The pilot did not meet the instrument currency requirements as prescribed in Federal Aviation Regulation § 61.57(c) Recent flight experience, which in-part required the completion of six instrument approaches. Review of commercially available flight track data for the accident airplane, and review of the pilot’s logbook from August 1, 2022, to November 1, 2022, found that the pilot had completed over 35 flights originating from either McGhee Tyson Airport (TYS), Knoxville, Tennessee, or DKX airport (the accident departure airport), to Middlesboro Bell County Airport (1A6), Middlesboro, Kentucky, or I35 airport. The 1A6 airport was along the route of flight between DKX and I35, located about 23 miles southwest from I35. In the three months before the accident, the pilot landed at I35 at least 15 times. The investigation further reviewed recent commercially available flight track data for the accident airplane and recent flights the pilot had logged to I35 airport. The review identified that the pilot routinely landed at I35 when the airport was reporting instrument flight rule (IFR) conditions or low IFR conditions. The flight track approaches varied; however, multiple flights displayed a similar circling maneuver and approach to runway 8 as in the accident flight. On September 27, 2022, the pilot completed a flight to I35 and landed at 0950. The Meteorological Aerodrome Reports (METARs) published around the time of the approach indicated IFR conditions. The METAR published nearest to the time of the landing observed a broken cloud ceiling at 100 ft and 10 statute miles of visibility. The flight track data showed that the flight completed a similar circling maneuver pattern over I35 as compared to the accident flight; however, the flight landed after the second approach to runway 8. The flight track was not consistent with the published GPS-A instrument approach procedure. On September 6, 2022, the pilot completed a flight to I35 and landed at 1048. The METARs published around the time of the approach indicated IFR conditions. The METAR published nearest to the time of the landing observed a broken ceiling at 500 ft and 10 statute miles of visibility. Review of the flight track showed that the pilot completed a straight-in approach to landing, which was not consistent with the GPS-A instrument approach procedure. On September 1, 2022, the pilot completed a flight to I35 and landed at 1004. The METARs published around the time of the approach indicated IFR conditions with a broken ceiling at 300 ft and 10 statute miles of visibility. Shortly before the approach, visibility was reported as 7 statute miles and the ceiling was overcast at 100 ft. The pilot completed a straight-in approach to runway 8; however, before landing, a 360° right turn was completed before rejoining the final approach and landing on runway 8. The track was not consistent with the GPS-A instrument approach procedure. On August 30, 2022, the pilot completed a flight to I35 and landed at 0912. The METARs at I35 published around the time of the approach indicated IFR conditions. On August 28, 2018, an additional notable flight to I35 was identified in the pilot’s logbook. The flight track data were not available. The logbook remarks entry stated that the weather conditions at I35 were IFR, with cloud ceilings reported at 100 ft and visibility at 1/4 statute miles. The remarks further stated that he conducted a “fly by” to check the ceiling at I35 and “confirmed” the weather conditions. He then diverted to 1A6 airport. The logbook remark stated: “IFR at i35 did a fly by to check ceiling reported at 100 and .25 viz. Confirmed, went back to 1a6.” According to the autopsy report from the Office of the State Medical Examiner, Frankfort, Kentucky, the pilot’s cause of death was extensive blunt force injuries and thermal burns, and the manner of death was accident. No significant natural disease was identified. Toxicology testing performed for the coroner’s office was positive for methamphetamine in the pilot’s brain tissue. Toxicology testing by the FAA Forensic Sciences Laboratory detected methamphetamine in the pilot’s brain tissue at 40 nanograms per gram (ng/g) and in his lung and muscle tissue; results were inconclusive in his liver tissue and his kidney tissue was unsuitable for analysis. The stimulant phentermine was detected in his liver, brain, kidney, muscle, and lung tissue. The sedating antihistamine chlorpheniramine and the non-sedating cough suppressant dextromethorphan and its metabolite dextrorphan were detected in the pilot’s liver and muscle tissue. No blood specimens were available for analysis. Methamphetamine is a Schedule II controlled substance that is a central nervous system stimulant. It is medically indicated to treat attention deficit hyperactivity disorder (ADHD), narcolepsy, and obesity. Methamphetamine has a high potential for abuse, and providers are cautioned to sparingly prescribe the medication and not to prescribe methamphetamine to combat fatigue or replace rest in normal persons. The use of methamphetamine may impair the ability to engage in hazardous activities such as driving a motor vehicle. The FAA does not allow a medical certificate to be issued if the pilot is using methamphetamine. Phentermine is a Schedule IV prescription medication indicated for treating obesity in patients with a body mass index 30 kilograms per meter squared or greater. Phentermine is a stimulant and has similar activity to amphetamine. There is a risk for abuse and dependence and so should be only prescribed as a short-term adjunct for weight reduction. Adverse reactions can include overstimulation, dizziness, insomnia, tremor, and headache. Phentermine may impair the ability to operate machinery or drive a motor vehicle. The FAA does not allow a medical certificate to be issued if the pilot is using phentermine. Chlorpheniramine is a sedating antihistamine available over the counter to temporarily relieve symptoms of allergies and colds such as runny nose or watery eyes. The FAA provides guidance on wait times before flying after using this medication; post-dose observation time is 60 hours, and the medication is not for daily use. All major portions of the airplane were located; a post-impact fire consumed a majority of the cockpit, fuselage, and portions of the left wing. Figure 4 provides an overview of the airport environment approaching runway 8 and the distribution of wreckage. Figure 4: Overview of the airport environment and distribution of wreckage Flight control cable continuity was established from the elevator, rudder, and elevator trim tabs to the fire-damaged forward cabin area. The left and right aileron control cable ends were identified in the forward cabin area and traced to the outboard wing areas where they were separated in tensile overload. Due to the impact and fire damage, the position of the flaps, landing gear, and fuel selector could not be determined. The cockpit, switches, levers, and flight instruments were all severely damaged or entirely consumed by fire. It was not possible to obtain any instrument reading from the recovered instrumentation. The attitude indicator was disassembled, and its gyro and housing exhibited rotational scoring. The engine had separated from its mount and the airframe. A large fracture hole was observed at the right forward area of the engine crankcase, which was consistent with impact related damage, and which prevented engine rotation. Examination of the engine and its components revealed no evidence of preimpact mechanical malfunctions or failures. Only one propeller blade was recovered at the acc