WPR12FA339

The pilot’s failure to maintain control of the airplane during initial climb. Contributing to the accident was the pilot’s impairment by prescription pain medication.

Two witnesses who were onboard the airplane during an attempted takeoff before the accident flight stated that, during the takeoff, the airplane appeared to accelerate and lift off normally. However, as the airplane climbed about 20 feet above the runway, it wobbled to the left and right and drifted slightly to the left. The pilot subsequently aborted the takeoff. Upon returning to the terminal, the pilot had both passengers exit the airplane, and he then taxied back to the active runway. During the second attempted takeoff, several witnesses observed the airplane begin a normal takeoff roll, lift off about one-third of the way down the runway, and enter a nose-high attitude. The airplane was observed rotating back and forth along its longitudinal axis before entering a steep right turn. Subsequently, witnesses observed the airplane descend into an unoccupied hangar. All of the witnesses reported that the engine sounded normal and appeared to be producing power during the takeoff and accident sequence. Postaccident examination of the accident site and airplane wreckage revealed signatures consistent with a near-vertical impact with the hangar. Examination of the airplane, flight control systems, engine, and propeller revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. At the time of the accident, the airplane was within weight and balance limitations. Review of the pilot's personal primary care medical records revealed treatment for shift-work sleep disturbance with zolpidem and treatment of hypertension with valsartan. On each visit, the primary physician recorded that the pilot reported no use of drugs or alcohol. Postaccident toxicology testing revealed positive results for losartan (also used to treat hypertension), zolpidem, and buprenorphine, which is a controlled substance used to treat severe pain. The pilot's primary care medical records did not mention acute or chronic pain or its treatment. Buprenorphine carries a warning from the Federal Drug Administration that it "may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery)." Further, opiates cause, in part, sedation, alterations in cognitive and sensory efficiency, respiratory depression, nausea, vomiting, headache, and sleep and concentration disorders. With chronic use, tolerance can develop, which mitigates the drug's effects. Several issues made the interpretation of the toxicology report difficult. Opioids may undergo postmortem redistribution, which may result in postmortem levels not directly reflecting antemortem levels. In addition, depending on the pilot's pattern of use, it is possible that he had some degree of tolerance for the drug's effects. Further, his actual dosing interval may not have been the same as the dosing interval noted on the prescription bottle found in the airplane. Thus, it was not possible to determine the exact effects of the drug on the pilot at the time of the accident. In addition, the effects of the underlying chronic pain syndrome on the pilot's performance are unknown. However, it is likely that the pilot was using a significant amount of opiate medication at the time of the accident, and, therefore, that he was impaired to some degree as a result.

The Truckee-Tahoe Airport is a non-tower controlled airport with a reported field elevation of 5,901 feet. The airport was equipped with two asphalt runways, runway 10/28 (7,000 feet long by 100 feet wide) and runway 01/19 (4,630 feet long by 75 feet wide). Airport personnel reported that runway 10/18 was closed due to runway resurfacing and an active Notice to Airmen (NOTAM) was in effect during the time of the accident. Investigative personnel noted that rising terrain was present in all quadrants of the airport, including the departure end of runway 19. The Nevada County Coroner conducted an autopsy on the pilot on August 3, 3012. The medical examiner determined that the cause of death was "…Multiple blunt force injuries." The FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology tests on the pilot. According to CAMI's report, carbon monoxide, cyanide, volatiles, and drugs were tested with negative results, and had positive results for 0.046 (ug/mL, ug/g) Buprenorphine detected in Liver, 0.011 (ug/mL, ug/g) Buprenorphine detected in Blood (Aortic), Losartan detected in Urine, Losartan detected in Liver, 0.026 (ug/mL, ug/g), Norbuprenorphine detected in Blood (Aortic), Norbuprenorphine detected in Liver, Zolpidem detected in Liver, and Zolpidem detected in Muscle. The FAA blue ribbon medical file, autopsy results, toxicology report, investigator's report, and personal medical records were reviewed by the Chief Medical Officer for the National Transportation Safety Board. According to the FAA blue ribbon medical file, this pilot was first medically certified in 1971, limited by a requirement for corrective lenses. In 1988, he returned his medical certificate to the FAA because of ongoing treatment for drug and alcohol addiction. The pilot participated in a diversion program for physicians which required routine drug and alcohol testing in addition to treatment and support group attendance, which ended 5 years later. By 1990 he had two years of sobriety and was again granted a second class medical certificate. In 1992, he reported having completed five years of sobriety in California's diversion program for physicians. In 2005 he reported treatment for hypertension and high cholesterol. His most recent medical certification was issued February 13, 2012; at that time he reported only using Diovan (Valsartan, a blood pressure medication). The toxicology results from the Civil Aeromedical Institute revealed Losartan (marketed under the trade name Cozaar and used to treat hypertension) in liver and urine; zolpidem (marketed under the trade name Ambien and used to treat insomnia) in liver and muscle; 0.011ug/mL of buprenorphine in the blood and 0.046ug/mL in liver, and its primary active metabolite norbuprenorphine in blood at 0.026ug/mL. Buprenorphine is a semi-synthetic opioid analgesic prescribed as a schedule III controlled substance and used in the treatment of severe pain (marketed under the brand name Subutex). The therapeutic range for buprenorphine is 0.0003 to 0.0080ug/mL and it carries a warning from the FDA: "may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery)." No ethanol was found in the vitreous. Review of the pilot's personal primary care medical records revealed treatment for shift work sleep disturbance with Zolpidem and treatment of hypertension with Diovan (valsartan). His primary care records made no mention of acute or chronic pain or its treatment. However, records received from a second physician indicate the chronic use of prescribed buprenorphine for neck pain. Two Apple iPads, one Stratus Foreflight GPS device, a handheld spot device and a spot connect device were shipped to the NTSB Vehicle Recorders Laboratory, Washington, DC, for further examination. No data was recovered from any of the recovered devices. A review of recorded data from the Truckee-Tahoe Airport automated weather observation station revealed at 0755 conditions were wind calm, visibility 10 statute miles, clear sky, temperature 6 degrees Celsius, dew point -4 degrees Celsius, and an altimeter setting of 30.33 inches of Mercury. Using the reported weather conditions and field elevation, the calculated density altitude was about 5,842 feet and a pressure altitude of about 5,523 feet. Examination of the accident site revealed the airplane impacted an enclosed airplane hangar on row E, about 924 feet northwest of runway 19, and about 4,166 feet from the approach end of the runway. Wreckage debris was located within about 350 feet of the main wreckage. The fuselage came to rest inverted on a heading of about 351 degrees magnetic along with the left wing and engine, within the hangar. A small portion of the fuel bladder and associated wing structure remained lodged within the roof structure on top of the hangar. The outer portion of the right wing was located outside of the hangar about 50 feet to the east. Portions of the right wing structure were found about 75-feet on the northwest side of the main wreckage. A propeller tip was located northwest of the accident hangar about 350 feet from the main wreckage. An impact crater was observed within the asphalt hangar floor which measured about 18 inches by 18 inches and was about 7 inches deep. Rotational ground scarring was observed extending from the crater. The hangar and ground impressions were found to be consistent with an almost vertical impact angle. The measured elevation of the accident site was about 5,901 feet. Examination of the wreckage revealed that the left wing was partially separated from the fuselage at the wing root area. The aileron remained attached to the wing via its respective mounts. The flap actuator jackscrew showed an extension of 15 threads which was consistent with a flap setting of about 10 degrees flaps down. Flight control continuity was established from the left aileron to the cockpit controls. However, the control cables were separated at an area near the control column. The separated control cables exhibited splayed signatures, consistent with overload. The left main landing gear was found in the extended and locked position. In addition, the landing actuator cable was found in the extended position. The right wing was separated in two main sections. One section separated outboard of the main landing gear. The inboard section including the main landing gear and fuel tank was found within the hangar adjacent to the fuselage. The outboard section of the right wing was found outside the hangar and exhibited a large impact impression on the leading edge about mid span of the flap. The impression extended aft to the flap structure. The flap actuator jackscrew exhibited an extension of 15 threads which is consistent with an approximate 10 degree flap down setting. The right aileron remained attached to its respective mounts. The aileron balance cable was separated near the center fuselage section and exhibited splayed signatures consistent with overload. The right aileron control cable was found secured to the bell crank and continuous to the wing root. The right main landing gear extension cable was in the extended position. The fuselage was in an inverted position. The right door structure was damaged and separated from the fuselage. The fuselage structure surrounding the cabin area was compressed. The left and right stabilators, rudder, and vertical stabilizer remained attached to the empennage. The stabilator trim tab remained attached via respective mounts. The stabilator trim actuator was measured and found to be in a position consistent with slightly nose up. Control continuity was established from the stabilator balance tube to the cockpit controls. The vertical stabilizer and rudder were in place and secure. Continuity was established from the rudder bell crank to the cockpit controls. The engine remained attached to