WPR16FA014

The non-instrument rated pilot's improper inflight decision-making to attempt to outclimb clouds along his planned route rather than reverse course, which resulted in his inadvertent entry into instrument meteorological conditions, spatial disorientation, and a resultant loss of control. The pilot's preexisting medical conditions and his use of impairing medications contributed to his degraded performance.

The non-instrument rated private pilot and his passenger completed a cross-country flight from their home base to another airport in the airplane earlier that day. They delayed their initial planned departure time for that flight due to weather concerns, ultimately arriving 3 hours later than planned. During that flight, they flew over a high mountain range and through a mountain pass. For the return (accident) flight a few hours later, the weather had deteriorated, resulting in low ceilings along the original route (including in the pass), with high cloud tops and rapidly building cloud formations west and north of the departure airport in the intended direction of the return flight. However, there is no record that the pilot obtained weather information before departing on the return flight. While on the ground, the pilot reported to air traffic control that he was planning to take a "northern route," which would have taken them around the north side of the east-west mountain range that they had crossed on the inbound leg. Shortly after takeoff, the pilot reported to air traffic control that, due to clouds, he would need to climb to an altitude of 9,000 ft mean sea level (msl), which was almost twice as high as originally requested. The request was most likely because, once airborne, the pilot could see the full extent of the building cloud formations to the north along his route, as well as the formations building just west of the departure airport. As the flight proceeded, the air traffic controller began the first of what would become a series of warnings to the pilot about mountainous terrain. The pilot responded that he was aware of the terrain. He then began a series of six climbing 360° turns, rolling out on a west heading directly toward, and about 700 ft lower than, the mountain peak. The controller warned the pilot of the peak several times, and the pilot responded, sounding confused, stating that he was still climbing. Now cruising at an altitude of about 11,000 ft msl, the airplane's climb capabilities had diminished. Furthermore, the pilot did not appear to be flying the airplane at a speed that would have resulted in optimal climb performance. The airplane continued heading west, now no longer climbing and most likely just above the cloud tops. With high and ominous-looking cloud formations now building to the left and right of the flight track, the pilot most likely opted to continue on his homeward westerly track, while attempting to climb over the terrain and clouds ahead. The airplane then suddenly reversed course and rapidly descended. It then transitioned to a fast spiraling descent, and, when challenged by the controller as to whether he had the terrain in sight, the pilot exclaimed, "Negative! Negative!" The turn rate increased as the airplane descended to about 7,500 ft msl and then impacted mountainous terrain just below the cloud bases. Examination of the accident site indicated that the airplane struck the ground in a wings-level attitude at a high forward speed. Damage patterns indicated that the engine was producing power at impact. It is likely that, unable to outclimb the terrain and the cloud tops, the airplane entered the clouds and thus instrument meteorological conditions during the final portion of the flight, and the pilot then experienced spatial disorientation and lost control of the airplane, which resulted in the rapid descent. Additionally, prior to the descent into clouds, he was flying almost directly towards the sun, which could have been a further distraction and additional source of stress. Many of the 71-year-old pilot's medical conditions, including hypertension, low testosterone, Barrett's esophagus, chronic obstructive pulmonary disease, deafness, chronic neck pain, vitamin D deficiency, and prediabetes, were unlikely to cause acute symptoms or be chronically impairing. Similarly, his blood pressure medication, cholesterol medication, testosterone, and prostate medication would not have impaired judgement, decision-making, or flight skills. However, several medications that the pilot was using would have impairing effects. Hydrocodone, which was detected in the toxicology testing, is an impairing opiate pain medication and carries warnings regarding hazards while driving or operating machinery; however, with regular use, a chronic user may appear to function normally, so the pilot may not have been impaired by his use of opiods. Quetiapine, also detected during toxicology testing, is an antipsychotic indicated for the treatment of schizophrenia and bipolar syndrome and carries warnings for an increased risk of seizures and somnolence. It can also impair judgment, thinking, or motor skills, and may have impaired the pilot's performance during the accident flight. The pilot's medical records revealed that he had required years of ongoing psychotherapeutic support to manage the combined symptoms of PTSD and depression; at the time of the accident he had been experiencing an exacerbation of those symptoms for several months, and it did not appear that the symptoms had been completely resolved. Patients with PTSD experience marked cognitive, affective, and behavioral responses to stimuli. These symptoms are likely to occur in stressful situations and may have contributed to his confusion during the high workload period while attempting to ascend above mountain peaks. Further, depression is associated with cognitive degradation, particularly in executive functioning.  Therefore, under the stressful conditions of this flight, the combined effects of impairing medications, depression, and PTSD likely resulted in the pilot experiencing significant cognitive degradation.

FAA Medical Records At the time of the pilot's most recent FAA medical examination, he was 70 inches tall, weighed 157 pounds, and reported hypertension treated with atenolol and amlodipine (prescription blood pressure medications often marketed with the names Tenormin and Norvasc, respectively). The physical examination was unremarkable. Autopsy and Toxicology An autopsy was performed by the San Bernardino County Sheriff's Department, Coroner Division; the cause of death was reported as multiple blunt force injuries. Thermal damage limited the scope of the examination, with no significant natural disease identified from the available remains, and no tissues beyond lung and liver available for toxicology testing. Toxicology testing performed by the Office of the Medical Examiner, County of San Diego, identified an opiate and confirmed the presence of quetiapine and its metabolites in liver tissue. Furthermore, testing performed by the FAA's Bioaeronautical Research Sciences Laboratory identified amlodipine, atenolol, losartan, atorvastatin, hydrocodone (0.116 ug/g) and its metabolites hydromorphone (0.045 ug/g) and dihydrocodeine as well as quetiapine (0.725 ug/g) in liver tissue. In addition, atenolol, hydrocodone (0.056 ug/g), and quetiapine were identified in lung tissue. Losartan is a prescription blood pressure medication often marketed with the name Cozaar. Atorvastatin is used to treat high cholesterol and is commonly marketed with the name Lipitor. Hydrocodone is a prescription opioid identified as a Schedule II controlled substance by the Drug Enforcement Administration. It is most commonly sold in combination with acetaminophen, often with the names Vicodin and Lortab. It carries several warnings, including, "Hydrocodone, like all narcotics, may impair the mental and/or physical abilities required for the performance of potentially hazardous tasks such as driving a car or operating machinery" and "Alcohol and other CNS (central nervous system) depressants may produce an additive CNS depression, when taken with this combination product, and should be avoided." Quetiapine is an antipsychotic indicated for the treatment of schizophrenia and bipolar syndrome. It carries several warnings including one for an increased risk of seizures and a specific warning about somnolence, which states, "quetiapine has the potential to impair judgment, thinking, or motor skills, patients should be cautioned about performing activities requiring mental alertness, such as operating a motor vehicle (including automobiles) or operating hazardous machinery until they are reasonably certain that quetiapine therapy does not affect them adversely. Somnolence may lead to falls." Personal Medical Records The pilot was receiving treatment from medical facilities of the US Department of Veterans Affairs (VA). According to records obtained from the VA covering the period from 1999 to the date of the accident, the pilot had a history of chronic neck pain requiring the use of opioids, a vitamin D deficiency, hypertension, an abnormal stress thallium test suggesting coronary artery disease, deafness requiring hearing aids, prediabetes, chronic obstructive pulmonary disease, Barrett's esophagus, and low testosterone. His medications at the time of the accident included a hydrocodone/acetaminophen combination (7.5mg/325mg every 6 hours), losartan, atenolol, amlodipine, aspirin, atorvastatin, finasteride, gabapentin, and topical testosterone. Gabapentin is a prescription medication initially developed as an antiseizure drug, which is also used to treat nerve pain. It is commonly marketed with the name Neurontin. Gabapentin carries a warning about increased risk of suicidal thoughts or actions with its use and risk of somnolence and dizziness. As a result, it carries a recommendation that patients are to be notified that it "may cause dizziness, somnolence, and other symptoms and signs of CNS depression. Accordingly, they should be advised neither to drive a car nor to operate other complex machinery until they have gained sufficient experience on gabapentin to gauge whether or not it affects their mental and/or motor performance adversely." Gabapentin is excreted unchanged in urine and is not stored in organ tissues. As a result, its absence on the toxicology testing of liver and lung in this case does not indicate whether or not the pilot was using it. Because of existing risk factors, the pilot underwent cardiac testing in 2001. The results revealed abnormal exercise and thallium stress test results, indicating likely early single vessel coronary artery disease. As the pilot was asymptomatic at the time, the decision was to improve the control of his blood pressure and cholesterol levels. Follow-up stress testing was unchanged, and, as the pilot remained asymptomatic, no further intervention was performed. The pilot periodically reported neck pain, which was first treated with opioids in 2007. It recurred in 2010, and, following a telephone consultation with the physician, he was prescribed hydrocodone/acetaminophen 5/325mg, one tablet 4 times a day as needed. He continued on this regimen until the dose was increased to the 7.5/325mg tablets in July 2012. In November 2014, the pilot's prescription for hydrocodone for chronic pain was changed because the Drug Enforcement Administration changed it from a Schedule III to a Schedule II controlled substance, indicating an increased risk for abuse. Over the next few months, he tried using codeine and tramadol instead but was unable to get sufficient pain relief. He returned to hydrocodone/acetaminophen 7.5/325 mg four times a day on February 19, 2015, and maintained that dosing regimen until the accident. Records indicated he routinely refilled the prescription monthly. In a visit with his primary care physician dated August 25, 2015, the physician noted the pilot had a normal neurologic exam including motor and nerve function as well as normal gait and that his mood was stable and calm. The physician documented his impression that the pilot's judgment and insight were intact. According to the pilot's psychology and psychiatry report, he suffered from post-traumatic stress disorder and major depressive disorder, for which he was treated with quetiapine and psychotherapy from 2003 forward. He attended regular psychotherapy sessions, and, several months before the accident, he had been feeling "pretty bad" and requested biweekly rather than monthly therapy sessions to obtain additional support for the stressors in his life. During a session on September 14, 2015, the therapist noted the pilot reported he was "doing OK" but seemed edgy. On September 22, 2015, about 3 weeks before the accident, the pilot met with his therapist. The records documented that, at that time, he was doing "pretty good." Although the plan was to return to monthly sessions beginning in October, the therapist noted that he "seemed to be isolating" himself and documented her intent to review the issue with him at the next visit. The pilot did not call Lockheed Martin Flight Service for a telephone weather briefing either the day before or the day of the accident, and there was no record of him downloading an official weather briefing from any DUAT vendor. Satellite Data Geostationary Operational Environmental Satellite number 15 (GOES-15) imagery taken at 1545 and 1600 indicated an area of low- to mid-level clouds over the accident site, with cloud tops near 11,000 ft (figure 4). During that period, an area of clouds was observed developing near Big Bear, California, 12 miles northwest of the accident site, along with rapidly developing enhanced clouds (tops near 33,000 ft) between the accident site and Palm Springs. Multiple layers of clouds extended from west of Palm Springs through to the accident site and obscured Banning Pass to the south. The Riverside County Sheriff's Department helicopter crew reported clo