WPR16FA178

The pilot's decision to depart with the airplane loaded above its maximum gross weight and at or just beyond its aft center of gravity limitations, which resulted in a loss of control during the initial climb. Contributing to the accident was the pressure to complete the flight as planned, and the pilot's use of multiple impairing drugs, which degraded his decision-making.

The private pilot and two passengers were departing on a cross-country flight to transfer the rear-seat passenger to California, where a series of warrants had been issued for her arrest. A California-based bail bondsman was seated in the front right seat and the pilot was seated in the front left seat. The arrested passenger was restrained on the rear left seat by the lap belt. Witnesses, surveillance camera footage, and recorded data from on board the airplane indicated that the airplane began its takeoff roll and climbed to about 200 ft above ground level (agl) before leveling off. One witness stated that the airplane immediately began to rock its wings, and the nose pitched up to a high angle and remained in that attitude as the airplane continued to fly over the runway. About 2/3 of the way down the runway, the airplane began to veer right of the runway centerline and entered a right, descending turn. The last recorded data showed the airplane in a 41° right bank with a 64° nose-down attitude. The airplane impacted a lamppost, vehicles, and the ground in a parking lot with the landing gear extended. Postaccident examination did not reveal any anomalies with the airframe or engine that would have precluded normal operation. Sound spectrum analysis of the background noise recorded during the pilot's radio transmissions, along with examination of the propeller's internal and external witness signatures, revealed that the engine was likely producing takeoff power throughout the flight. The rear-seat passenger was found buckled in her seat after the accident; her legs were cuffed by leg-chains, and her hands were cuffed to her waist through a belly chain, thus, there was no evidence to suggest that the rear seat passenger interfered with the flight. The pilot fueled the airplane almost to capacity before he definitively established the total weight of all occupants for the accident flight. Furthermore, he added more fuel than originally requested to avoid paying a facility fee to the fixed base operator (FBO). Further, the pilot's statements to FBO personnel indicated that he was concerned about the airplane being overweight. Although the pilot could have defueled the airplane in order to remain within weight and balance limitations, this would have been a time-consuming process, and it is likely that he felt pressured to proceed with the flight as planned in order to return the passenger to California that evening. Also, the time spent defueling would have resulted in the flight taking place in night conditions over mountainous, dark, uninhabited terrain. The airplane was about 178 lbs over its maximum gross weight and loaded at or just beyond its aft center of gravity limit when it departed on the flight. Under such conditions, the airplane likely encountered longitudinal instability during takeoff and altitude and pitch oscillations. Strong gusty wind conditions and high density altitude (6,900 ft) further exasperated the situation and likely resulted in the pilot's difficulty controlling the airplane during the initial climb, which ultimately led to a loss of control. The airplane was fitted with an aftermarket turbo intercooler system. Its manufacturer did not provide specific performance data, instead stating that the engine performance would have been "equal to or better than" standard equipment. It is possible that the pilot felt this system would have given the airplane increased performance capability. Toxicology testing indicated the pilot had recently used 3 separate opioid drugs in addition to a sedating benzodiazepine (diazepam), and either meprobamate or its parent drug, carisoprodol. Although medical records indicated that the pilot had at one point been prescribed one opioid (oxycodone) and carisoprodol, the nearly simultaneous use of three separate opioids strongly suggests that he was misusing these substances. All of these medications are sedating and carry specific warnings against using them in combination. While the levels identified in cavity blood may be higher or lower than antemortem drug levels, the toxicology tests suggest that the pilot had 4 impairing substances in his blood at the time of the accident, and it is likely that his use of the combination of impairing medications contributed to his poor decision-making and willingness to attempt/proceed with the flight as planned.

RNO is located at an elevation of 4,145 ft mean sea level and is equipped with three grooved concrete runways. Runway 16R/34L is 11,001 ft long by 150 ft wide, and runway 16L/34R is 9,000 ft long by 150 ft wide. Runway 7/25 is 6,102 ft long by 150 ft wide on a gradient of 0.2%, and is bisected at its midpoint by runway 16/34. The airport is located on the eastern flank of the Sierra Nevada mountain range. The route of flight to SQL would have been to the southwest and would have required traversing the range at an initial minimum en route altitude of 13,000 ft. Sound Spectrum Study Audio recordings from the RNO ground and tower control positions were analyzed by a specialist from the NTSB Vehicle Recorders Division to identify frequencies associated with the engine, propeller, turbocharger, and stall warning horn. The audio data consisted of an 8,000-kHz sampled monotrack. A spectrogram was generated for the pilot's final two transmissions showing the frequency content of the sound and how it changed over time. Examination revealed that the sounds of the engine and propeller were not visible, because the recording did not capture anything below the 150-Hz frequency. The turbocharger compressor contained 7 blades and the turbine contained 11 blades. According to representatives from Hartzell, the turbocharger shaft speed would have been about 76,900 rpm during the reported takeoff conditions, which equated to a fundamental shaft frequency of 1,282 Hz. The blade passage frequencies of the turbine and compressor were both above the upper limit of the spectrogram. Analysis of the pilot's transmission just after the tower controller cleared him for takeoff revealed a faint tone increasing from about 2,150 Hz to 2,300 Hz. This was a potential match for the turbocharger shaft second harmonic as the throttle was increased, and corresponded to a turbocharger shaft speed increasing from 64,500 to 69,000 rpm. One hundred eight seconds later, during a pause in the pilot's speech while he made the last transmission, a tone at about 2,500 Hz was recorded. This was also a potential match for the turbocharger shaft second harmonic, corresponding to a shaft speed of 75,000 rpm. Electronic Devices The airplane was equipped with an Appareo Status PRX V2, combination GPS/WAAS (wide area augmentation system) and automatic dependent surveillance-broadcast receiver. The unit contained an internal attitude and heading reference system (AHRS) and was capable of recording GPS position and AHRS information internally on a non-volatile flash memory (NVM) chip at a rate of about 5 data records per second (5 Hz). The unit was recovered and sent to the NTSB Vehicle Recorders Division. It sustained impact damage, but NVM data was successfully extracted. The extracted data included GPS position and elevation, ground speed, ground track, heading, pitch, roll, and vertical speed. The data revealed that the airplane taxied onto runway 25 and was aligned on a true heading of 270°. The nose pitched up to 6° as the ground roll began. Twenty-one seconds later, after travelling about 1,700 ft, the ground speed had reached 53 knots, the nose pitched up to 10°, and the vertical speed and altitude began to increase. For the next 26 seconds, a series of pitch oscillations occurred, varying between 3° nose down and 11° nose up. The ground speed remained constant, and the vertical speed varied between +275 and +700 ft per minute (fpm) as the airplane reached an altitude about 150 ft agl. The nose then pitched up to about 15° as the airplane began a right turn to a heading of 300°. A few seconds later, it reached its highest altitude of 209 ft agl. Over the next 20 seconds, the airplane began a series of slight descents and climbs. It then began to bank to the right, reaching 45° right wing down about 15 seconds later. The last recorded data, which occurred 1 minute 29 seconds after the takeoff roll began, indicated that the airplane was on a heading of 070°, traveling at a ground speed of 89 knots, in a 41° right bank, with a 64° nose-down attitude. The data revealed that, throughout the flight, the airplane experienced 3 to 9° roll oscillations with periods varying between 0.5 to 1 HZ. Weight and Balance The FBO supervisor reported that the pilot initially requested that 5 gallons of fuel be added to each tank but then changed his mind and wanted 7 gallons per tank. The supervisor informed him that the FBO waives the facility fee if 15 gallons of fuel is purchased, so the pilot elected to add 7.5 gallons to each tank. The supervisor then serviced the airplane with the agreed fuel quantity, after which the right tank was full, and the left tank level was within ½ to 1 inch of the filler neck. According to the most recent aircraft weight and balance report, dated October 30, 2014, the airplane basic empty weight was 1,874.10 lbs, resulting in a total useful load of 1,025.90 lbs (maximum gross weight 2,900 lbs). The center of gravity range was between 78 and 90 inches aft of datum. At the time of autopsy, the pilot weighed 184 lbs, the bail bondsman located in the front right seat weighed 264 lbs, and the passenger in the rear left seat weighed 278 lbs. A total of 88 lbs of cargo, including bags, engine oil and a stepladder, was recovered from the rear baggage area at the accident site. Using the passenger and baggage weights, along with an estimated fuel load of 90% capacity (65 gallons), at the time of initial taxi, the airplane would have weighed about 3,078 lbs and its center of gravity would have been 90.36 inches aft of datum. These values were 178 lbs above the airplane's maximum gross weight and 0.36 inch aft of the center of gravity range. The weight and balance section of the Turbo Arrow III pilot's operating handbook (POH) states the following: Misloading carries consequences for any aircraft. An overloaded airplane will not take off, climb or cruise as well as a properly loaded one. The heavier the airplane is loaded, the less climb performance it will have. Center of gravity is a determining factor in flight characteristics. If the C.G. is too far forward in any airplane, it may be difficult to rotate for takeoff or landing. If the C.G. is too far aft, the airplane may rotate prematurely on takeoff or tend to pitch up during climb. Longitudinal stability will be reduced. This can lead to inadvertent stalls and even spins; and spin recovery becomes more difficult as the center of gravity moves aft of the approved limit. The center of gravity range and weight chart indicated that the moment due to retracting the landing gear is + 819 inch-lbs. Performance According to the POH, with flaps set to 25°, the takeoff ground roll distance at maximum gross weight for the field conditions and a 10-knot headwind component would have been about 1,800 ft. The distance required to climb over a 50 ft barrier fell outside of the envelope of the performance chart, and although extrapolation indicated that the distance would have been about 2,700 ft, the POH stated that performance information derived by extrapolation should not be used for flight planning purposes. Under the same conditions, but with flaps set to 0°, the ground distance would have been 3,250 ft, and 4,100 ft to climb over a 50 ft barrier. With the flaps set to 0°, the gear-extended climb performance at maximum gross weight would have been 690 fpm, and the gear-retracted climb performance 850 fpm. The handbook recommended a takeoff speed of 77 knots indicated air speed with 0° flaps, and 64 knots with 25° flaps. The FBO supervisor stated that the pilot had expressed concern about the airplane's weight and stated to the supervisor that it was his understanding that the arrested passenger weighed 180 lbs. While the pilot was waiting in the lounge area, he was pacing back and forth and seemed anxious. A customer service representative who over