WPR18FA045

The pilot's loss of airplane control due to spatial disorientation during an instrument approach in instrument meteorological conditions, and the flight instructor's delayed remedial action. Contributing to the accident was the flight instructor's impairment from the use of prescription pain medication.

The flight instructor, commercial pilot receiving instruction, and commercial pilot-rated passenger were conducting an instructional flight in the multi-engine airplane during instrument meteorological conditions. After performing a practice instrument approach, the flight was cleared for a second approach; however, the landing runway changed, and the controller vectored the airplane for an approach to the new runway. The pilot was instructed to turn to a southwesterly heading and maintain 1,600 ft until established on the localizer. Radar information revealed that the airplane turned to a southwesterly heading on a course to intercept the localizer and remained at 1,600 ft for about 1 minute 39 seconds before beginning a descending right turn to 1,400 ft. The descent continued to 1,100 ft; at which time the air traffic control controller issued a low altitude alert. Over the following 10 seconds, the airplane continued to descend at a rate in excess of 4,800 ft per minute (fpm). The controller issued a second low altitude alert to the crew with instructions to climb to 1,600 ft immediately. The pilot responded about 5 seconds later, "yeah I am sir, I am, I am." The airplane then climbed 1,400 ft over 13 seconds, resulting in a climb rate in excess of 6,700 fpm, followed by a descent to 1,400 ft over 5 seconds, resulting in a 1,500-fpm descent before radar contact was lost in the vicinity of the accident site. Radar data following the initial instrument approach indicated that the airplane was flying a relatively smooth and consistent flightpath with altitude and heading changes that were indicative of autopilot use until the final turn to intercept the localizer course. Maneuvering the airplane in restricted visibility placed the pilot in conditions conducive to the development of spatial disorientation. The accident circumstances, including altitude and course deviations and the subsequent high-energy impact, are consistent with the known effects of spatial disorientation. Additionally, examination of the airframe, engines, and propellers revealed no evidence of any preexisting anomalies that would have precluded normal operation. Therefore, it is likely that the pilot receiving instruction was experiencing the effects of spatial disorientation when the accident occurred. Toxicology testing of the flight instructor identified significant amounts of oxycodone as well as its active metabolite, oxymorphone, in liver tissue; oxycodone was also found in muscle. Oxycodone is an opioid pain medication available by prescription that may impair mental and/or physical ability required for the performance of potentially hazardous tasks. The flight instructor's tissue levels of oxycodone suggest that his blood level at the time of the accident was high enough to have had psychoactive effects, and his failure to recognize and mitigate the pilot's spatial disorientation and impending loss of control further suggest that the flight instructor was impaired by the effects of oxycodone.  Toxicology testing of all three pilots identified ethanol in body tissues; however, given the varying amounts and distribution, it is likely that the identified ethanol was from postmortem production rather than ingestion.

Flight Instructor The Seminole County Medical Examiner, Daytona Beach, Florida, performed an autopsy of the instructor. The autopsy report indicated that the cause of death was multiple blunt force injuries. Toxicology testing performed by the National Medical Services (NMS) Labs at the request of the medical examiner identified oxycodone (370 ng/gm; 0.370 µg/gm) and its active metabolite, oxymorphone (340 ng/gm; 0.340 µg/gm), in liver tissue. Toxicology testing on specimens recovered from the flight instructor performed at the FAA Forensic Sciences Laboratory identified ethanol at 0.073 gm/dg and N-butanol in muscle tissue, as well as 0.028 gm/dg of ethanol in lung. In addition, oxycodone was found at 0.382 µg/gm and its active metabolite, oxymorphone, at 0.253 µg/gm in liver tissue; in muscle there was 0.102 µg/gm of oxycodone, but testing was inconclusive for oxymorphone. Oxycodone is an opioid pain medication available by prescription, usually in combination with acetaminophen (Tylenol); common marketing names are Percocet and Oxycontin. Oxycodone is a Schedule II controlled substance, indicating significant potential for abuse and addiction. Oxycodone carries a warning, "Patients should be advised that oxycodone hydrochloride tablets may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery)." Oxymorphone is its primary active metabolite, but is also available as a prescription drug alone; a common marketing name is Opana. It carries the warning, "Warn patients not to drive or operate dangerous machinery unless they are tolerant to the effects of oxymorphone hydrochloride tablets and know how they will react to the medication." The instructor's wife reported that her husband had back issues. She was unsure of the extent but knew that he took prescription ibuprofen. She could not recall if her husband had a prescription for oxymorphone or oxycodone. Pilot Receiving Instruction (Flying Pilot) The Seminole County Medical Examiner, Daytona Beach, Florida, performed an autopsy of the pilot. The autopsy report indicated that the cause of death was multiple blunt force injuries. Toxicology testing on specimens recovered from the pilot performed at the FAA Forensic Sciences Laboratory identified ethanol at 0.022 gm/dg of ethanol in lung; no ethanol was identified in muscle tissue. No other tested-for substances were identified. Pilot-Rated Passenger The Seminole County Medical Examiner, Daytona Beach, Florida, performed an autopsy of the pilot-rated passenger. The autopsy report indicated that the cause of death was multiple blunt force injuries. Toxicology testing on specimens recovered from the passenger performed at the FAA Forensic Sciences Laboratory identified ethanol at 0.022 gm/dg of ethanol in brain tissue, but no ethanol in muscle tissue. No other tested-for substances were identified. Given the varying amounts and distribution of ethanol identified in body tissue of all three pilots, it is likely that the identified ethanol was from postmortem production rather than ingestion. Recorded data at 1053 from the SFB automated weather observation station, located about 10 miles west of the accident site, included wind from 170° at 8 knots, 10 statute miles visibility, a broken cloud layer at 800 ft, an overcast cloud layer at 1,600 ft, temperature 21°C, dew point 18°C, and an altimeter setting of 29.89 inches of mercury. The National Weather Service (NWS) Weather Forecast Office, located in Melbourne, Florida, issued the SFB Terminal Aerodrome Forecast at 0627, which was valid for a 24-hour period beginning at 0700. The forecast from 0700 to 1100 was for wind from 030° at 3 knots, visibility better than 6 miles, scattered clouds at 800 ft agl, overcast at 1,500 ft. From 1100 to 1300, wind was predicted to be from 190° at 5 knots, visibility better than 6 miles, ceiling broken at 1,500 ft agl. AIRMET Sierra for IFR conditions was current at the time of the accident for most of central Florida, including the area of the accident site. For further meteorological information, see the weather study in the public docket for this investigation. Flight Instructor The instructor, age 56, held an airline transport pilot certificate with an airplane multi-engine land rating, with commercial privileges for airplane single-engine land. He held a flight instructor certificate with airplane single- and multi-engine and instrument airplane ratings. The pilot's most recent FAA third-class airman medical certificate was issued on August 19, 2017, with a limitation for corrective lenses. On the application for that medical certificate, he reported 4,500 total hours of flight experience. Flight school personnel reported that, at the time of the accident, the instructor had accumulated 4,800 total hours of flight experience, of which 357 hours were in the accident airplane make/model, 233 hours were in the previous 90 days, 62 hours were in the previous 30 days, and 6 hours were in the previous 24 hours. Representatives of the flight school reported that the instructor provided training in their flight instructor and high-performance courses. The instructor was also a company check pilot for their single- and multi-engine courses. In addition, the instructor was approved to provide end-of-course exams, which included the issuance of a pilot certificate or rating for that respective course. Pilot Receiving Instruction The pilot receiving instruction, age 23, held a commercial pilot certificate with airplane single-engine land, multi-engine land, and instrument airplane ratings. His most recent second-class FAA airman medical certificate was issued on December 8, 2016, with a limitation for corrective lenses. Flight school personnel reported that, at the time of the accident, he had accumulated 243 total hours of flight experience, of which 44 hours were in the previous 90 days. In addition, he had accumulated 8 hours of actual instrument experience and 49 hours of simulated instrument experience. The airplane impacted the waters of Lake Harney near the northwestern shoreline, just south of the final approach course for the ILS Runway 27R approach. Wreckage was spread throughout a 200-square-ft area along the bottom of the lake. The reported water depth was 10 ft. According to recovery company personnel, the recovery of the wreckage from the lake spanned about 8 days with the use of a diver who specialized in underwater construction and operation. The diver reported that the underwater visibility was about 5 inches. A dredger was used to displace the mud/silt in order to locate additional debris; however, company personnel reported that due to the restricted underwater visibility, various parts and/or components may not have been located. The company personnel further reported that both engines were located about 15 ft under the floor of the lake, lodged within the mud/silt. Examination of the recovered wreckage revealed that the fuselage was severely fragmented. The structure was bent, buckled, and torn throughout. Remains of the cockpit area were located within the wreckage, which included the control column, a rudder pedal, and trim wheel pedestal. The instrument panel was fragmented into multiple portions with numerous instruments displaced. The directional gyro and compass gyros were removed from their housings and exhibited rotational scoring. The left and right engine nacelle structure and the inboard portions of the left and right wing structure from the nacelles to the fuselage were fragmented. The left wing exhibited accordion-like compression damage throughout. The left aileron and inboard flap were separated from the left wing structure. The outboard left flap remained attached. The right wing exhibited accordion-like compression damage throughout. The right aileron, inboard and outboard flaps were separ