WPR18FA053

The sport pilot's decision to depart in and continue flight in instrument meteorological conditions, which resulted in controlled flight into terrain.

The sport pilot was picking up his airplane following maintenance and intended to return the airplane to its base 57 nautical miles away. The owner of the maintenance facility cautioned the pilot about the weather along the route of flight and stated that the conditions at the departure airport included overcast clouds at 400 ft above ground level (agl). The pilot replied that the weather was improving and that he was familiar with the area. There was no record of the pilot having obtained a weather briefing prior to departure. The maintenance facility owner watched as the pilot subsequently took off from a taxiway and made a steep left banking turn to depart on course to his destination. About 25 minutes after departure, a witness saw the airplane flying between 150 and 200 ft agl with the engine running at a high-power setting.The airplane impacted trees and terrain about 34 nautical miles from the departure airport and oriented toward the departure airport. A nearby resident stated that the weather in the area at the time of the accident included low clouds about treetop level with very limited visibility. Review of reported weather conditions from nearby airports about the time of the accident revealed cloud ceilings ranging between 400 ft and 1,400 ft agl. Examination of the airplane and engine revealed no mechanical anomalies that would have precluded normal operation. The pilot's decision to depart and continue flight in instrument meteorological conditions resulted in controlled flight into terrain. As the airplane impacted a stand of trees in a wings-level attitude prior to impact with the ground, this supports the position of controlled flight into terrain rather than that of spatial disorientation. Autopsy of the pilot revealed evidence of severe cardiovascular disease with an implanted defibrillator; however, interrogation of the pacemaker revealed no anomalies and it is unlikely that the pilot's cardiovascular disease contributed to the accident. Toxicology testing revealed that the pilot had used a potentially impairing medication, clonazepam, at some time before the accident; however, the blood level was well below the therapeutic and impairing level and therefore did not affect the pilot's decision-making or directly contribute to the accident. The pilot's physician documented a caregiver's concerns for the pilot's impulsive behavior and difficulty remembering where he was while driving. The pilot's actions and decision to attempt to fly his airplane in poor weather conditions that exceeded his skill and ability are consistent with the reported impulsive behavior. Review of the pilot's medical history was unable to determine whether the pilot's baseline history of poor decision-making and airmanship as assessed by a previous flight instructor was solely responsible for the circumstances leading up to the accident, or the assessment of his impulsive decision-making by undiagnosed neuropsychiatric deficit, contributed to the circumstances of this accident.

The Office of the Medical Examiner, Center for Forensic Medicine, Nashville, Tennessee, conducted an autopsy on the pilot. The cause of death was determined to be "multiple blunt force injuries." The autopsy revealed a significantly enlarged heart with left ventricular and septal hypertrophy. Additionally, the pilot had significant coronary artery disease with a stent in the right coronary artery. The mid left circumflex coronary artery showed up to 75% narrowing and the mid left anterior descending and proximal first diagonal coronary arteries each showed 50% and 60% narrowing, respectively. Interrogation of a Medtronic implanted defibrillator did not identify evidence of a heart rhythm that would have resulted in defibrillation around the time of the accident. Toxicology testing performed at the FAA's Forensic Sciences Laboratory was negative for ethanol and carbon monoxide. Testing for drugs revealed the following: Naproxen was detected in urine; metoprolol, rosuvastatin were detected in urine and blood; clonazepam was detected in urine and blood; 0.019 (µg/mL, µg/g) amino-clonazepam (7-) was detected in blood and a nonquantified amount was in urine; 0.332 (µg/mL, µg/g) sertraline was detected in blood and a nonquantified amount was in urine; 0.418 (µg/mL, µg/g) desmethylsertraline was detected in blood and a nonquantified amount was in urine, and clopidogrel detected in blood and urine. Naproxen is a non-narcotic pain medication, metoprolol is a blood pressure medication, clopidogrel is a blood thinner, and sertraline is an antidepressant. These medications are generally considered not to be impairing. The potentially impairing Schedule IV benzodiazepine (clonazepam) and its metabolite were detected below quantifiable/therapeutic levels. On September 18, 2017, the pilot's family physician worked with the pilot's caregiver to coordinate rehabilitation care due to weakness following a knee replacement. The patient was not present for the evaluation, but the caregiver, stated that the pilot was often short-tempered and impulsive, would occasionally hear something that no one else did, and needed help with directions while driving along a route that he traveled many times. Based on this history, the physician wrote in the pilot's medical record that the pilot had possible early dementia with heightened impulsivity. The physician referred the pilot to a rehabilitation center and prescribed 0.5 mg clonazepam with up to 2 pills every 12 hours. The patient terminated care with the physician's office on October 11, 2017, when he was told the physician was not available to refill medications; no additional primary care treatment records were available. Records from the rehabilitation center from September 20 through October 4, 2017, were reviewed. The pilot was admitted due to progressive weakness at home following his total knee replacement. During his stay, he underwent physical therapy and his strength and mobility improved. He was noted to have anxiety treated with clonazepam. Neurologic and psychiatric examinations during his rehabilitation documented no abnormalities; however, the pilot declined a formal neuropsychiatric evaluation during his rehabilitation stay. He was discharged to outpatient physical therapy. No additional post-rehabilitation progress or neuro-psychiatric evaluations were available. . The Surface Analysis Chart for 1200 showed a west-to-east-oriented stationary front in northern Tennessee immediately north of the accident location. Station models in the area identified overcast sky conditions and generally southerly winds of 10 knots or less; some models denoted dew point depressions of 0°C. An Automated Weather Observing System (AWOS) located at SYI, about 34 miles southeast of the accident site at an elevation of 800 ft indicated overcast ceilings between 1,100 and 1,400 ft agl, visibilities of 10 statute miles or greater, and dew point depressions of 2°C during the times surrounding the accident. An AWOS located at Maury County Airport (MRC), Columbia, Tennessee, about 17 miles south-southwest of the accident site at an elevation of 681 ft indicated overcast ceilings between 400 and 600 ft agl, visibilities from 7 statute miles to 10 statute miles or greater, and dew point depressions of 0°C during the times surrounding the accident. Weather observations from John C. Tune Airport (JWN), Nashville, Tennessee, about 23 miles north-northeast of the accident location at an elevation of 501 ft, identified overcast ceilings between 600 and 800 ft agl, visibilities from 8 to 10 statute miles or greater, and dew point depressions of 1°C and 2°C during the times surrounding the accident. An Area Forecast Discussion (AFD) was issued at 1147 by the NWS Weather Forecast Office in Nashville, Tennessee. The Aviation section of that AFD stated: Widespread IFR ceilings have been slow to lift and expected to generally remain this way, although some breaks into MVFR are likely later this afternoon, at least for a few hours. IFR expected to redevelop later this evening and overnight ahead of precipitation that will overspread the region early Friday. This activity will initially begin light, possibly as drizzle, then increase in intensity by late Friday morning and last through much of the day and evening. Prolonged IFR or LIFR is likely through this time. (For additional information, refer to the NTSB Weather Study, which is appended to the docket for this accident.) There was no record of the pilot having obtained a weather briefing prior to departure. The sport pilot had previously possessed a private pilot certificate, which he surrendered in 2012 following an airplane accident. His most recent Federal Aviation Administration third-class medical certificate was issued on April 4, 2005, with a limitation for corrective lenses and that the certificate was not valid for night flying or by color signal control. On the application for that certificate, the pilot reported 1,000 total hours of flight experience, with 25 hours in the previous 6 months. A flight instructor, who reported that the accident pilot contacted him for transition training in the accident airplane, stated that he provided the pilot 2 hours of training over a 2-week period in November 2016. The next time he saw the pilot was on February 15, 2017, when he was again scheduled for training. When the pilot arrived, instead of doing the training as scheduled, the pilot stated that he was taking the airplane home; the instructor told him that was not a good idea. Two hours later, the pilot called the instructor to inform him that he had made it home. The instructor stated that he typically requires 5 hours of transition training for a signoff, which the pilot did not want to pay for. The instructor stated, " He was behind the airplane; it was too fast for him. He could not judge distance, and he was always cutting the [traffic] pattern short and low." The airplane came to rest intact except for the main landing gear and some small pieces of fuselage. First responders reported the presence of fuel upon initial arrival at the accident site. The initial impact point was a stand of trees about 60 ft high and about 115 ft northwest of the main wreckage site. The second impact point, about 35 ft southeast of the first impact point, was with another stand of trees about 40 ft high. The airplane subsequently came to rest upright in an open field next to a residential rural dirt road. Postaccident examination of the airframe and engine revealed no mechanical anomalies that would have precluded normal operation. An iFLY 740 portable GPS, serial number VH16050313, and a Lowrance AIRMAP 1000 GPS receiver, serial number 100660358, were sent to the NTSB Vehicle Recorder Division for examination and potential data download. Examination of the iFLY 740 revealed that data extracted from the unit included about 3 minutes 39 seconds of th