WPR19FA077

The pilot's decision to fly the airplane in close proximity to mountainous terrain in an area of mountain wave activity that exceeded the performance capabilities of the airplane. Contributing to the accident was the pilot's degraded decision making and performance due to his use of multiple sedating and impairing drugs.

The pilot departed on a visual flight rules flight toward a nearby mountain with a summit elevation of 11,239 ft. After completing one orbit around the summit at a radial distance of about 3 miles, the pilot flew the airplane to within 1,500 ft horizontally for a second orbit. As the airplane turned around the southern side of the mountain, it began to descend at a rate of about 2,500 ft per minute (fpm) and impacted an almost-vertical face of the mountain about 1,600 ft below the summit. Due to the treacherous and remote nature of the accident site, an on-scene examination could not be performed, and the airplane was not recovered from the site. The airplane's flight path around the summit revealed significant ground speed variations consistent with the airplane encountering headwinds as it circled. The pilot was likely aware of the wind conditions aloft because he appeared to perform a heading correction during the first orbit, as wind likely pushed the airplane toward the mountain. This should have served as a cue for the pilot to prepare for terrain-induced downdrafts and turbulence and to avoid flying too close to the peak; however, he continued with the second pass. Atmospheric analysis indicated that the airplane was operating in an area of mountain wave conditions at the time of the accident, with modeling indicating the presence of rapid changes in horizontal wind speed. Vertical velocity data showed that the airplane likely encountered updrafts of between 100 and 300 fpm during its first orbit around the mountain, and downdrafts greater than 2,000 fpm during the second, closer orbit, significantly exceeding the airplane's 200-fpm climb performance for that altitude. There was no evidence to suggest that the pilot obtained an official weather briefing before the flight. Had he done so, he would have been made aware of the winds aloft conditions, which indicated the likelihood of terrain-induced turbulence close to the mountain. Review of the pilot's medical records indicated that he was experiencing ongoing back pain due to an injury. Toxicological testing indicated that he had been using oxycodone, mitragynine, and metoclopramide, all of which are sedating and impairing. The levels of oxycodone in his blood were considered impairing. Use of the stimulant modafinil suggested that the pilot was attempting to counter fatigue. Toxicology also indicated that the pilot had used marijuana; however, it could not be determined if the concentration would have been impairing or decreased his performance. Given that multiple drugs involved were sedating or impairing both individually and combined, the pilot would most likely have experienced diminished decision-making ability, increased reaction times, and degraded motor skills. Thus, it is likely that the use of these drugs contributed to the accident.

The airplane was purchased by the pilot in September 2000. Neither the airplane logbooks nor the airplane's airworthiness information on file with the FAA indicated that the airplane was equipped with a GPS receiver; however, a friend of the pilot stated that the pilot always carried an iPad mounted to the control yoke. At the airplane’s most recent annual inspection 7 days before the accident, FAA Airworthiness Directive 12-02-10, which required the inspection of the elevator spar for cracks, was completed. The most recent maintenance event was for a dynamic propeller balance, completed about 2 hours before the accident. The mechanic who performed the procedure stated that the annual inspection had revealed a crack in an engine turbocharger bracket, indicative of excessive vibration, and this was the reason the pilot wanted to have the balance performed. The mechanic stated that the balance procedure was routine and uneventful, and that the pilot wanted to get the work completed in advance of a trip he was taking to Arizona the following week. Fueling records indicated that 30 gallons of aviation gasoline was added to the airplane 3 days before the accident. There was no evidence to suggest the airplane had been flown beyond the local area since then. According to the airplane's flight manual, at a gross weight of 2,650 lbs with the landing gear and flaps retracted, the airplane's rate of climb at 12,000 ft with an outside temperature of -4°C, would have been about 220 fpm. According to the autopsy performed by the Office of the State Medical Examiner, Clackamas, Oregon, the pilot’s cause of death was multiple blunt force traumatic injuries. The medical examiner noted the finding of a recent diagnosis of hepatitis and early cirrhosis of the liver. No other significant natural disease was identified. Postmortem toxicological testing by the Oregon State Medical Examiner's Department of State Police Forensic Laboratory was positive for oxycodone (0.35 mg/L), noroxycodone (0.30 mg/L), and oxymorphone (<0.010 mg/L). Cannabinoids and modafinil were also present in chest cavity blood but not quantified. Toxicological examination of the pilot's urine detected the presence of oxycodone, noroxycodone, cannabinoids, and modafinil. Toxicology testing by the FAA Forensic Sciences Laboratory revealed the inactive metabolite of marijuana, THCA, at 3 ng/mL in the pilot’s chest cavity blood. THC, its psychoactive metabolite 11-hydoxy-delta-9-THC (20.3 ng/mL), and THCA (86.1 ng/mL) were detected in the pilot's urine. Oxycodone was detected in both chest cavity blood and urine (0.368 mg/L and 7.993 mg/L, respectively). The oxycodone metabolite oxymorphone was detected in chest cavity blood and in urine (14.747 mg/L). Mitragynine and modafinil were detected in chest cavity blood and urine; 7-hydroxymitragynine and metoclopramide were only detected in urine. Oxycodone is a synthetic opiate used to treat severe pain. Among other precautions, the medication carries the warning that use may impair mental or physical ability to drive a car or operate machinery. Its usage has a high risk of addiction, abuse, and misuse. Therapeutic levels are typically between 0.013 to 0.099 mg/L for infrequent users, but tolerance, where increasing doses are needed to achieve the same effect, is seen in more frequent and chronic users. One study found that the range of oxycodone concentrations in 37 postmortem cases where oxycodone was an incidental finding was 0.017 to 1.300 mg/L. The primary metabolite of oxycodone is noroxycodone, which is a considerably weaker analgesic. Oxymorphone is also a metabolite of oxycodone; while usually produced in lesser amounts, it also has analgesic properties. Oxycodone and its metabolites are excreted in the urine. The elimination half-life of oxycodone is about 4 hours. Oxycodone is on the FAA pharmaceutical do not fly list. The pilot did not mention the use of Oxycodone to the aviation medical examiner at the time of his last application for an FAA medical certificate. Mitragynine and 7-hydroxymitraginine are the primary psychoactive compounds found in the leaves of the southeast Asian kratom tree. It has stimulant effects at low doses, such as increased alertness, physical energy, and talkativeness, and sedative effects at high doses. It is considered a drug of concern by the U.S. Drug Enforcement Administration (DEA) , and the U.S. Food and Drug Administration (FDA) has asked the DEA to attempt to place the drug into Schedule 1 drugs with high potential for abuse and no medical value, similar to heroin. The FDA has not approved mitragynine for any medical use. Metoclopramide is a prescription medication for short-term gastroesophageal reflux treatment for those who do not respond to conventional therapy. Side effects include restlessness, drowsiness, and fatigue. Metoclopramide can impair physical and mental abilities needed to drive a motor vehicle or operate machinery. Additive sedative effects occur when taken concurrently with alcohol, sedatives, or narcotics. The FAA states that airmen should not fly while using any medication that carries a label precaution or warning that it may cause drowsiness or advises the user, "be careful when driving a motor vehicle or operating machinery. Personal medical records showed that the pilot had experienced a back injury requiring surgery in December 2017. At medical office visits in December 2018, he complained of fatigue, poor sleep, and continued back pain. He reported use of ibuprofen, kratom, and marijuana. The pilot had a recent diagnosis of hepatitis C and a diagnosis of esophageal reflux. The pilot's wife reported that he was recently experiencing lower back problems, and she presumed it was because of the physical nature of his work, which involved installing commercial flooring. He was planning to have surgery to resolve the problems the month following the accident. The mechanic who performed the propeller balancing on the day of the accident stated that the pilot usually appeared in good health; however, he noted that on the morning of the accident, the pilot appeared in pain, was hobbling, and was having trouble getting in and out of the airplane. Due to the treacherous and remote nature of the accident site and the immediate threat of avalanches, an on-scene examination could not be performed. First response personnel, who recovered the pilot, were not able to gain access to the main wreckage; therefore, a description of the accident site was compiled using photographs provided by first responders. Fragmented sections of the airplane were spread along the 70° slope of Eliot Glacier, on the northeast flank of Mount Hood. The first identifiable point of impact was represented by a horizontal slice in the snow and ice at an elevation of about 9,700 ft msl. Debris and slide marks in the snow extended down toward the main wreckage, which was located at an elevation of about 8,700 ft msl, and comprised the crushed fuselage, fragments of the left wing, and the entire right wing. The engine and horizontal stabilizer were identified about 200 ft below, with the lowest debris located around 8,000 ft msl. The entire area was strewn with crushed and fragmented airframe and engine components and surrounded by crevasses and deep, unstable snow. (see Figure 2.) The airplane was not insured, and an immediate wreckage recovery was not possible. Seven months after the accident, representatives from the Forest Service returned to the site for field reconnaissance; however, by that time, most of the airplane had either disappeared into a crevasse or been pulverized and fragmented by avalanches. The airplane was never recovered. Figure 2. Accident Site On January 25, 2019, at 1459 Pacific standard time, a Rockwell International 112, N1332J, was destroyed when it was involved in an accident near the summit of Mount Hood, Oregon. The private pilot sus