WPR24FA080

A total loss of engine power during takeoff due to a separated fuel line and the pilot’s subsequent failure to maintain control of the airplane. Contributing to the accident were the pilot's medical condition and the effects of multiple impairing substances.

The pilot was conducting touch-and-go landings and takeoffs and had completed several. After the last takeoff, the airplane climbed to about 100 ft mean sea level (msl), and the engine lost power. The airplane’s nose lowered, and engine power momentarily returned. The airplane’s nose then pitched up and, about that time, the engine lost total power. The airplane subsequently banked left and entered a near-vertical descent to the ground, consistent with an aerodynamic stall. Postaccident examination of the engine revealed that the fuel pump output line B-nut, which connects to the carburetor fuel inlet filter screen fitting, was detached. The B-nut exhibited no evidence of impact-related damage, and the threads on both the B-nut and the corresponding fitting were found to be intact and undamaged. The lack of damage on the threads and the in-flight detachment suggest that the B-nut was not properly torqued. There was no record of any recent maintenance having been done to that area of the engine, and the engine had operated only about 40 hours since its last condition inspection more than a year before the accident. Thus, it is likely the pilot may have performed airplane maintenance which was not reflected in the maintenance logbooks. Examination of the flight controls revealed no evidence of any preimpact mechanical malfunction or failure that would have precluded normal operation. The pilot’s medical history indicated that he had sustained a severe traumatic brain injury (TBI) in 2000. Severe TBIs commonly result in permanent cognitive damage, such as impairments in attention, executive functioning, and decision-making; these may include diminished reaction time and impaired reasoning and judgment. Also, the pilot’s toxicology results identified multiple potentially impairing substances, which could have adversely and unpredictably interacted with one another to worsen impairment, as well as a medication commonly used to treat moderate to severe symptoms of dementia, a potentially impairing condition. The loss of engine power may have saturated the pilot’s attention, leading to his failure to maintain control of the airplane. Also, the combination of the pilot’s medical conditions and use of multiple impairing substances likely adversely affected his ability to react accordingly to maintain airplane control after the engine power loss. In 2000 and 2001, the FAA denied the pilot medical certification due to his TBI and continued neurocognitive deficits. However, beginning in 2003, the pilot subsequently applied for (and obtained) multiple third-class medical certificates over the years after providing the FAA with a different social security number, different spelling of his name, and nondisclosure of his disqualifying medical history. In 2012, the FAA identified the pilot’s social security number discrepancy and merged his two medical files but did not identify the pilot’s disqualifying medical history, and it continued to issue him medical certificates as recently as 2023. Whether the pilot would have continued to fly if the FAA had detected his disqualifying medical history and again denied him a medical certificate cannot be known.

The pilot’s last aviation medical examination was August 14, 2023, and he was issued a third-class medical certificate with the limitation he must use corrective lenses to meet vision standards at all required distances. On his application for the medical certificate, the pilot reported no medical conditions or medication use and that his civil flight experience was 8,786 total hours, 36 hours of which were accumulated in the last 6 months. According to the pilot’s logbook, he had accumulated 20 hours of flight time in the 90 days before the accident. A review of the pilot’s FAA medical certification file revealed that on February 5, 2000, the pilot was involved in an airplane accident and sustained a severe TBI, which affected his vision, left arm motor function, and neurocognitive skills. In May 2000 and in 2001, the FAA denied multiple applications from the pilot for a medical certificate because the pilot failed to provide all of the requested medical documentation. In 2001, the pilot also did not pass an FAA-requested competency checkride due, in part, to his difficulty multitasking and ease of becoming distracted. In 2002, the FAA sent the pilot a general letter of denial due to his TBI and continued neurocognitive deficits. In 2003, the pilot applied for and was issued a third-class medical certificate after providing a new spelling of his name, a different social security number, and an incomplete medical history that did not disclose his TBI. Between 2003 and 2023, the pilot was issued several subsequent third-class medical certificates. The pilot’s FAA medical certification file contained medical records associated with both social security numbers used by the pilot. According to an FAA Office of Aerospace Medicine official, the FAA had identified the social security number discrepancy in 2012 and merged the pilot’s two medical certification files but did not identify the disqualifying medical history. A review of the airplane’s maintenance records revealed the most recent engine logbook entry was on November 21, 2023, for work that included a 100-hour inspection, oil change, magneto timing, and pushrod tube replacement at an airframe total time of 2157.8 hours and an engine total time of 2,132.9 hours. A review of work orders since that inspection revealed a December 19, 2023, work order for the removal and replacement of the left main tire and left brake linings, and a January 15, 2024, work order for the removal and replacement of the airplane’s battery. An autopsy of the pilot was performed by the Contra-Costa County Office of the Sheriff-Coroner. According to the autopsy report, the cause of death was multiple extreme blunt force injuries, and the manner of death an accident. Toxicology testing performed at the FAA Forensic Sciences Laboratory found that Delta-9-THC, 11-hydroxytetrahydrocannabinol (11-hydroxy-THC), Carboxy-delta-9-THC, Gabapentin, Codeine, Morphine, Hydrocodone, Dihydrocodeine, Atomoxetine, Trazodone, Metachlorophenylpiperazine Memantine, alfuzosin, and guaifenesin were detected in the pilot's blood, tissue samples, and urine. Delta-9-THC is the primary psychoactive chemical in cannabis, including marijuana, hashish, and cannabis edibles. Delta-9-THC may be smoked or ingested recreationally by users seeking mind-altering effects. It may also be used medicinally to treat illness-associated nausea, chronic pain, and other symptoms of some chronic diseases. The specific psychoactive effects of delta-9-THC vary depending on the user, user history of use, dose consumed, and route of consumption. Delta9-THC use may impair motor coordination, worsen reaction time, impair decision-making and problem-solving, distort perceptions of reality, and decrease vigilance. Eleven-hydroxy-THC is the primary psychoactive metabolite of delta-9-THC. Carboxydelta-9-THC is a nonpsychoactive metabolite of delta-9-THC. Gabapentin is a prescription medication that can be used to treat nerve pain, certain types of seizures, restless legs syndrome, and other conditions. Gabapentin generally, carries a warning that use may cause drowsiness, dizziness, blurred vision, and general central nervous system depression. Precautions are advised when driving a vehicle or operating heavy machinery until the user can assess the impact of dosing on alertness and motor activities. Gabapentin use in adults over the age of 65 may increase the risk of decline of executive function, information processing, and motor skills. The use of opioids with gabapentin is not advised due to increased risk of central nervous system side effects, especially in older adults. The FAA considers gabapentin a “do not issue/do not fly” medication. Codeine, morphine, hydrocodone, and dihydrocodeine are opioid drugs. These drugs can be individual prescription medications or metabolites of other opioid drugs. Because morphine and hydrocodone are metabolites of codeine (and dihydrocodeine is a metabolite of hydrocodone), use of codeine alone can cause a person to test positive for codeine, morphine, hydrocodone, and dihydrocodeine. Codeine commonly is used to treat moderate to severe pain. Codeine is also commonly used in prescription cough medications to relieve shortness of breath and cough. Codeine carries a warning that use may impair the mental or physical ability needed to perform potentially hazardous activities such as driving a car or operating dangerous machinery. Use of opioids with other central nervous system depressants increases the risk of sedation. Codeine also can be used illicitly. An open prescription for codeine generally is disqualifying for FAA medical certification, although case-by-case certification may be granted by the FAA in certain cases of infrequent use for acceptable medical conditions. The FAA states that a pilot should not fly after using an opioid like codeine until adequate time has elapsed for the drug to be eliminated from circulation. Atomoxetine is a prescription medication commonly used to treat attention-deficit/hyperactivity disorders in adults. The FAA considers atomoxetine a “do not issue/do not fly” medication. Trazodone is a prescription antidepressant medication that may be used to treat major depression and is also commonly used to treat insomnia. Trazodone typically carries a warning that use can slow thinking, impair motor skills, and that users should not drive, operate heavy machinery, or perform other dangerous activities until they know how the drug affects them. The FAA considers trazodone a “do not Issue/do not fly” medication. Meta-chlorophenylpiperazine is the primary active metabolite of trazodone. Memantine is a prescription medication used to treat moderate to severe dementia of the Alzheimer’s type. Memantine use may cause dizziness, headaches, and worsened confusion. A pilot taking memantine and seeking FAA medical certification requires a deferral to the FAA for review of the medication effects and the underlying condition for which the drug is used. Alfuzosin is a prescription medication commonly used to treat symptoms of an enlarged prostate. Guaifenesin is an over-the-counter medication commonly used in combination with cold medications to loosen mucous to make coughs more productive. Alfuzosin and guaifenesin are not generally considered impairing. On January 30, 2024, at 1029 Pacific standard time, an experimental amateur-built Vans RV-6 airplane, N30AK, was substantially damaged when it was involved in an accident near Concord, California. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Based on numerous witness statements, the accident pilot was performing touch-and-go landings and takeoffs in the traffic pattern and had successfully completed several. As the airplane climbed during the accident takeoff, the engine lost power, the nose lowered, and engine power momentarily resumed. The airplane’s n