NTSB Factual Report

HISTORY OF FLIGHT

On July 15, 2001, about 1826 eastern daylight time, a Beech A23-24, N5962S, was substantially damaged while maneuvering near Bridgeville, Delaware. The certificated private pilot was fatally injured. Visual meteorological conditions prevailed for the flight that departed Sugar Hill Airport (DE17), Greenwood, Delaware. No flight plan was filed for the local personal flight conducted under 14 CFR Part 91.

According to witnesses, the pilot departed DE17, about 1715. He flew over Rehoboth Bay about 1800, and was circling in the vicinity of the accident site, about 1820.

One witness stated that the airplane initially climbed, then descended rapidly into a cornfield. The witness added that she heard a consistent engine noise. Another witness stated that the airplane circled his house twice, and he thought the airplane was "a crop-duster setting up for a low pass." The witness heard the engine noise continuously, followed by the sound of the impact.

The accident occurred during the hours of daylight; located approximately 38 degrees, 45.39 minutes north latitude; and 75 degrees, 32.22 minutes west longitude.

PILOT INFORMATION

The pilot was an orthopedic surgeon. He held a private pilot certificate, with ratings for single engine land and instrument airplane. Although the pilot's logbook was not recovered, he reported a total flight experience of 1,030 hours on his most recent application for a Federal Aviation Administration (FAA) third class medical certificate.

AIRCRAFT INFORMATION

The airplane's last annual inspection was performed on May 20, 2001. At that time, the airplane had accumulated approximately 2,138 hours of operation. At the time of the accident, the airplane had accumulated approximately 2,142 hours of operation.

METEOROLOGICAL INFORMATION

The reported weather at an airport approximately 10 miles away, at 1854 was: wind from 320 degrees at 6 knots; visibility 10 miles; clear sky; temperature 80 degrees Fahrenheit, dew point 55 degrees; altimeter 29.97 inches Hg.

WRECKAGE INFORMATION

The wreckage was examined at the accident site on July 16, 2001. It was located in a cornfield, about 55 feet above sea level. At the beginning of the debris path, the corn stalks were observed cut at an approximate 45-degree angle. The pilot tube and red navigation light were found near the beginning of the debris path. The path extended about 16 feet from the origin, on a heading about 130 degrees, to the main impact crater. The path then extended about 105 feet, on a heading about 100 degrees, to the main wreckage. Along the 105-foot debris path, the propeller, rudder, nose gear, and right aileron were found.

All major components of the airplane were accounted for at the scene. The main wreckage was oriented about a northerly heading. Both wings were folded aft of the fuselage, and both fuel tanks were ruptured. Flight control continuity was confirmed from all control surfaces on the empennage to the cockpit control column. Continuity was also confirmed from the right aileron bellcrank to the cabin area. One of the left aileron bellcrank arms was observed fractured, consistent with overload, and its respective aileron cable (forward) was not recovered. However, control continuity of the 2nd left wing aileron cable (aft) was confirmed from the bellcrank to the cabin area.

The left wing exhibited impact damage along the leading edge, and was buckled. The left flap was broken and deflected downward. The left aileron was separated from the wing. The right wing also exhibited impact damage along the leading edge, and was severely crushed. The right flap was broken and deflected downward. The right aileron was separated from the wing.

The empennage was twisted, and resting on top of the fuselage. The horizontal stabilator was intact, the vertical stabilizer had separated from the aft fuselage, and the rudder was found separated from the stabilizer. The elevator trim actuator measurement was beyond the full nose down trim position, which was consistent with trim system being subjected to impact forces. The fuselage was crushed, and the emergency locator transmitter was damaged during the impact. The cockpit was destroyed, and the pilot's seat had been ejected. However, a few readings were secured from the cockpit. The magneto switch was selected to "BOTH", and the throttle and mixture controls were found in the full forward position. The manual flap control corresponded to a flaps retracted setting.

The propeller had separated from the crankshaft, and was located about 18 feet beyond the main impact crater. Both propeller blades exhibited s-bending and gouges on both the leading and trailing edges. One blade was curled near the tip. The top spark plugs and valve covers were removed from the engine for inspection. The spark plugs appeared gray in color, and their electrodes were intact and absent of debris.

Where the propeller had separated, the crankshaft was bent consistent with impact damage. In an attempt to rotate the crankshaft, the forward top and bottom through-bolts were loosened. The crankshaft was then rotated by hand using an accessory gear drive in the rear of the engine, with the assistance of a strap that was wrapped around the forward section of the crankshaft. Crankshaft and camshaft continuity were confirmed. Valve train continuity was confirmed, and thumb compression was attained on all cylinders.

Both magnetos suffered impact damage, and did not produce spark when rotated by hand. However, when the left magneto was rotated by hand, the impulse coupling engaged. The right magneto cover was removed for inspection. When the right magneto was rotated by hand, all points opened. The injector was inspected, and the throttle valve was found open. Approximately 1/2 ounce of fuel was recovered from the engine driven fuel pump and the fuel injector. The fuel was light blue in color, and consistent in smell to aviation gasoline. The oil filter was inspected, and was found absent of debris.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by the Office of the Chief Medical Examiner, Wilmington, Delaware. The autopsy report stated that the cause of death was "multiple severe traumatic injuries due to plane crash." The report also noted "transection of the great vessels (aorta, pulmonary artery, venae cavae, and pulmonary veins)."

Noted pre-existing disease included:

Cardiovascular System: "fibrous pericarditis," "focal fibrosis of myocardium," "myocardial infarction, healed, of posterior left ventricle," and "arteriosclerotic coronary artery disease with coronary artery bypass drafts x 2"

Respiratory System: "fibrous pleuritis, bilateral"

Gastrointestinal System: "obliteration of the peritoneal cavity by dense fibrous adhesions," "sub-total gastrectomy, healed," and "sub-total colectomy, healed"

Liver and Gall Bladder: "chronic cholecystitis and cholelithiasis"

Genitourinary System: "Atherosclerotic nephrosclerosis, early"

The pilot's most recent Federal Aviation Administration (FAA) medical examination was performed on April 23, 2001. In a letter dated May 9, 2001, the FAA Manager of the Aeromedical Certification Division authorized a special issuance for a third class medical certificate, valid until April 30, 2002.

According to the NTSB Medical Officer's factual report, the pilot listed only Synthroid as any currently used medication on his application for an FAA third class medical certificate. He also indicated "yes" for "Heart or vascular trouble," "Stomach liver, or intestinal trouble," "Military medical discharge," and "Admission to hospital." The pilot indicated "no" for "Mental disorders of any sort; depression, anxiety, etc."

The pilot's aviation medical examiner noted the pilot's height at 71 inches and weight at 152 lbs. The examiner's comments on history and findings included "multiple abdominal scars, anterior chest wall feeding reservoir and midline sternotomy scar, please see attached summary." The examiner added, "No certificate issued - deferred for further evaluation."

In the attached summary, the examiner noted a history of Hodgkin's Disease, coronary artery disease, bowel adhesions, and "a central line which he still uses for occasional enteral feeding."

However, in the letter dated May 9, 2001, in which the Manager of the FAA Aeromedical Certification Division authorized a special issuance of a medical certificate, there was no mention of abdominal problems, the presence of a central line, or the pilot's need for parenteral feedings. The Manager did note a history of coronary artery disease.

Review of the FAA medical records, surgical medical records, and pharmacy records revealed that within 1 year prior to the accident, the pilot filled prescriptions for Synthroid, Zoloft, Deseryl, Prozac, Imodium, and Lasix. The records did not reveal any prescriptions for tramadol. All of the pilot's most recent prescriptions had been written by the pilot himself.

Additionally, a treatment plan signed by the pilot's surgeon and dated January 22, 2001 required that he, "infuse TPN [total parenteral nutrition] 2500 mL IV over 10 hours with taper down over 2 hours, 3-5 days weekly." An assessment note dated May 11, 2001, stated that the pilot was using 2-3 TPN bags per week. The most recent assessment note, dated July 9, 2001, stated that 3 TPN bags would be delivered for that week.

Toxicological testing was conducted at the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma. According to the toxicology report:

"1.86 (ug/mL, ug/g) SERTRALINE detected in Blood

1.772 (ug/mL, ug/g) DESMETHYLSERTRALINE detected in Blood

SERTRALINE detected in Gastric

SERTRALINE detected in Liver

TRAMADOL detected in Gastric

TRAMADOL present in Liver

TRAMADOL detected in Kidney

43.359 (ug/ml, ug/g) SALICYLATE detected in Blood

5.716 (ug/mL, ug/g) TRAMADOL detected in Blood"

According to the Physician's Desk Reference, Sertraline (Zoloft) is a prescription antidepressant, and tramadol is a prescription narcotic-like painkiller.

ADDITIONAL INFORMATION

The wreckage was release to a representative from the owner's insurance company, on July 16, 2001.

NTSB Probable Cause

The pilot's incapacitation, which resulted in a loss of aircraft control while maneuvering. A factor was the FAA Aeromedical Certification Division's inadequate certification/approval of the pilot's medical certificate. Findings were the pilot's inappropriate use of medication, and depression.