NTSB Factual Report

HISTORY OF FLIGHT

On November 30, 2013, at 1316 central standard time, a Piper PA-28-161, N8878E, was destroyed when it impacted terrain in Elkmont, Alabama. The private pilot was fatally injured. Visual meteorological conditions prevailed, and no flight plan had been filed for the flight from Pryor Field Regional Airport (DCU), Decatur, Alabama, to Abernathy Field (GZS), Pulaski, Tennessee. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91.

According to the responding Federal Aviation Administration (FAA) inspector, the pilot was moving the recently-purchased airplane to the destination airport where it would be permanently based.

According to a witness, he was outside his house when he saw the airplane, "extremely low, below 100 feet, at high speed doing knife edge turns." The airplane was maneuvering for about 5 minutes, then maneuvered directly above the witness, recovered from one apparent stall, and flew off to the east. About 3 minutes later, the airplane returned and flew the same maneuvers. It made two to three "tight" turns at a low level and high speed, then went wings level. The witness then heard a "pop" and the engine quit. The airplane nosed down, the witness lost sight of it behind trees, and 2 to 3 seconds later he heard a crash.

Global positioning system (GPS) data, recorded about every 3 seconds, indicated that near the end of the flight, the airplane was headed west-southwest, and passed by some farm buildings near a small community at 1,142 feet above mean sea level (msl) or about 270 feet above ground level (agl). The airplane then began a climbing left turn toward the southeast, over the community, reaching an apex of 1,442 feet msl or about 640 feet agl at 1316:24. No additional data points were recorded.

With a 3-second time differential between recordings, the minimum rate of descent from the last data point would have been 1,920 feet per minute.

AIRPLANE INFORMATION

The airplane, which was manufactured in 1977, was powered by a Lycoming O-320-D3G engine driving a two-bladed metal propeller.

All of the airplane's logbooks were not located. There was, however, an airframe logbook and an engine logbook, both labeled "Log #2." The first entry in both logbooks occurred on January 9, 1998, at a tachometer time of 4,377 hours, for the completion of an annual inspection. The engine logbook noted the engine's total time in service as 4,377 hours, and the Time Since Major Overhaul (TSMO) as 1,995 hours.

Between the annual inspections of August 11, 2004, and August 23, 2010, no maintenance was recorded, and there were only 5 hours of operation noted between those dates. At the 2010 inspection, the tachometer time was listed as 4,559 hours, with an engine TSMO of 2,167 hours. There was no 2011 inspection, but there was an April 2012 annual inspection with a tachometer time listed as 4,565 hours, and an engine TSMO time of 2,173 hours.

The logbooks indicated that the airplane's latest annual inspection was completed on May 5, 2013, at a tachometer time of 4,590 hours, and with an engine TSMO of 2,198 hours. No engine compression results were included, although the same technician recorded compressions about year earlier, with the lowest of the four cylinders being 70 psi at that time.

There were no further logbook entries.

The tachometer reading after the accident was 4,595 hours, indicating an engine TSMO of 2,203 hours.

A bill of sale indicated that the airplane was acquired by the pilot on November 5, 2013.

Lycoming Service Instruction 1009AV, "Recommended Time Between Overhaul [TBO] Periods," notes that the recommended TBO for the O-320 series engine is 2,000 hours. Also, "engines that do not accumulate the hourly period of TBO specified in this

publication are recommended to be overhauled in the twelfth year."

A bill of sale indicated that the airplane was acquired by the pilot on November 5, 2013.

Lycoming Service Instruction 1009AV, "Recommended Time Between Overhaul [TBO] Periods," notes that the recommended TBO for the O-320 series engine is 2,000 hours. Also, "engines that do not accumulate the hourly period of [TSMO]…are recommended to be overhauled in the twelfth year."

A fuel receipt indicated that the pilot's father bought 23 gallons of fuel for the airplane on November 27, 2013.

PILOT INFORMATION

The pilot, age 18, held a private pilot certificate, issued July 6, 2012, with a rating for single engine land airplanes. No pilot logbooks were available. The FAA inspector spoke with the pilot's parents, but noted that they were unable to find the pilot's logbook. The FAA inspector estimated that the pilot had about 180 hours total flight time.

The pilot had applied for his only FAA medical certificate on January 31, 2011. At the time, he reported having 7.2 flight hours and that he previously had ear surgery but used no medications. During the examination, the pilot failed color vision testing, but in April 2011, he passed an operational color vision test. He was then issued an FAA third class medical certificate.

WRECKAGE INFORMATION

From photographs provided by the FAA inspector and satellite imagery, the initial impact point was in the vicinity of 34 degrees, 56.04 minutes north latitude, 086 degrees, 58.33 minutes west longitude.

The FAA inspector reported impact marks that were consistent with the left wing of the airplane hitting a power pole about 10 feet above the ground. The airplane then struck the ground about 35 feet beyond the power pole, and continued for about 120 feet until the left wing struck an abandoned house. The airplane then spun around and came to rest about 30 feet from the house.

Due to the extent of damage to the airplane, flight control continuity could not be established at the scene. Both fuel tanks were ruptured, but upon arrival of firefighters, the odor of fuel was so strong as to prompt them to establish two water lines. The fuel selector was found on the right fuel tank, and both wing boost pump switches were in the off position. The gascolater was ruptured and the fuel filter was absent of debris.

A photograph of the propeller revealed a lack of torsional bending or other signatures of power. One blade was straight, while the other was bent aft 90 degrees. The propeller spinner exhibited aft crushing with no sign of rotation. The inspector was able to rotate the propeller to verify engine compression, and piston, valve and engine accessory drive continuity.

A review of topographical mapping imagery revealed agricultural fields commencing about 1,200 feet to the east of the last data point, and a much larger agricultural field to the north of that.

On April 8, 2014, the airframe and engine were further examined under NTSB oversight at a secure storage facility. All flight control surfaces were present, and control continuity was confirmed to all flight control surfaces from the cockpit except for postcrash cuts made to facilitate wreckage transport.

The forward portion of the fuselage was found separated between the seats and the instrument panel. Both front seats were in place and secure, and the lower seat frames were broken. Both front seats were equipped with lap belts and shoulder belts. None of the belts was found fastened at the time of the examination, and there was no stretching of belt fabric. No airframe anomalies were noted that would have precluded normal operation.

The engine, which was impact-damaged, was rotated by hand, confirming crankshaft continuity and compression in all cylinders. Both magnetos were rotated using an electric drill, and furnished spark at all outlet points.

The carburetor, which was found impact-separated from its mount, was disassembled. The internal metal floats exhibited hydraulic deformation consistent with liquid having been present at the time of impact.

All four engine cylinders were examined using a lighted borescope, and due to the extended wear observed, were removed and dissembled. Further examination found that the exhaust valves, guides and valve seats exhibited extensive deposits of combustion by-products.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by the Alabama Department of Forensic Sciences, Huntsville, Alabama. Cause of death was determined to be "multiple blunt force injuries" and manner of death was determined to be "accident."

Toxicological testing was subsequently performed at the FAA's Civil Aeromedical Institute, Oklahoma City, Oklahoma, where methylphenidate was found in the pilot's blood and liver samples.

According to the National institute of Health, MedlinePlus internet site, "Methylphenidate is used as part of a treatment program to control symptoms of attention deficit hyperactivity disorder (ADHD). Methylphenidate is in a class of medications called central nervous system (CNS) stimulants. It works by changing the amounts of certain natural substances in the brain." A family member confirmed that the pilot had been taking a name-brand version of the drug for his ADHD, and that he had been taking it "for several years."

According to the NTSB Medical Factual Report, "ADHD is not just associated with deficits in attention and susceptibility to distraction but also with impulsivity and impairments in motor inhibition, reaction time, visual-motor coordination, executive functioning, decision-making, and rule-governed behavior. Adolescents and young adults with ADHD are 2 to 4 times more likely to have been the driver in a motor vehicle accident, have higher rates of moving violations, and are more likely to have had their license revoked or suspended than peers without the illness. When involved in accidents, drivers diagnosed with ADHD are more likely to be the at-fault driver and tend to incur greater damage to their vehicles. The large majority of these driving studies did not differentiate between subjects with ADHD treated with medication and those that were not using medication. Results of a recent metanalysis indicate there may be a beneficial effect of methylphenidate (and other medications for ADHD) on driving performance but the effect size remains unclear; medication does not appear to fully negate the safety hazards associated with the illness."

The Guide for Aviation Medical Examiners requires that aviation medical examiners defer medical certification for pilots who report the diagnosis of ADHD or use of medications to treat it until the pilot has undergone extensive neuropsychological evaluation and review.

Additional Information

Per Federal Aviation Regulations (FAR), Part 91, §119, Minimum Safe Altitudes, General:

"Except when necessary for takeoff and landing, no person may operate an aircraft below the following altitudes:

1. Anywhere: an altitude allowing a safe emergency landing without undue hazard to person or property on the ground;

2. Over Congested Areas: an altitude of 1,000 feet above the highest obstacle within a horizontal distance of less than 2,000 feet;

3. Over Populated Areas: an altitude of 500 feet AGL;

4. Over Open Water or Sparsely Populated Areas: an altitude allowing for a linear distance greater than 500 feet from any person, vessel, vehicle, or structure."

NTSB Probable Cause

A stuck exhaust valve, which resulted in a total loss of engine power at low altitude. Contributing to the accident were the pilot’s decision to fly at a low altitude, which reduced his forced landing options when the loss of engine power occurred; and poor long-term engine maintenance, which resulted in the buildup of combustion by-products on exhaust valve parts. Contributing to the pilot’s poor aeronautical decision-making was his underlying attention deficit hyperactivity disorder.