NTSB Factual Report

HISTORY OF FLIGHT

On October 30, 2000, about 0810 Pacific standard time, a Piper, PA-28-140 single engine airplane, N16503, was substantially damaged when it collided with terrain near Gorman, California. The commercial pilot sustained fatal injuries and the passenger sustained serious injuries. The pilot/owner was operating the airplane under the provisions of 14 CFR Part 91 as a personal flight. The cross-country flight departed General William J. Fox Airfield (WJF), Lancaster, California, about 0740, and was en route to Pearson Field Airport (VUO), Vancouver, Oregon. Instrument meteorological conditions (IMC) prevailed at the accident site, and no flight plan had been filed.

A witness, who was in an automobile, stated he and his passenger had just departed Interstate 5 at Gorman for a break. They observed the airplane flying from north to south over Interstate 5, and initially thought the airplane was operated by the police as a speed trap and was searching for someone on the interstate. The witnesses indicated the airplane began a turn toward the north and was "shaking or vibrating" as it neared a small mountain. The airplane then turned south momentarily, then north. The witnesses described the airplane as shaking or vibrating before it descended and impacted the ground. The witness did not see the airplane's ground impact.

Another witness, who was driving south on Interstate 5, stated that he saw the airplane flying 50-100 feet above ground level (agl), flying directly over Interstate 5 in a northbound direction. The airplane looked as if it were going to land on the side of the interstate; however, it started moving from side to side before banking left and flying over the southbound lanes of the highway. The witness added that when the airplane started moving side to side in a violent manner; it looked as if the wind was strong and he was trying to fight for control of the airplane. The airplane then made a sharp bank to the right and descended to the ground in a 45-degree angle with the right wing and nose of the airplane hitting the ground first. The witness further stated that the propeller was "working" at the time of impact. He also reported the weather as breezy, cold, and cloudy.

According to the Federal Aviation Administration (FAA), the pilot was not in radio contact with air traffic control at the time of the accident.

PERSONNEL INFORMATION

A review of FAA airman records revealed the pilot held a commercial pilot certificate with airplane single and multiengine land and instrument ratings. The pilot also held a certified flight instructor certificate with airplane single and multiengine land ratings and instrument airplane ratings. The pilot added the instrument airplane rating to his flight instructor certificate on October 29, 2000 (the day before the accident). The pilot held a first-class medical certificate that was issued on August 14, 2000, with no limitations or waivers.

An examination of the pilot's logbook and the completed FAA Form 8710.1 (Airmen Certificate and/or Rating Application) indicated he had accumulated a total of 1,115 flight hours as of October 29, 2000. According to the application, he had accumulated a total of 236 hours of instrument flight time. He logged 40 hours in the last 90 days, and 30 hours in the last 30 days.

AIRCRAFT INFORMATION

The airplane was a Piper PA-28-140, serial number 28-7325286 and was powered by a 150-horsepower Lycoming O-320-E3D engine, serial number L-33402-27A. A review of the airplane's logbooks revealed the airplane had accumulated a total airframe time of 3,289.2 hours at the last annual inspection. The last annual inspection was completed on November 9, 1999. The tachometer read 3,289.2 hours at the last inspection; the Hobbs hour meter time was not recorded. At the accident site, the tachometer and Hobbs meter read 3,334.9 and 1,523.4 hours, respectively.

Examination of the maintenance and flight department records revealed the last static system, transponder, and altimeter checks were completed on July 3, 1997. In Federal Aviation Regulation (FAR) Part 91.411 it states altimeter and static system checks must be completed within the preceding 24 months in order to operate under IMC in controlled airspace.

Fueling records at Fox Field established that the airplane was last fueled on October 30, 2000, with the addition of 25.5 gallons of 100 Low Lead (LL) aviation fuel.

METEOROLOGICAL CONDITIONS

The closest official weather observation station was Sandburg, California (SDB), which was located 7 nautical miles southeast of the accident site. The elevation of the weather observation station was 4,523 feet msl. A routine aviation weather report (METAR) for SDB was issued at 0811, and reported the winds from 330 degrees at 11 knots; broken clouds at 400 feet agl and overcast clouds at 1,200 feet agl; visibility 10 statute miles; temperature 2 degrees Celsius; dew point 2 degrees Celsius; and an altimeter setting of 30.02 inches of mercury. The remarks section of that METAR indicated rain ended at 0810, and the cloud bases were variable between 300, 600, and 1,000 feet.

Federal aviation requirements for visual meteorological conditions are a ceiling of 1,000 feet or more and at least 3 statute miles of visibility.

The METAR for Palmdale, California, which is located approximately 10 miles southeast of the departure airport, reported a broken layer of clouds at 4,600 feet and 10 miles visibility at 0753. This indicates visual flight conditions existed when the flight departed Lancaster.

In-flight weather advisories were reviewed and it was noted that an AIRMET for instrument flight rules (IFR) was issued at 0645 on October 30, 2000, and was valid until 1300 on the same day. The AIRMET reported occasional ceilings below 1,000 feet agl and visibilities below 3 statute miles in mist. These conditions were forecast until 1000.

An AIRMET for turbulent conditions was issued on October 30, 2000, at 0645, and was valid until 1300 on the same day. According to the AIRMET, occasional moderate turbulence below 14,000 feet was forecast after 1000.

The accident site was contained with in the area encompassed by both AIRMETs.

A carburetor icing probability chart obtained from the DOT/FAA/CT-82/44 Publication: Light Aircraft Piston Engine Carburetor Ice Detector/ Warning Device Sensitivity/Effectiveness, dated June 1982, indicated serious icing at cruise power conditions were favorable at the time of the accident.

It is unknown whether the pilot obtained weather information prior to departing.

WRECKAGE AND IMPACT INFORMATION

Investigators from the FAA, New Piper Aircraft, and Textron Lycoming examined the wreckage at the accident scene. The primary wreckage was located at 34 degrees 47.631 minutes north latitude and 118 degrees 51.497 minutes west longitude. The airplane came to rest upright in a field near a group of trees at a global position system (GPS) elevation of 3,955 feet. The accident site was located approximately 32 miles on a 262-degree bearing from the departure airport.

A 12-foot ground scar was located 30 feet to the southeast of the airplane's final resting position. The directional orientation of the ground scar was along a 315-degree heading. The airplane came to rest with its nose pointing to a heading of 350 degrees. The propeller and left main landing gear were located within the ground scar.

The airplane remained intact; however, the engine and cockpit area sustained substantial upward and aft impact damage. The right wing remained in its proper location; however, it sustained impact damage from its bottom side up and came to rest inverted. The right main landing gear was separated, but remained attached to the right wing via its brake line. The cabin area sustained buckling damage and bottom side impact damage. The empennage remained intact, but the left horizontal stabilizer was crushed and partially torn aft. The left wing was bent up at the aileron flap junction. Flight control continuity was confirmed from the cockpit to all flight control surfaces with the exception of the right aileron.

According to the FAA inspector, who responded to the accident site, fuel was found in the left wing; however, the right fuel tank had been compromised. The fuel selector was found selected to the right fuel tank. The cockpit engine controls were documented with the mixture control found in the lean position, the throttle control found in the closed position, and the carburetor heat found in the "ON" position.

The engine remained attached to the airframe via its mount. There was no evidence of pre-mishap catastrophic mechanical malfunction when viewed externally. The exhaust pipes, carburetor, and alternator were displaced aft. The top spark plugs and vacuum pump were removed, and the crankshaft was rotated manually through the vacuum pump drive pad utilizing a drive tool. Thumb compression was observed in proper order on all four cylinders, and crankshaft/camshaft continuity was confirmed throughout the engine to the accessory case. The cylinders were examined through the spark plug holes utilizing a lighted borescope. There was no evidence of foreign object damage and the combustion signatures displayed coloration consistent with normal operation. No anomalies were noted with the lubrication system.

The magneto-to-engine timing could not be ascertained due to the flywheel's destruction. The magnetos remained securely clamped at their mounting pads and the ignition harness was secure at each magneto. After the magnetos were removed for examination, it was noted that each magneto produced spark at the end of the respective spark plug lead during manual rotation of their drives.

The carburetor and induction system were examined and observed to be free from obstructions. The throttle and mixture controls remained securely attached to the carburetor control arms, and continuity to the cockpit was confirmed. Approximately 1 ounce of fuel was drained from the carburetor fuel bowl at its drain plug. The carburetor discharged fuel at its accelerator discharge tube during actuation of the throttle lever. The fuel inlet screen was removed and found free of contamination. Internal examination of the carburetor revealed no anomalies. Fuel was drained from the engine compartment fuel lines, fuel pump, gascolator, and fuel selector valve during their respective examinations.

The propeller blades displayed leading edge gouging, chordwise scoring across the cambered surface, and trailing edge "S" bending.

MEDICAL AND PATHOLOGICAL INFORMATION

The Los Angeles County Coroner completed an autopsy of the pilot. According to the coroner's report, the pilot died as a result of multiple blunt force injuries. A toxicological test for carbon monoxide, cyanide, volatiles, and drugs were positive with the following:

0.05 ug/ml of dextromethorphan detected in the pilot's blood,

an unquantified amount of dextromethorphan detected in the pilot's urine,

5.567 ug/ml of dextromethorphan detected in the pilot's liver,

0.173 ug/ml of dextromethorphan detected in the pilot's kidney,

0.033 ug/ml of destrorphan detected in the pilot's blood,

an unquantified amount of dextrorphan detected in the pilot's urine,

0.699 ug/ml of dextrorphan detected in the pilot's liver,

0.12 ug/ml of dextrorphan detected in the pilot's kidney,

an unquantified amount of nordextrorphan detected in the pilot's urine,

0.269 ug/ml of doxylamine detected in the pilot's blood,

an unquantified amount of doxylamine detected in the pilot's urine,

1.082 ug/ml of doxylamine detected in the pilot's liver,

0.334 ug/ml of doxylamine detected in the pilot's kidney,

8.788 ug/ml of acetaminophen detected in the pilot's blood,

177.576 ug/ml of acetaminophen detected in the pilot's urine,

and unquantified amounts of ephedrine, pseudoephedrine, and phenylpropanolamine detected in the pilot's blood, urine, liver, and kidney.

Dextromethorphan is an over-the-counter cough suppressant, commonly used in multisymptom cold relievers. Dextrorphan and nordextrorphan are metabolites of dextromethorphan.

Doxylamine is an over-the-counter antihistamine used to treat rash, hives, watery eyes, runny nose, itching, and sneezing due to allergies or the common cold. It is also used to treat motion sickness, anxiety, or as a sleep aid.

Ephedrine is sold as a stimulant, weight loss product, or decongestant in many nutritional supplements and is an asthma medication available over-the-counter in tablet form.

Pseudoephedrine is a common decongestant with a trade name Sudafed that is found in many over-the-counter cold and allergy preparations, including the multisymptom cold relief preparations.

Phenylpropanolamine is an over-the-counter decongestant, and is also a metabolite of ephedrine and pseudoephedrine.

Acetaminophen is an over-the counter pain-reliever and fever-reducer, often known by the trade name Tylenol.

The FAA does not regulate the use of any specific prescription or over-the-counter medications by pilots, though the Federal Aviation Regulations do state under 14 CFR 91.17, "No person may act or attempt to act as a crewmember of a civil aircraft...while using any drug that affects the person's faculties in any way contrary to safety."

ADDITIONAL INFORMATION

The Safety Board released the wreckage to the owner's representative.

NTSB Probable Cause

the pilot's failure to maintain airspeed while maneuvering, which resulted in an inadvertent stall. A contributing factor was the pilot's use of impairing medications.