NTSB Factual Report

On December 25, 1998, about 1344 hours Pacific standard time, a Piper PA-28, N7776W, descended into the Salton Sea near Thermal, California. The airplane sank and is presumed to have been destroyed in the accident sequence. The owner, who does not hold a pilot certificate, was operating the airplane under the provisions of 14 CFR Part 91. The personal cross-country flight was believed to have departed the airport at Chiriaco Summit, California, at 1333. The nonrated pilot and his one passenger sustained fatal injuries. Visual meteorological conditions prevailed and no flight plan had been filed.

Concerned family members reported the aircraft missing when it failed to return in the evening hours as scheduled. The Civil Air Patrol (CAP) initiated a search mission, which included interviewing witnesses and reviewing recorded radar data from the Federal Aviation Administration (FAA).

According to the CAP report of the search mission, the pilot informed his daughter-in-law about 0945 on the day of the accident that he and his wife would be flying from the airplane's home base in Ramona, California, to a restaurant at Chiriaco Summit and return in the early afternoon hours. A recorded radar target departed Ramona about 1207 and appeared to terminate at Chiriaco Summit about 1248. A witness at Chiriaco Summit said he talked to the couple after noon and the airplane departed about an hour later. Recorded radar data identified a secondary 1200 (VFR) beacon code target that departed Chiriaco Summit at 1333 and headed to the southwest. About 1343, the target started a descent from a mode C reported altitude of 6,500 feet msl (mean sea level) and descended to 3,100 feet in 1 minute 36 seconds. The data lost the beacon code at this altitude but two primary targets remained. The last hit was at 1344. The location was 33 degrees 28 minutes north latitude and 115 degrees 37.9 minutes west longitude. This was over the northern end of the Salton Sea (a large salt water lake about 30 miles long by 10 miles wide).

One piece of wreckage was found floating in the water on Wednesday, December 30, 1998. On Friday, January 1, 1999, a fisherman discovered the passenger's remains and some debris in the southern end of the Salton Sea. The pilot's remains were recovered on February 12, 1999. An intensive sonar search by the Imperial and Riverside County Sheriff's Offices and a U.S. Navy detachment did not discover the main wreckage. Pieces of wreckage recovered included insulation, one seat, some personal items, the right main landing gear, and the nose wheel. The section of the wheel pant covering the right main tire was attached on both sides. The forward and rear portions of the pant were missing. The nose wheel pant had a section of its right side attached. Also recovered with the nose wheel was the U-shaped nose fork and the lower half of the nose wheel scissor.

A review of FAA records revealed the pilot did not have a pilot certificate. A third-class medical certificate was issued on July 15, 1997. On the application for this medical certificate, the pilot reported an estimated total time of 800 hours and 100 hours in the last 6 months. A review of a certified copy of the pilot's medical records revealed the FAA Aeromedical Certification Division initiated a request for permanent withdrawal of the pilot's medical certificate. The FAA accident coordinator was unable to locate any airplane or pilot logbooks.

The FAA Toxicology and Accident Research Laboratory performed toxicological testing of specimens of the pilot. They did not perform tests for carbon monoxide and cyanide due to lack of suitable specimens. Tests for volatiles were positive for ethanol, N-Butanol, and acetaldehyde in muscle and the kidney. A positive result for N-Proponal was detected in the kidney. This report noted putrefaction. Tests for drugs were positive for ephedrine and pseudoephedrine in the kidney and pseudoephedrine in the liver.

Dorland's Illustrated Medical Dictionary lists the principle uses of ephedrine as a decongestant, stimulant, to prevent hypertension, and to dilate the pupils. It says pseudoephidrine has less pressor action and stimulant effect than ephedrine. One of pseudoephidrine's salts is typically used as a nasal decongestant and as a bronchodilator.

Goodman and Gilman's "The Pharmacological Basis of Therapeutics. 9/e" discusses the pharmacological actions, therapeutic uses, and toxicity of certain drugs. It says ephedrine stimulates heart rate, cardiac output, and usually increases blood pressure. Effects include risk of hypertension and cardiac arrhythmias. Pseudoephedrine is less potent than ephedrine in producing tachycardia and increased blood pressure.

The FDA requires regulated over-the-counter drug products containing ephedrine or pseudoephedrine to carry the warning: Do not take this product if you have heart disease, high blood pressure, thyroid disease, diabetes, or difficulty in urination due to enlargement of the prostate gland unless directed by a doctor.

The FAA Civil Aeromedical Institute (CAMI) Aeromedical Certification Branch provided a certified copy of the pilot's medical records. The Safety Board's Medical Officer reviewed these records. He extracted pertinent facts from the medical records and submitted a factual report. A summary of the report follows. The full report is attached.

On July 11, 1978, a hospital admitted the pilot with the chief complaint of chest pain. The hospital listed the principal diagnosis as, "Arteriosclerotic heart disease with acute inferior and posterior myodardial infarction."

An application for an airman medical certificate in 1981 was withdrawn. The certification branch denied applications submitted in 1982 and 1983.

An FAA Working Paper/Specialist's Recommendation written in February 1983 highlighted a consultant's review of the pilot's case. The consultant noted the pilot's most recent electrocardiogram, ". . . demonstrated one and a half millimeter ST segment depression compatible with myocardial ischemia." The report noted multiple atrial and ventricular contractions, which demonstrated the presence of myocardial irritability. The report recommended that the request for medical certification be denied.

The pilot submitted results of various medical tests throughout 1983, 1984, 1985, and into June 1986. The Federal Air Surgeon repeatedly concluded that the pilot's medical condition precluded safe performance of airman duties. The Director of the Aircraft Owners and Pilots Association Medical/Technical Assistance Department sent a letter to the Federal Air Surgeon in July 1986. The letter asked for reconsideration of the application for airman medical certificate. It included a letter from a consulting cardiologist.

On July 28, 1986, the Federal Air Surgeon sent a memo to the Manager of the FAA-CAMI Aeromedical Certification Branch. It stated, "Denied 6/14/83 and 11/1/85. Submitted new information. Remains symptom free and stress to 85 percent negative, normal blood pressure. Cardiologist recommends reconsideration. ACTION: Certify Class III annual GXT and clinical followup . . . ."

The manager of the FAA-CAMI Aeromedical Certification Branch informed the pilot on August 20, 1986, that he had been approved for special issuance of a third-class medical certificate. It said his physical report had expired for third-class certification. He could go to an AME, who could reissue a third-class medical certificate, which would be valid until July 31, 1987. The pilot received special issuances of limited (1 year) third-class medical certificates in 1986 and 1988.

An AME (different from previous examiners seen by the pilot) issued a medical certificate on April 6, 1989. The applicant checked no in the block asking if an FAA airman medical certificate had been denied, suspended, or revoked. Item 21.g (heart trouble) had a mark in the block labeled no. The application listed 6 hours total time and an estimated 6 hours in the previous 6 months. The Aeromedical Certification Branch sent a letter to the pilot in November 1989 informing the pilot that they did not receive a complete cardiovascular evaluation. It instructed him to return his medical certificate.

The records contained an application for airman medical certificate dated July 15, 1997. The application had the no block marked in the section asking if an airman medical certificate had ever been denied, suspended, or revoked. Item 21.g (heart trouble) had a mark in the no block. The application listed 800 hours total time and 100 hours in the last 6 months. The block for the date of last FAA medical application contained "8/94."

The medical records contained an FAA Medical Certification System Medical Inquiry dated November 28, 1997. A handwritten note on it was not dated. The note said, "Please Recall for SI." Another handwritten note stated, "I recalled 11-5-98."

The records contained a pre-review sheet dated December 10, 1998. It contained the notation, "Airman Called 12/10/98 left msg for call," and "12/10/98 will get."

The Riverside County Coroner's office performed an autopsy on the pilot on February 17, 1999. The description of the cardiovascular system contained in the autopsy report stated in pertinent part: "There is no blood within the heart. The coronary arteries show normal branching with severe calcification, particularly in the right main branch. The calcified right coronary artery shows a segment of thrombus measuring approximately 0.5 cm in length. This appears to be a few days old. The sections of the myocardium are markedly decomposed and it is difficult to assess the extent of the infarction."

The autopsy recorded injuries to the extremities. Both lower legs had compound fractures. The left forearm showed lacerated skin and soft tissue. The report did not specify any other injuries to the extremities.

The autopsy report on the pilot's wife showed fractures to both wrists and ankles.

NTSB Probable Cause

The occurrence of an in-flight incapacitating heart rhythm to the pilot. A factor was the pilot's ingestion of over-the-counter medications that made him more susceptible to an abnormal heart rhythm.