NTSB Factual Report

HISTORY OF FLIGHT

On August 13, 1999, about 1744 eastern daylight time, a Piper PA-28-140, N754AR, registered to Rubin & Rubin P.A., crashed into a house shortly after takeoff from the North Perry Airport, Pembroke Pines, Florida. Visual meteorological conditions prevailed at the time and a visual flight rules (VFR) flight plan was filed for the 14 CFR Part 91 personal flight. The airplane was destroyed and the private-rated pilot and one passenger were fatally injured. The house sustained fire and impact damage and there were no reported injuries to the four individuals in the house at the time of the accident. The flight originated approximately 2 minutes earlier.

According to a transcription of communications with the North Perry Air Traffic Control Tower (HWO ATCT), at 1739:01, the pilot contacted the combined local/ground position and advised that the flight was at Hollywood Aviation with Automated Terminal Information Service (ATIS) information "Delta", departing to the east. The controller cleared the pilot to taxi to runway 9R, and at 1741:29, the pilot advised the controller that the flight was ready for departure eastbound from runway 9R. The flight was cleared to takeoff at 1741:33, which was acknowledged by the pilot. There were no further recorded radio transmissions from the pilot.

According to a pilot-rated witness standing outside hangars located east and south of the departure end of runway 09R, he saw the airplane climbing out of runway 9R. He reported, "It was unusually low considering its location. It reached about 150' then leveled off-the nose then pitched down slightly then back up and the wings rocked a little...." The airplane appeared to "slow down" and looked "floaty". The airplane then "started a slow left bank becoming steeper, then disappeared from view behind a hangar. Approx [approximately] 10 secs [seconds] later a black smoke could be seen rising from the ground. No unusual sound but engine noise was less than normal sound heard from aircraft in same vicinity." According to another witness who is an automobile mechanic and was located across the street from where the airplane crashed, he first heard the engine which sounded like it was missing/stalling, and observed the airplane flying eastbound approximately 100 feet above ground level. He then observed the airplane banking to the left which increased to a wings vertical position. The airplane then descended, crashed into the house, and an explosion and fire occurred 5-10 seconds after the impact. He did not observe any smoke before the accident.

PERSONNEL INFORMATION

Federal Aviation Administration (FAA) records indicate that the pilot was the holder of a private pilot certificate with a single engine land rating.

Review of a certified copy of the pilot's medical file from the FAA indicated he was issued a third class medical certificate on July 6, 1998. The pilot indicated on the application that he was not taking any medication and his total flight time to date was approximately 350 hours. His previous third class medical certificate was dated June 19, 1996. The application for the 1996 medical indicated he was taking "Paxil 40mg/day", for depression. The pilot was advised by the FAA in August 1996, that "By virtue of your history of depression and present use of disqualifying medication (Paxil), it has been determined that you are not qualified for any class of medical certificate at this time." The pilot's doctor wrote a letter to the FAA dated January 28, 1997, advising that the pilot "...has been off of Paxil since October 30, 1996 and has been doing excellent." The FAA advised the pilot in a letter dated February 14, 1997, that "...you are eligible for a third class medical certificate." The letter also stated, "Because of your history of depression, operation of aircraft is prohibited at any time new symptoms or adverse changes occur or any time medication is required." Copies of excerpts of the pilot's medical file are an attachment to this report.

Review of a copy of the pilot's pilot logbook containing entries from July 30, 1970, to the last entry May 26, unknown year, revealed he had accumulated a total of 251.2 hours. This time is exactly the time listed as the "Total Pilot Time To Date" on the application for a third class medical certificate dated June 19, 1996. No determination was made as to the date of the pilots last biennial flight review.

AIRCRAFT INFORMATION

The aircraft was registered in the name Rubin & Rubin, P.A., on June 11, 1996.

The airplane was inspected last in accordance with an annual inspection of September 18, 1998, at a tachometer time of 5,658.61 hours. The engine was inspected last in accordance with a 100-hour inspection the same day; the estimated engine total time since major overhaul at that time was 1,851.61 hours. The differential compression check of each cylinder performed during the inspection indicated all cylinders were 73 psi or greater. The engine oil was changed three times since the annual/100-hour inspection, the last time occurring on July 7, 1999. The airplane had accumulated approximately 74 hours at the last oil change since the annual/100-hour inspection. No determination was made how much time the airplane had been operated since the last oil change. The permanent maintenance records were not located. METEOROLOGICAL INFORMATION

A special weather observation taken at the Hollywood North Perry Airport at 1746 indicates the wind was from 190 degrees at 4 knots, 10 statute miles visibility, clear, the temperature and dew point were approximately 82 degrees and 73 degrees Fahrenheit, respectively, and the altimeter setting was 29.89 inHg.

COMMUNICATIONS

Transcriptions of communications with the North Perry Air Traffic Control Tower are an attachment to this report.

WRECKAGE AND IMPACT INFORMATION

The airplane crashed into a house located at 7051 SW 12th Street, which was located at 25 degrees 59.983 minutes North Latitude and 080 degrees 13.729 minutes West Longitude. The house is located in a residential area east of the airport. The distance from the departure end of runway 9R to the house was approximately .3 nautical mile and 071 degrees. Examination of the accident site revealed the airplane impacted the front of the house that faces south adjacent to the southwest bedroom. The left wing of the airplane was on the ground in front of the house and a section of the right wing and left horizontal stabilator were on the roof of the house. The engine with attached propeller, firewall, and instrument panel were found in the southwest bedroom of the house adjacent to the impact location. The airplane was destroyed by impact and post crash fire. No ground scars were noted on the driveway of the house. A vehicle parked in the driveway was destroyed by the postcrash fire,and exhibited slight impact damage by an unknown part of the airplane. The house was impact and fire damaged. Medication (Venlafaxine) was found inside luggage that was recovered from the airplane. Additionally, located in a purse that contained the driver's license of the passenger was a small gold colored pouch that contained three small unburned envelopes each containing a green leafy substance. The envelopes were retained for testing (see Tests and Research section of this report). The airplane was recovered for further examination.

Examination of the airplane wreckage revealed that both wings were nearly consumed by the fire. The left fuel cap was in place, the right fuel cap was not located. The finger screen at the outlet of the left fuel tank was clean. Examination of the fuel cap sealing surface of the right fuel tank revealed corrosion pits. Examination of the fuel cap sealing surface of the left fuel tank revealed slight corrosion. Aileron flight control cable continuity was confirmed. Examination of the rudder control cables revealed the left and right were connected at the rear sector and at the rudder tube attach fittings; both rudder bar attach fittings were broken at the welds. The left and right rudder cables were fractured approximately 6 feet and 5 feet aft of the rudder tube attach points, respectively. Examination of the stabilator control cables revealed all were connected at all attach points but were fractured in three locations, comprising of five segments. The five segments of the cables were retained for further examination (see Tests and Research section of this report). The flap selector handle was positioned between the retracted position and the first notch of flaps (10 degrees). The fuel selector valve was separated from the airplane and was positioned approximately 1/2 way on the "left" tank. Disassembly of the valve revealed no evidence of scoring of the valve shaft and no evidence of impact damage was noted. Examination of the auxiliary fuel pump revealed no evidence of fuel or contaminants; power was applied and the unit was found to operate. The carburetor heat control in the cockpit was found in the midrange position. The engine was retained for further examination.

Examination of the engine revealed crankshaft, camshaft, and valve train continuity. Cold differential compression of each cylinder revealed the Nos. 1 and 2 cylinders were 70 psi, the No. 3 cylinder was 58 psi, and the No. 4 cylinder was 71 psi. The left magneto was timed 22.5 degrees before top dead center and the right magneto which was tight on the accessory case, was timed 35 degrees before top dead center. The magnetos were retained for further examination (see Tests and Research section of this report). Heat damage was noted to the engine driven fuel pump. The oil suction and pressure screens were found clean. Pumping action was noted when the engine driven fuel pump was operated by hand. Disassembly of the engine driven fuel pump revealed no water was found. The carburetor was impact and heat damaged; the float and venturi were not located. The throttle plate was found in the full open position. A crack in a section of exhaust aft of the No. 3 cylinder was noted. The damaged segment of the exhaust was retained for further examination (see Tests and Research section of this report).

Examination of the propeller revealed blade No. 1 was bent aft approximately 45 degrees; slight gouges were noted in the leading edge. Blade No. 2 had gouges on the trailing edge of the blade with slight gouges on the leading edge of the blade. Chordwise scratches were noted near the hub on the blade back.

MEDICAL AND PATHOLOGICAL INFORMATION

Postmortem examinations of the pilot and passenger were performed by Eroston A. Price, M.D., Associate Medical Examiner, Broward County Medical Examiner's Office. The cause of death of the pilot was listed as blunt trauma injuries and inhalation of products of combustion. The cause of death of the passenger was listed as multiple blunt trauma injuries.

Toxicological testing of specimens of the pilot were performed by the FAA Toxicology and Accident Research Laboratory (CAMI), and the Broward County Medical Examiner's Office. The result of testing by CAMI of specimens of the pilot was negative for carbon monoxide, cyanide, and ethanol. Tetrahydrocannabinol (.012 ug/ml), Tetrahydrocannabinol Carboxylic Acid (.03 ug/ml), Venlafaxine (.071 ug/ml), and Desmethylvenlafaxine (.273 ug/ml) were detected in the blood. Tetrahydrocannabinol Carboxylic Acid (.493 ug/ml) was detected in the urine. Additionally, Venlafaxine and Desmethylvenlafaxine were detected in the liver. Venlafaxine is antidepressant medication. The result of analysis by the Medical Examiner's Office was positive in the urine for Cannabinoids. Carbon Monoxide (12%) was detected in blood. The result was negative for ethanol. According to the Chief Toxicologist for the Medical Examiner's Office, they did not test for venlafaxine.

Toxicological testing of specimens of the passenger was performed by CAMI and the Broward County Medical Examiner's Office. The result of analysis by CAMI was negative for carbon monoxide, cyanide, and ethanol. Tetrahydrocannabinol (.005 ug/ml) and Tetrahydrocannabinol Carboxylic Acid (.042 ug/ml) were detected in the blood. Tetrahydrocannabinol Carboxylic Acid (.025 ug/ml) was detected in liver fluid. The result of analysis by the Medical Examiner's Office was negative for ethanol and carbon monoxide. No drugs were detected in chest blood. According to the Chief Toxicologist for the Medical Examiner's Office, they did not perform THC analysis on specimens of the passenger.

Field testing of the substance found in one of the envelopes found in the passenger's purse was performed by the Pembroke Pines Police Department; the result was positive as cannabis. One of the envelopes found in the passenger's purse was tested by the Broward County Sheriff's Department Crime Laboratory; the results was also positive for Cannabis. A copy of the reports from the Pembroke Pines Police Department and from the Broward County Sheriff's Department are attachments to this report.

TESTS AND RESEARCH

Review of 14 Code of Federal Regulations (CFR) Part 61.53 revealed that the holder of a medical certificate issued under 14 CFR Part 67 shall not act as pilot-in-command while that person is taking medication or receiving other treatment for a medical condition that results in the person being unable to meet the requirements for the medical certificate necessary for the pilot operation. Additionally, review of 14 CFR Part 91.17 revealed that no person may act or attempt to act as a crewmember of a civil aircraft while using any drug that affects the person's facilities in any way contrary to safety. Copies of the regulations are an attachment to this report.

Examination of the left magneto revealed heat damage. Testing of the condenser revealed it was .01 microfarads less than specification. The point gap was found to be .004 inch less than specification and the E-Gap was found to be 9 degrees greater than specified. The magneto was placed on a test bench and found to spark at all towers from 598 revolutions per minute (rpm) through 5,000 rpm. The magneto was removed from the test bench and the E-Gap was set to specification; the point gap then fell within range. Disassembly of the magneto revealed no evidence of arching inside the distributor block.

Examination of the right magneto revealed heat damage, no evidence of impact damage was noted. The cam follower was heat damaged and the point cam follower was noted to be above the normal position. Testing of the condenser revealed it was .12 microfarads less than specification. The point gap and the E-Gap were within limits. The magneto was placed on a test bench and spark was noted at all towers from 598 rpm through 5,000 rpm. Disassembly of the magneto following the bench test revealed a crack in the distributor block at the No. 1 cylinder position. No evidence of arching was noted inside the distributor block. The five segments of the retained stabilator control cables were examined for determination where the fracture surfaces were located in the airplane. The segment of cable marked "No. 1" attaches at the upper attach point of the balance weight in the rear of the airplane and was fractured approximately 28 inches from the attach point. The segment of cable marked "No. 2" attaches at the forward attachment at the "Tee bar" assembly in the cockpit, makes a 180-degree turn around a pulley located approximately 12 inches forward of the clevis, and was fractured approximately 92 inches from the attach point. The segment of cable marked "No. 3" was the mating cable for Nos. 1 and 2. The segment of cable marked "No. 4" attaches at the lower attach point of the balance weight in the rear of the airplane and was fractured approximately 132 inches from the attach point. The segment of cable marked "No. 5" attaches at the aft attachment of the Tee bar assembly and was fractured approximately 63 inches from the attach point.

Metallurgical examination of the five segments of the stabilator control cables was performed by the NTSB Materials Laboratory located in Washington, D.C. The results of the examination of the No. 1

NTSB Probable Cause

The failure of the pilot to maintain airspeed and inadvertent stall of the airplane by the pilot-in-command resulting in the uncontrolled descent and in-flight collision with a house. Contributing factors in the accident were the loss of engine power due to undetermined reasons, the operation of the airplane by the pilot-in-command under the influence of marijuana contrary to federal regulations, and the unsuitable terrain encountered after takeoff. A finding in the investigation was the operation of the airplane by the pilot-in-command contrary to federal regulations for his use of antidepressant medication which he was warned against.