NTSB Factual Report

HISTORY OF FLIGHT

On May 27, 2001, about 0830 central daylight time, a Geertz Zenith CH 200, marked as N77VZ, piloted by a private pilot, was destroyed on impact with terrain near Kankakee, Illinois. The airplane was on climb out from runway 34 at Greater Kankakee Airport (IKK), near Kankakee, Illinois. The personal flight was operating under 14 CFR Part 91. Visual meteorological conditions prevailed at the time of the accident. No flight plan was on file. The pilot was fatally injured. The local flight was originating at the time of the accident.

A witness stated:

On Sunday morning, May 27, at approximately 0830, I was driving south on

US highway 45 toward Interstate 57. Approximately 1/4 mile before

County Road 40, I looked up (approximately 45 degree angle) and saw a

small civil aviation aircraft flying parallel to and east (between 50 and

100 yard) of the highway also heading south. I watched it start a bank

turn to the left and then nosed straight down. There were no other movements

of the aircraft after it nosed down. It did not spin while going down.

The approximate time from the turn until I lost sight of the aircraft in

the trees was between 5 and 6 seconds. Total observation time was not

more than 15 seconds.

I saw no smoke or fire coming from the aircraft and I saw no parts fall

off during the descent. I could not tell if the engine was running

because I had my windows up and [heard] no noise nor did I notice the

propeller. It appeared to me that there was no control of the aircraft

after the left bank.

There were high clouds, but it was clear and dry.

PERSONNEL INFORMATION

The pilot held a private pilot certificate dated March 30, 2001. His logbook indicated 88.9 hours of total flight time. He held a third class medical certificate dated August 7, 2000. The pilot's application for that medical certificate indicated "yes" in response to Item 17.a. "Do you currently use any medication" and lists "Prevacid," "Zoloft," and "Motrin." "Date of last FAA medical application" notes "1978." The application notes "no" in response to Item 18.m. "Mental disorders of any sort: depression, anxiety, etc."

A letter dated 9/18/00 from the pilot's personal physician to his Aviation Medical Examiner notes that the pilot "stopped taking Zoloft in excess of 30 days ago. He is not and has not been experiencing any problems as a result of its discontinuance."

The Federal Aviation Administration's Civil Aeromedical Institute (CAMI) reviewed the pilot's application for that medical certificate. Their letter to the pilot, dated April 9, 2001, stated:

Our review of your medical records has established that you are

eligible for a third-class medical certificate.

The certificate you now hold is valid until the normal date of

expiration.

You are cautioned to abide by Federal Aviation Regulations,

Section 61.53, relating to physical deficiency, medication, or

treatment. Because of your history of anxiety and sleep

disturbance, operation of aircraft is prohibited at any time new

symptoms or adverse changes occur or any time medication and/or

treatment is required.

The pilot's personal medical records were requested from his treating physician. The NTSB's Medical Officer extracted the following facts from those records:

A memo dated 1/15/00 indicates the prescription of "Ambien 10mg

at night as needed #30 with 3 refills."

A note dated 2/22/00 indicates "... occasionally depressed ... takes

5 mg Ambien, 2-3 times per week ... relationship problems ...

Assessment - ... anxiety ..."

A memo dated 3/20/00 indicates "Would like to try Zoloft ... 50 mg

each evening #50 ..."

A note dated 5/23/00 indicates "... feeling better on Zoloft ... 50 mg

# 84 ..."

A note dated 8/29/00 indicates "... self-discontinued Zoloft 2 weeks

ago because of conflict with FAA licensing - patient feels fine off of

it. ..."

A note dated 1/4/01 indicates " ... complains of depression since

breaking up with girlfriend a few months ago. Weight decreased 15

pounds in the last year, attributed to exercise and depression;

problem with staying asleep ... problem with concentration; taking

Zoloft 25 mg per day (stopped for 6 - 7 weeks in 9-00); no suicidal

ideation. ... Assessment - ... depression ... increase Zoloft 100 mg ½

tablet each day # 30 with 3 refills ..."

A note dated 4/6/01 indicates " ... broke up with girlfriend 2 months

ago after 3 year relationship; secondary depression has resolved ...

occasional problem staying asleep - has taken Ambien in past ... no

problem with concentration ... meds - Zoloft 50 mg per day,

approximately 3 days per week ... Assessment ... depression ... sleep

disturbance ... prescription temazepam 15 mg at night as needed #30

with one refill"

The pilot's logbook noted he flew the accident airplane 1.9 hours on May 18, 1 hour on May 20, 1.3 hours on May 20, 1.1 hours on May 22, and 1 hour on May 23.

AIRCRAFT INFORMATION

The airplane was an amateur built experimental Geertz Zenith CH 200, serial number A-142. A piece of paper showing specifications was found in the wreckage. That paper noted that a Lycoming O-235 engine powered the airplane. It listed a McCauley propeller. Its fuel capacity was noted as, "fuel 24 gal." The airplane was fueled on May 14, 2001 with 23.5 gallons of 100 LL fuel.

METEOROLOGICAL INFORMATION

At 0835, the IKK weather was: Wind 290 degrees at 9 knots; visibility 10 statute miles; sky condition scattered 1,000 feet; temperature 13 degrees C; dew point 11; altimeter 29.74 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

The Kankakee County Sheriff's general case report stated, "The plane was found in a creek bed located behind the property of 2155 S [Route] 45/52. FAA inspectors examined the wreckage. No anomalies were found.

MEDICAL AND PATHOLOGICAL INFORMATION

The Coroner of Kankakee County performed an autopsy on the pilot. The NTSB's Medical Officer extracted the following facts from that autopsy:

"Diagnoses" include (among others):

- "multiple skull fractures with avulsion of the brain"

- "multiple rib fractures constituting a flail chest"

- "multiple lacerations of the lung"

- "laceration of the left ventricle and septum"

- "avulsion of the cervical and upper thoracic spinal cord"

- "fracture and dislocation of the thoracic spine, T-2, T-3"

- "multiple lacerations of the aorta with complete transection at the

root and proximal descending aorta"

- "multiple pelvic fractures"

- "multiple lower extremity fractures"

- "coronary atherosclerosis - left anterior descending artery, 75%

occlusion, right coronary artery, 50% occlusion"

There is no mention in the autopsy report of any injuries

to the upper extremities.

CAMI prepared a Final Forensic Toxicology Accident Report. The report stated:

SERTRALINE detected in Liver

0.283 (ug/ml, ug/g) DESMETHYLSERTRALINE detected in Liver

DESMETHYLSERTRALINE detected in Blood

ADDITIONAL INFORMATION

The FAA was a party to the investigation.

The all retained items were released to a family member.

Excerpts, from http://www.cami.jccbi.gov/aam-600/610/600For-DRU.html, stated:

Desmethylsertraline: Desmethylsertraline is the predominant metabolite of

the antidepressant sertraline, Zoloft. While it is an active metabolite,

it is substantially less active than sertraline. Desmethylsertraline has a

plasma half-life of 62 to 104 hours. Warnings - may impair mental and/or

physical ability required for the performance of potentially hazardous

tasks (e.g., driving, operating heavy machinery). ...

Sertraline: Sertraline, Zoloft is [a] SSRI antidepressant. Sertraline

has a plasma half-life of 24 to 26 hours. Therapeutic levels range from

0.020 - 0.300 ug/mL in plasma. Sertraline has a volume of distribution of

76 L/kg. Lethal: 1.5 ug/mL. Warnings - may impair mental and/or physical

ability required for the performance of potentially hazardous tasks (e.g.,

driving, operating heavy machinery).

NTSB Probable Cause

The loss of control on initial climbout for undetermined reasons.