NTSB Factual Report

HISTORY OF FLIGHT

On April 19, 2010, about 1038 central daylight time, a Piper PA-24-250, N5425P, was destroyed when it impacted the ground near Madison, Indiana. The private pilot, who was the sole occupant, was fatally injured. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight, which was not operated on a flight plan. The local flight originated from the Madison County Airport (IMS), Madison, Indiana, about 1030.

A witness to the accident reported that he heard the airplane’s engine “rev up” and then he saw the airplane pitch up, roll to the right to an inverted position, and nose dive toward the ground.

PERSONNEL INFORMATION

The pilot held a private pilot certificate with single-engine land airplane, and instrument airplane ratings. He was issued a third-class airman medical certificate, with a restriction for corrective lenses, on June 3, 2009.

Review of the pilot’s flight logbook indicated that the pilot had accumulated 6,006 hours as of the last entry dated March 23, 2010. All of the pilot’s recent flight entries were for flights in the accident airplane. The pilot’s most recent flight review, as required by 14 CFR 61.56, was completed on July 16, 2009.

AIRCRAFT INFORMATION

The accident airplane was a Piper model PA-24-250 Comanche, serial number 24-479. It was a four-place, low-wing, single-engine airplane, with a retractable tricycle landing gear configuration. The airplane was constructed predominately of aluminum alloy materials. The airplane was powered by a 250-horsepower Textron Lycoming model O-540-A1D5, six-cylinder, reciprocating engine, serial number L-20446-40A.

Maintenance records indicated the most recent annual inspection was completed on November 19, 2009, and the airframe had 2,598.8 hours at the time of the inspection. The engine had accumulated 402 hours since overhaul at the time of the annual inspection.

According to Federal Aviation Administration (FAA) records, the pilot had owned the airplane since June 3, 1974.

METEOROLOGICAL CONDITIONS

At 1053, the reported weather at the Bowman Field Airport, Louisville, Kentucky, about 34 nautical miles south of the accident site were: Variable wind at 3 knots; 10 miles visibility; clear skies; temperature 16 degrees Celsius; dew point 4 degrees Celsius; altimeter setting 30.16 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

The airplane impacted an open agricultural field about 4 miles northwest of IMS. The airplane was resting in the field about 500 feet south of a tree line along an east-west access road, and about 150 feet west of a north-south access roads that bordered the property. The only recognizable portion of the airplane was the empennage section. The remainder of the airplane was largely located in one area with the engine embedded about 4 feet into the ground. The firewall was approximately level with the surrounding terrain. Examination of the airplane’s instruments and the debris field indicated that the impact occurred at a high rate of speed in a near vertical attitude on path of about 220 degrees magnetic.

The airplane’s engine remained attached to the tubular engine mount structure. The propeller hub was shattered and all three propeller blades were found within the impact crater. The propeller blades exhibited chordwise .

Examination of the debris field enabled identification of all major airframe and control surface components at the accident site. No preimpact anomalies were detected with respect to the airframe, control system, or engine; However, due to the extent of damage to the airframe, a comprehensive determination of the airplane’s preimpact condition was not possible.

MEDICAL AND PATHOLOGICAL INFORMATION

According to the pilot’s FAA blue ribbon medical file, his first third class certificate was awarded in 1956. The most recent aviation medical examination had been conducted on June 3, 2009, and a third class medical certificate awarded on that date, limited only for corrective lenses. At the time, the pilot denied any medication use except occasional Tylenol. Earlier evaluations document orthopedic procedures and the resection of a benign thyroid mass. The FAA records contain correspondence from his physicians between 2003 and 2005 which included mention of the pilot’s ongoing use of sedating medications including Darvocet (propoxyphene and acetaminophen, a narcotic pain medication) and Halcion (sleep aid). These are not included in the pilot’s report of medications on any visit.

A week before the fatal crash, the pilot saw his personal physician who documented the pilot had complained of increasing fatigue and an episode of confusion and feeling unstable that had lasted about five or six minutes. He was accompanied on this visit by his daughter who expressed concern that the pilot appeared to be having more memory problems than previously. The physician recorded the patient’s active medical problems to include polymyalgia rheumatica, peripheral neuropathy, and arthritis. At that time his medications included Xanax (alprazolam, a benzodiazepine), Halcion (triazolam, a benzodiazepine sleep aid), aspirin, Darvocet (combination of propoxyphene and acetaminophen, a sedating narcotic pain medication), Ambien (zolpidem, another sleep aid), and prednisone (a steroid used to treat the muscle weakness associated with polymyalgia rheumatica). The physician noted the pilot had “decreased memory”; a significant change from February 2, 2010 when the pilot was described as “alert and in no distress”. The physician ordered blood work and an magnetic resonance imaging (MRI) of the brain to further investigate. He asked the pilot to decrease his use of sedating medications including Ambien, Darvocet, and Xanax. In addition, the physician recommended that the pilot, also a physician, refrain from working in his position at the local Health Department for the next six weeks.

The pilot’s last visit with the primary care physician occurred on the day of the accident. The pilot reported feeling somewhat better, but reported occasional palpitations. At that time, the physician and the pilot discussed the findings of the MRI. The radiologist had interpreted the images directly and described two small areas in the left brain (“9mm in length region in the left posteromedial occipital parietal lobe junction and a moderate sized area … in the left temporal lobe”) as having increased signal on the axial diffusion images that “do not have corresponding low signal on the axial apparent coefficient diffusion weighted images indicating these are not related to simple acute ischemic events”. It goes on to suggest “underlying necrosis or hemorrhagic transformation (are) not excluded as potential considerations. Other considerations can include neoplasm, inflammatory process, or recent insult.” The radiologist suggested a contrast enhanced MRI and a computerized tomography (CT) scan of the brain to further investigate the findings.

An autopsy of the pilot was performed at The King's Daughters' Hospital, Madison, Indiana, on April 20, 2010. The autopsy report concludes that the cause of death was multiple blunt force injuries. No brain or blood was available for examination due to the severity of injury.

Toxicology testing was performed by the FAA Civil Aerospace Medical Institute. The toxicology report was limited by the unavailability of blood; this precluded testing for cyanide or carbon monoxide poisoning. There was no ethanol found in muscle or brain. Dextromethorphan (an over the counter cough suppressant) was identified in liver and kidney; propoxyphene (sedating narcotic pain medication) was identified in liver (6.025 ug/ml) and kidney (0.779 ug/ml); norpropoxyphene was also identified in liver (25.594 ug/ml) and kidney (2.777 ug/ml); and phenobarbital (sedating anti-seizure medication) was identified in liver (0.299 ug/ml) and kidney (0.172 ug/ml). Both propoxyphene and phenobarbital carry a warning: “may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery).” Neither is FAA approved for use by pilots.

NTSB Probable Cause

The pilot’s failure to maintain control of the airplane. Contributing to the accident was the pilot’s decision to conduct the flight with known physiological impairment and his use of unapproved sedating medication, both of which likely impaired his ability to operate the airplane.