NTSB Factual Report

HISTORY OF FLIGHT

On May 25, 1998, about 1650 eastern daylight time, a Cessna 182R, N9885E, operated by the Civil Air Patrol (CAP) as CAP flight 1927, was destroyed when it struck trees during a go-around from a private airport in Middleborough, Massachusetts. The certificated commercial pilot (pilot-in-command), and airline transport pilot (second pilot) received fatal injuries. Visual meteorological conditions prevailed for the local training flight, which had departed from Taunton Airport (TAN), Taunton, Massachusetts, at 1604. The flight had departed on an instrument flight rules flight plan that was cancelled, about 1635. No flight plan was in effect at the time of the accident, for the instrument proficiency flight that was conducted under 14 CFR 91.

According to documents from the CAP, Mission Flight Plan/Briefing Form, the purpose of the flight was, "...Instrument Proficiency Flt...." The projected flight time was 1 hour. The pilot-in-command (PIC) signed the form.

A pilot who flew with the PIC in N9885E earlier in the day reported that he did not experience any problems with the airplane, and that it was topped with fuel after his flight. He also reported that he did not observe anything unusual about the PIC.

According to Federal Aviation Administration (FAA) records, the second pilot accessed the Data User Access Terminal (DUAT), at 1432. He received both area METAR reports and terminal forecasts for area airports. At 1516, a person who used the identification "CAP flight 1927", received a weather briefing, and filed an instrument flight rules (IFR) flight plan.

At 1546, the pilots received their instrument clearance via telephone.

The flight departed and established radio contact with Cape TRACON. Prior to terminating the IFR portion of the flight, the pilots requested the IFR approach to Taunton. The request was approved and the airplane proceeded toward the Taunton non-directional beacon. Prior to completion of the approach, and as the airplane passed over the Taunton non-directional beacon at 1635, the IFR clearance was cancelled by the pilots and the transponder was reset to code 1200. No further communications were heard from N9885E.

Several witnesses next observed the airplane as it conducted a low approach and go-around over a private airport on the east side of Middleborough. According to them, the airplane initiated a climbing right turn that continued to increase in bank as the turn continued. The climb transitioned into a descent and the airplane impacted a wooded area with no change in engine noise. The initial climb was steep enough that a witness reported she could see the belly of the airplane.

The accident occurred during the hours of daylight at 41 degrees, 53.46 minutes north latitude and 70 degrees, 52.47 minutes west longitude.

PERSONNEL INFORMATION

Pilot-In-Command

The PIC held a commercial pilot certificate with ratings for airplane single and multi-engine land, and instrument airplane. He also held a flight instructor certificate for airplane single engine land. According to the pilot's logbook records, he had a total of 2,215 hours, with 143 hours in make and model. He had flown 24 hours and 8 hours in the preceding 90 and 30 days respectively.

The PIC was issued a first class FAA airman medical certificate on May 21, 1997. At the request of the NTSB Investigator-In-Charge, the NTSB Medical Officer contacted the pilot's personal physician. The NTSB Medical officer wrote:

"[the pilot] had been a patient of his since 1988, when...[the doctor] began treating him for migraines. When [the doctor] first saw him,...[the pilot] had been routinely taking about 100 tablets of Tylenol #3 (acetaminophen and codeine) per month for his migraines. [the doctor]...switched...[the pilot] to Fiorinal (butalbital, aspirin, and caffeine). When he last saw [the pilot]...in 1997, [the doctor]...had been prescribing 20 tablets of Fiorinal about 2 to 3 times per year."

"[The NTSB Medical Officer], contacted by telephone the pharmacy which had dispensed the Fiorinal to...[the pilot]. The pharmacy confirmed that...[the pilot]had filled prescriptions for Fiorinal from [the doctor]...as described, but found no additional filled prescriptions with the exception of one prior prescription for Lodine (an anti-inflammatory medication) by [another doctor]...[the pilot's]... Aviation Medical Examiner."

Examination of the pilot application for medical certificate revealed that under question 18a, "Medical History, Frequent or severe headaches", the pilot had checked the NO block. A review of his two prior medical applications, dated May 1, 1996, and April 19, 1995, revealed the same answers. In addition, according to question 19, "Visits to Health Professionals Within Last 3 Years", the pilot only listed his visits to his aviation medical examiner. The visits to the doctor who prescribed the Fiorinal were not listed.

According to the FAA Guide for Aviation Medical Examiners, dated September 1996:

"18.a. Frequent or severe headaches. A history of headaches without sequelae is not disqualifying. Some require only temporary disqualification during periods when the headaches are likely to occur or require treatment. Other types of headaches may preclude certification by the Examiner and require special evaluation and consideration (e.g., migraine and cluster headaches) (Also see Item 46 for a discussion of headaches)...."

"46...Pain in some conditions, may be acutely incapacitating. Chronic recurring headaches or pain syndromes often require medications for relief or prophylaxis, and in most instances, the use of such medications is disqualifying because they may interfere with the pilot's alertness and functioning. The Examiner may issue a medical certificate to an applicant with a long standing history of headaches if mild, seldom requiring more than simple analgesics, occur infrequently and are not incapacitating, or are not associated with neurological stigmata."

Second Pilot

The second pilot held an airline transport pilot certificate for multi-engine airplanes, and a commercial pilot certificate for single engine airplanes. He also held a flight instructor certificate for single and multi-engine airplanes, with an airplane instrument rating. According to the pilot's logbook, he had a total of 3,822 hours, with over 100 hours in make and model. He had flown 13 hours and 6 hours in the proceeding 90 and 30 days respectively.

The pilot had received a third class FAA airman medical certificate on December 3, 1996. The FAA subsequently requested addition medical information from the pilot, which was supplied. According to a letter issued on January 8, 1998, from the FAA Aeromedical Certification Division:

"...I have reviewed the information submitted by you in support of your request for an airman medical certificate. The medical evidence reveals a history of myocardial infraction and coronary artery disease that has required treatment (percutaneous transluminal coronary angloplasty) and diet controlled diabetes mellitus. You are ineligible for third-class medical certification under Section 67.11, (a) (1) (3), 67.211, (a) (c) and 67.311, (a) (c) and 67.113, 67.213, and 67.313 (b) of the Federal Aviation Regulations (FARs). However, based on the complete review of the available medical evidence, I have determined that you may be granted authorization for special issuance of the enclosed third-class airman medical certificate under Section 67.401 of the FARs. This certificate supersedes any previously issued medical certificates...."

"This authorization expires on June 30, 1998."

AIRCRAFT INFORMATION

The airplane was a 1985 Cessna 182. It was maintained under a 100 hour/annual inspection program. The airplane had last been serviced prior to departure and departed with full fuel tanks.

WRECKAGE AND IMPACT INFORMATION

The airplane was examined at the accident site on May 26 and 27, 1998. The examination revealed that tree branches were broken on a descending 30-degree path. From the initial tree strike to ground impact, was about 55 feet. The fuselage, which was fragmented and missing the wings was an additional 45 feet beyond the ground impact. Debris from the airplane was found 85 feet beyond the fuselage.

The debris path was narrow except for some items associated with the engine and nose landing gear, which were found on the left side of the debris path. In addition, portions of the right wing were found near the initial tree strike while left wing items were found further along on the debris path. In the area of the right wing, where the fuel tank had broken open, the vegetation was wilted.

Flight control continuity was verified to the rudder and elevator torque tube. The elevators had sheared off of the torque tube. Flight control continuity to the ailerons could not be verified due to fragmentation of the wings. All breaks in flight control cables were observed at other than cable attaching points.

The right wing navigation light was found to have filament stretch.

The engine crankcase was broken open and fragmented. The camshaft was found in a nearby bush. Two cylinders were separated from their pistons.

The propeller had separated from the engine. Both blades of the propeller were bent forward, and rotational chord wise scoring was found on the front of one propeller blade. The trailing edges of both propeller blades were wavy in appearance.

The throttle and propeller controls were found full forward. The portion of the instrument panel that they attached to was separated from the rest of the instrument panel. The carburetor heat was extended and bent over. The carburetor heat control was pushed out of the instrument panel and laying loose in its hole. The magneto switch was found in the BOTH position with the key missing. The switch could be rotated to all positions and returned to the BOTH position without a key.

Portions of the exhaust system and the muffler that were recovered were bent and crushed. Cracks were not visible on the bends.

A clear, light blue liquid similar in sight and smell to 100 LL aviation grade gasoline was found in the carburetor bowl. The carburetor bowl was absent of debris, and the main jet was clear. The fuel selector was found between the BOTH and RIGHT TANK positions.

The faces of two instruments were identified. The tachometer face was wavy, and the tachometer needle was stuck at about 2,300 RPM. The face of the vertical speed indicator was flat and the needle was stuck at 1900 feet per minute down.

MEDICAL AND PATHOLOGICAL INFORMATION

The FAA Toxicology Accident Research Laboratory in Oklahoma City, Oklahoma conducted toxicological testing.

The second pilot was negative for drugs and alcohol.

The PIC was found to contain morphine in his liver fluid and blood. The levels were 0.095 (ug/ml, ug/g) in liver fluid, and 0.216 (ug/ml, ug/g) in blood. In addition, ethanol was found in the blood and muscle fluid, and acetaldehyde was detected in muscle fluid; however, none was found in the vitreous fluid. The toxicological reported also stated, "The ethanol found in this case is from postmortem ethanol production."

On May 26, 1998, the Massachusetts Medical Examiner's Office in Boston, Massachusetts, conducted autopsies, and toxicological tests on both pilots. The second pilot was free of drugs. However, the PIC's blood was found to contain morphine at a level of 200 NG/ML. The report also reported, "Usual range following therapeutic doses: 10 - 70 NG/ML...."

According to the medical personnel who were first on the scene, neither pilot was administered first aid.

ADDITIONAL INFORMATION

According to CAP REGULATION 60-1(E), the following requirements were specified to act as an instructor pilot:

"1. Posses a current FAA certificated flight instructor certificate." "2. Be CAP current and qualified in the aircraft type." "3. Be designated in writing by the Executive Director, region or wing commander."

Examination of the PIC's last flight check found the following comment in the comments section:

"I find...[the pilot] competent to act as CAP instructor pilot...."

This was signed by the Massachusetts Wing Inspector General.

Further examination of CAP REGULATION 60-1(E) revealed there was no requirement for an instrument instructor rating to give instrument instruction.

Whether the PIC was serving as a flight instructor or a safety pilot was not determined.

Radar data from the Cape TRACON revealed that after the IFR clearance had been cancelled for the flight, the airplane turned east and then north, similar to a start to the procedure turn. The left turn was continued for 360 degrees and the flight continued in an easterly direction. When the airplane was about 8 nautical miles east of the Taunton non-directional beacon, it turned south and disappeared from radar at 1643:04. The altitude of the airplane had varied between 1,300 feet and 2,000 feet.

CAP Squadron and Wing personnel familiar with both pilots reviewed the air/ground voice communications tape. The second pilot was heard in the beginning, and the PIC was heard on the remainder of the tape. In a follow-up telephone interview the FAA inspector who hand carried the tape to the meeting, reported that the voice of the PIC was loud and clear throughout the tape. In addition, the voice did not change in tone or speed throughout the tape, and the voice was not slurred nor did the PIC sound lethargic.

The aircraft wreckage was released to the Civil Air Patrol on May 27, 1998.

NTSB Probable Cause

The pilot-in-command's failure to maintain control of the airplane during a VFR go-around. A factor was the impairment due to drugs.