NTSB Factual Report

On April 8, 1995, at 1629 central daylight time (cdt), a Piper PA32-260, N3631W, piloted by a private pilot, was destroyed during a collision with the ground and subsequent fire shortly after takeoff from runway 02 (3,200' x 60' dry asphalt) at the St. Clair Regional Airport, St. Clair, Missouri. The 14 CFR Part 91 personal flight was not operating on a flight plan. Visual meteorological conditions prevailed at the time of the accident. The pilot received fatal injuries. The flight departed St. Clair, Missouri, at 1629 cdt.

One witness had been in the airplane during an earlier takeoff attempt. He stated the propeller did not cycle the first time when the pilot was doing the engine runup and propeller check. He said it cycled the second time and the runup was continued to conclusion.

The witness said the airplane would not accelerate above 80 knots on takeoff. "I shouted: 'Let's abort,' and immediately took over the controls and brought the plane to a stop 40 feet from the end of the 3200 foot runway." After deplaning the witness said he told the pilot to have the airplane checked by a mechanic. He said the pilot told him he would have that done. Shortly after the conversation with the pilot the witness said the pilot taxied the airplane to the runway and took off. He stated the airplane "...rose no higher than 15 feet [after liftoff] then dropped to 10 feet. When he turned left to avoid the trees, I saw the airplane go into a left spin... ."

The airport manager stated he washed and parked the pilot's airplane on the day of the accident. Later in the day the pilot arrived and just walked around the airplane according to the manager. He said he cannot recall ever seeing the pilot perform a preflight inspection of the airplane before flight; and it was no different on the accident date. The pilot was a very large person who, in his opinion, was not able to bend down under the wing to drain the fuel tank sumps.

About one month before the accident the pilot had parked the airplane on the airport ramp at night according to the airport manager. He stated the airplane sat outside in rain all night. He said he fueled it the following morning and stored it in a hangar for the pilot. He said the pilot had not flown the airplane since it was refueled.

The on-scene investigation revealed flight control continuity. Examination of the engine revealed mechanical continuity throughout the engine. Cylinder numbers 5 and 6 camshaft had lobes that were worn down to the point where the valves would open and close about 30 percent of their normal travel. The propeller tear down and inspection revealed no mechanical anomalies that would prevent it from functioning properly. N3631W's fuel caps did not have gaskets installed on them according to the Federal Aviation Administration Principal Operations Inspector assisting in the on-scene investigation.

On November 11, 1994, the pilot was denied his third class medical due to high blood pressure, hypertension, and a right eye problem. An April 5, 1995, letter from the pilot to the FAA Medical Branch showed he had accomplished stress and thallium tests. His FAA medical file was in review at the time of the accident.

The pilot's autopsy was performed at the St. Louis Memorial Hospital, St. Louis, Missouri. According to the medical examiner's report, the pilot's toxicology examination revealed the following were found in his blood: 21 percent blood saturation with carbon monoxide, 147 ng/ml verapamil, 278 ng/ml norverapamil, more than 2,000 ng/ml of norpropoxyohene, and 16 micrograms/ml of acetaminophen. The urine drug screen revealed the following: more than 2,000 ng/ml of verapamil, more than 2,000 ng/ml of norverapamil, 135 ng/ml of morphine, and positive indications of norpropoxyphene and acetaminophen. The autopsy report stated the pilot's immediate cause of death was from "Acute Carbon Monoxide Intoxication."

The pilot's toxicology test performed by the FAA's Civil Aeromedical Institute in Oklahoma City, Oklahoma, detected 0.382 (ugml, ug/g) propoxyphene in the blood, 0.687 (ug/ml, ug/g) porpoxyphene in the liver fluid, 1.60 (ug/ml, ug/g) norproxyphene in the blood, 1.345 (ug/ml, ug/g) norproxyphene in the liver fluid, 0.017 (ug/ml, ug/g) diphenhydramine in the liver fluid, and 17.300 (ug/ml, ug/g) acetaminphen in the blood. Other drugs detected with quantities not shown were: verapamil in the blood and liver fluid, norverapamil in the blood and liver fluid, and diphenhydramine was detected in the blood.

According to the 1993 edition of the Physicians' Desk Reference (PDR), "Propoxyphene is a mild narcotic agent... [its] potency... is from two-thirds to equal that of codeine. Norpropoxyphene has substantially less central-nervous system depressant effect than propoxyphene... ." The PDR states its adverse reactions ranged from, "...dizziness, sedation..." to "...lightheadeness, hallucinations, and minor visual disturbances." The PDR states that diphenhydramine had adverse nervous system reactions such as, "...sedation, dizziness, disturbed coordination, confusion, blurred vision... ." Morphine, according to the PDR, can cause "... lightheadedness, dizziness,. ..central nervous system weakness, headache, ...uncoordinated muscle movements, disorientation, visual disturbances... ." Copies of the PDR drug reports are appended to this report.

The wreckage was released to Russell Day representing Loss Management Services of St. Peters, Missouri.

NTSB Probable Cause

the pilot's impairment of judgment and performance due to drugs which led to his operating the airplane with a known mechanical deficiency.