Aviation Accident Summaries

Aviation Accident Summary CHI94LA189

GOOD HOPE, IL, USA

Aircraft #1

N29952

WACO UPF-7

Analysis

THE PILOT WAS ON A LOCAL FLIGHT WHEN THE AIRPLANE CRASHED. A WITNESS, WHO DID NOT SEE THE AIRPLANE, REPORTED THAT HE HEARD THE SOUND OF THE ENGINE 'CUTTING OUT AND STARTING BACK UP.' A SECOND WITNESS, WHO WAS DRIVING A TRACTOR, SAW THE AIRPLANE, BUT DID NOT HEAR IT. HE STATED THE AIRPLANE MADE 'A COUPLE WIDE CIRCLES GOING DOWN FAIRLY FAST AS IT DID.' ACCORDING TO A POLICE REPORT, THE SECOND WITNESS OBSERVED THE AIRCRAFT IN A 'NOSEDIVE, TAILSPIN.' THE AIRPLANE IMPACTED IN AN OPEN FIELD AT A SLIGHT ANGLE, THEN SKIDDED. WRECKAGE WAS FOUND OVER A 379 FT AREA. AN EXAM OF THE WRECKAGE REVEALED NO PREIMPACT ANOMALIES OF THE AIRFRAME OR ENGINE. TOXICOLOGY TESTS OF THE PILOT'S LIVER TISSUE SHOWED 4.0 MG/KG OF IMIPRAMINE AND 2.0 MG/KG OF DESIPRAMINE. THE PILOT'S MEDICAL RECORDS REVEALED THAT SHE HAD BEEN PRESCRIBED ANTIDEPRESSANTS FOR OVER 2 YEARS, BUT SHE HAD NOT REPORTED THIS ON HER APPLICATION FOR FAA MEDICAL CERTIFICATION.

Factual Information

On June 4, 1994, at 0935 central daylight time, a Waco UPF-7, N29952, registered to Robert Runyan of Bushnell, Illinois, and operated by an airline transport pilot, experienced a departure from controlled flight and impacted the terrain, in an open farm field, near Good Hope, Illinois. The airplane was destroyed and the pilot sustained fatal injuries. The local personal CFR 14 Part 91 flight was being conducted in visual meteorological conditions. No flight plan was on file. The flight departed Bushnell, Illinois, at 0845. There were two eye witnesses to the final moments of the flight of N29952. One was a juvenile who advised her father that she had seen the airplane crash. The father had been working on his truck and did not see the airplane prior to the accident, but had heard the airplane engine sound, and heard the sound of the impact. He recalled the sound of the engine as though it was "cutting out and starting back up." The second eye witness was an individual who was operating a farm tractor with the engine running. He did not hear anything, but his attention was drawn to the airplane by a reflection from sun on the airplane. He stated that the airplane made "a couple wide circles going down fairly fast as it did." The McDonough County (IL) Sheriff's Department report indicated that the wreckage was distributed on a northwesterly direction. From the point of impact, the wreckage was scattered 379 feet. A wreckage diagram prepared by the Sheriff's Department is attached to this report. In examination of the wreckage subsequent to the accident by Federal Aviation Administration investigators revealed no pre-impact anomalies. A post mortem examination of the pilot failed to reveal any physical anomalies. A toxicological examination of specimens from the pilot indicated the presence of Imipramine an antidepressant and its metabolite, Desipramine in the liver. During an interview with the pilot's husband he denied knowledge of her taking any medication and he voluntarily identified her personal physician. In an interview with her employer, for whom she flew 14 CFR Part 135 flights, he stated that he was aware that she had been on medication previously, but said he thought she was no longer taking any medication. An interview with her physician and recovery of medical records from him and another physician revealed a history of her being prescribed antidepressants beginning on November 23, 1991. On November 23, 1991, the pilot was prescribed Ativan (an antianxiety agent). Notes from that office visit read, "... Note she is also using Fiorinal #3 about 1 tablet every other day for headache and was warned that the combination of the two could cause quite a bit of sedation and she understands this." On June 4, 1992, the pilot was attended by another physician who indicated in his notes, "Marilyn Runyan complains of several month history of classic symptoms of chronic depression including early morning awakening, decreased appetite, difficulty concentrating, etc." At that time she was prescribed Desyrel (an antidepressant). On November 20, 1992, she was attended by the same physician, who noted, "She is still having all the symptoms of chronic depression with early morning awakening, decreased appetite, difficulty concentrating, etc. She has no side effects except for some mild increase in sedation during the day with Desyrel." Desyral was discontinued and Imipramine was prescribed. On January 18, 1993, she was again attended by the same physician, who noted, "Her depression is about 80% improved. She has had minimal side effects from medication." At that time the dosage was increased from 50 mg at bed time to 75 mg. On February 2, 1993, and then on February 4, 1993, adjustments were made in the dosage of Imipramine. One physician interviewed stated that he was aware that she was a pilot when he prescribed the Imipramine on November 20, 1992. He stated that he was of the opinion that she had discontinued use of the drug subsequent to the last recorded contact by phone on February 4, 1993. On November 26, 1991 (3 days after being prescribed Ativan), the pilot was examined for a first class medical certificate. On the form she does not list any visits with health professionals within the preceding 3 years and the question "Mental disorders of any sort, depression, anxiety, etc.," is answered "No." On September 1, 1993, the pilot was examined for a first class medical certificate, at which time she indicated having seen the prescribing physician in April, 1992, for a cholesterol check, and another physician in August, 1993, for a skin rash, but she did not mention the previous office visits or the prescribed use of medication. She answered the question "Mental disorders of any sort: depression, anxiety, etc.," as "No." During the investigation it was not possible to determine exactly when the pilot ingested the medication nor the amount of medication taken, prior to the accident. Quantitative amount of Imipramine ingested by the pilot was not conclusive based on post mortem findings. Physicians contacted disagreed on the comparison between liver and blood levels, of which the latter were not available; however, they did agree that at least a low therapeutic level or greater was present as indicated by the level found in the specimens examined. The 1993 edition of "Physician's Desk Reference," indicates: Since imipramine hydrochloride may impair the mental and/or physical abilities required for the performance of potentially hazardous tasks, such as operating an automobile or machinery, the patient should be cautioned accordingly.

Probable Cause and Findings

FAILURE OF THE PILOT TO MAINTAIN CONTROL OF THE AIRCRAFT, WHILE MANEUVERING. A FACTOR RELATED TO THE ACCIDENT WAS: THE PILOT'S IMPAIRMENT DUE TO USE OF A PRESCRIPTION DRUG THAT WAS NOT APPROVED FOR USE WHILE FLYING.

 

Source: NTSB Aviation Accident Database

Get all the details on your iPhone or iPad with:

Aviation Accidents App

In-Depth Access to Aviation Accident Reports