Pleasantville, PA, USA
N28788
Grumman AA-5B
The pilot attempted an ILS approach, which consisted of an inbound, 331-degree course, magnetic. The minimum glideslope crossing altitude at the initial approach fix was 4,484 feet msl. Radar data indicated the airplane tracked inbound on headings varying from 360 degrees to 270 degrees. Approximately 6.7 miles from the initial approach fix, the airplane descended from 4,600 feet to 3,400 feet, at a rate of 850 fpm. The last radar hit was recorded at 3,400 feet, approximately 4.7 miles from the initial approach fix. The airplane was located about 11 miles from the end of the runway, at an elevation of 2,461 feet, about 300 feet below the peak of a ridgeline. Examination of the airplane revealed no mechanical deficiencies. According to the pilot's toxicology test results, 6.51 (ug/ml, ug/g) of DESIPRAMINE was detected in his blood, and DESIPRAMINE and IMIPRAMINE were detected in his urine. The pilot's wife reported that the pilot had been taking Desipramine for approximately 10 years, to treat depression. She stated that she was a doctor and had prescribed the Desipramine to him. A review of the pilot's FAA medical file revealed he never reported taking Desipramine, and never reported any history of mental disorders. Imipramine is a prescription antidepressant, and often results in sedation and psychomotor impairment in healthy adults. Desipramine is a metabolite of imipramine and a prescription antidepressant in its own right. The levels of desipramine found in the pilot's toxicology report were more than 20 times the expected level for chronic use of a typical dose. Nonfatal overdose effects of desipramine, at amounts lower than reported on the pilot's toxicology, have resulted in seizures, coma, low blood pressure, and electrocardiographic (EKG) abnormalities.
HISTORY OF FLIGHT On August 6, 2003, at 0740 eastern daylight time, a Grumman AA-5B, N28788, was substantially damaged when it impacted trees while on approach to the Johnstown-Cambria County Airport (JST), Johnstown, Pennsylvania. The certificated private pilot was fatally injured. Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the flight which originated at the Bay Bridge Airport (W29), Stevensville, Maryland, about 0600. The personal flight was conducted under 14 CFR Part 91. According to air traffic control information provided by the Federal Aviation Administration (FAA), the pilot had been vectored for the ILS Runway 33 approach at Johnstown by the Cleveland ARTCC. At 1135, the pilot was instructed to fly a heading of 300 to intercept the final approach course. The pilot acknowledged the instruction, and at 1136, he was instructed to "maintain four thousand six hundred til established on a segment of the approach cleared i l s three three at Johnstown." The pilot acknowledged the clearance and was subsequently instructed to "report established inbound." At 1137, the pilot reported, "…two eight seven eight's turning inbound now," and was subsequently instructed to "contact the tower." The pilot contacted the Johnstown Control Tower at 1139, and reported, "inbound on the i l s runway three three." The pilot was instructed to report a 3-mile final; however, no further transmissions were received by the pilot. A review of radar data revealed that a target emitting the same transponder code as the accident airplane approached the final approach course on a track of about 280 degrees magnetic, and about 105 knots groundspeed. Prior to turning onto the final approach course, the target descended from 6,100 feet to 4,600 feet. At 0736, the target initiated a right turn to about 330 degrees magnetic, and maintained an altitude of 4,600 feet. For the next 3 minutes, the target remained just to the right of the inbound course, and varied its track between about 360 degrees and 270 degrees magnetic. When the target was 6.7 nautical miles from RUMML, it began a descent from 4,600 feet to 3,400 feet at a rate of 850 feet per minute, and groundspeed of 81 knots. The last three radar hits indicated the target was oriented on a heading of about 330 degrees magnetic, and the last radar contact was recorded at 0739, 150 degrees magnetic, 4.7 nautical miles from RUMML, at an altitude of 3,400 feet. An Alert Notice (ALNOT) was issued for the airplane, and search and rescue operations were initiated. The airplane was located about 1300, in a heavily wooded area, about 150 degrees magnetic, 11.4 miles from the end of runway 33 at Johnstown. The airplane came to rest at an elevation of 2,461 feet, about 300 feet below the peak of a ridgeline. The accident occurred during the hours of daylight at 40 degrees, 09 minutes north, 78 degrees, 41 minutes west. PERSONNEL INFORMATION The pilot held a private pilot certificate with ratings for single-engine land and instrument airplane. His most recent FAA second class medical certificate was issued on March 8, 2002. At that time he reported 800 hours of total flight experience. The pilot's logbook was located in the wreckage. The logbook began with an entry on January 8, 2000 and the last entry was for a flight on June 18, 2003. All entries in the logbook were in the accident airplane. Examination of the entries revealed the pilot had accumulated 931 hours of total flight experience, of which, 45 hours were logged in actual instrument conditions, and 70 hours in simulated instrument conditions. During the previous 90 days, the pilot had accumulated 14 hours of flight time. AIRCRAFT INFORMATION Examination of the airplane and engine logbooks revealed the last annual inspection was completed on March 21, 2003, with no abnormalities noted. The airplane flew 43 hours since the inspection. According to the manager of the Bay Bridge Airport, the airplane was last refueled on July 30, 2003. At 1200 on July 30, the pilot purchased 13.2 gallons of fuel and at 1614, the pilot purchased 15.7 gallons of fuel. METEOROLOGICAL INFORMATION The weather reported at Lee Airport (ANP), Annapolis, Maryland, approximately 10 miles west of the pilot's departure airport, at 0554, included calm winds, 5 miles visibility with mist, few clouds at 3,700 feet, temperature 18 degrees Fahrenheit, and dew point 18 degrees Fahrenheit. Weather reported at Johnstown, at 0654, included calm wind, 1 mile visibility, mist, a broken cloud layer at 1,000 feet, temperature 61 degrees Fahrenheit, dew point 61 degrees Fahrenheit, and barometric pressure of 29.93 inches Hg. At 0727, a "special" METAR was issued which included winds from 250 degrees at 3 knots, 1-1/2 mile visibility, mist, few clouds at 400 feet, an overcast cloud layer at 800 feet, temperature 61 degrees Fahrenheit, and dew point 61 degrees Fahrenheit. A remark was issued with the METAR stating that the ceiling was variable between 700 feet and 1,200 feet. The pilot contacted POTOMAC TRACON, from his aircraft radio and filed his IFR flight plan. However, a search of FAA flight service station data revealed the pilot did not obtain a weather briefing prior to the flight. AIDS TO NAVIGATION The inbound course for the ILS Runway 33 approach was 331 degrees magnetic. The minimum glideslope crossing altitude at the initial approach fix, RUMML, was 4,484 feet msl. RUMML was located 6.7 nautical miles from the approach end of runway 33. The decision altitude for the approach was 2,481 feet msl, and the touchdown zone elevation was 2,284 feet. WRECKAGE AND IMPACT INFORMATION The airplane was examined at the accident site on August 7, 2003, and all major components were accounted for at the scene. The initial impact point was the top of a 75-foot tree, located on 40-degree up sloping terrain. The wreckage path was oriented on a heading of 320 degrees magnetic, and extended about 200 feet to the main wreckage. Located along the wreckage path were both wingtips, both ailerons, the right flap, and both wings. The wingtip sections contained circular concave dents with brown transfer marks on the leading edge, and the leading edges were crushed aft. The wings were located adjacent to each other along the wreckage path. The left wing came to rest inverted, and aft crushing was noted on the leading edge. The right wing came to rest upright, and the outboard portion of the wing displayed inward crushing toward the wing root. Both fuel tank caps were secured to the tanks; however, both wing tanks were breached. The left horizontal stabilizer was also located with the wing sections, and displayed a concave indentation on its outboard tip. The main wreckage came to rest inverted on a heading of 060 degrees magnetic. The wreckage had been up-righted by emergency personnel prior to the arrival of the Safety Board, with the nose of the airplane oriented on a heading of 240 degrees magnetic. The main wreckage consisted of the fuselage, empennage, engine, and flight control surfaces of the left wing. The fuselage canopy had broken off, and the cockpit and cabin area were exposed, but relatively intact. The left flap and a portion of the left aileron remained attached to the wing root. The empennage section of the airplane, containing the vertical and right horizontal stabilizer, was almost completely separated from the fuselage just forward of the vertical stabilizer attachment point. The empennage section remained connected by control cables and wires, and came to rest adjacent to the fuselage with the vertical stabilizer and right horizontal stabilizer resting on the ground. Flight control continuity was confirmed from the cockpit to the empennage section of the airplane. The engine remained attached to the airplane firewall, and the propeller remained attached to the engine. Examination of both propeller blades revealed aft bending and chordwise scratching. The engine was rotated by hand at the propeller flange. Rotation was observed to the rear accessory drive, and valve train continuity and compression were observed on all cylinders. Borescope examination of the cylinders revealed no abnormalities. Both magnetos were rotated by hand, and produced spark at all ignition leads. The top and bottom spark plugs were removed; their electrodes were intact and light gray in color. MEDICAL AND PATHOLOGICAL INFORMATION The FAA Toxicology and Accident Research Laboratory, Oklahoma City, Oklahoma conducted toxicological testing on the pilot. According to the pilot's toxicology test results, 6.51 (ug/ml, ug/g) of DESIPRAMINE was detected in his blood, and DESIPRAMINE and IMIPRAMINE were detected in his urine. Additionally, PROPRANOLOL was detected in his blood and urine, and 11.16 (ug/ml, ug/g) of ACETAMINOPHEN was detected in his urine. ADDITIONAL INFORMATION According to the pilot's wife, the pilot had been taking Desipramine for approximately 10 years, to treat depression. She stated he had seen a psychologist for the depression; however, she was a doctor and had prescribed the Desipramine to the pilot. She stated the most recent prescription was for 100 mg tablets to be taken twice a day. A review of the pilot's most recent FAA second-class medical certificate revealed he listed "Vasotec 5 mg daily," as the only medication he was currently taking. Additionally, he reported no history of "mental disorders of any sort: depression, anxiety, etc." A review of the pilot's entire FAA medical file revealed "Vasotec" as the only drug he ever reported taking, and he answered "no" each time he was asked if he had experienced "mental disorders of any sort." According to the pilot's employer, the pilot worked as an emergency room physician. Wreckage Release The wreckage was released to a representative of the owner's insurance company on October 16, 2003.
The pilot's improper IFR procedure by his failure to maintain published altitudes, which resulted in the in-flight collision with terrain. A factor was his impairment due to prescription medication.
Source: NTSB Aviation Accident Database
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