Incline Vlg, NV, USA
N20164
Brown Pitts S-1
The experimental bi-plane collided with the frozen surface of a lake in daytime visual flight rules conditions during a local area flight. The pilot built, maintained, and raced the airplane, in which he had accrued over 700 hours. The commercial air carrier pilot reported 30,000 hours on his last airman medical application. An examination of the wreckage revealed no anomalies that would have precluded normal operation prior to impact. Located within the pilot's flight suit was a broken beer bottle. The pilot's post-mortem chest blood ethanol level was 0.155 percent, and post-mortem urine ethanol level was 0.279 percent. These levels suggest recent ingestion of substantial amounts of alcohol, amounts which would render a non-tolerant individual unconscious or nearly so. The FAA was aware of the pilot's driver's license suspension 10 months prior to the accident, but had not obtained details of the arrest. The arrest record for that suspension detailed that this pilot had been driving a vehicle at a blood alcohol level of more than 0.250. Had the FAA obtained this arrest record, they would have been aware that the pilot met the FAA's definition for substance dependence due to increased tolerance, and he likely would not have been issued a medical certificate without having undergone thorough evaluation and treatment.
1.1 History of the Flight On February 6, 2007, about 1530 Pacific standard time, an experimental Brown Pitts S-1 airplane, N20164, collided with the frozen surface of Marlette Lake near Incline Village, Nevada. The pilot, who was also the registered owner of the airplane, was operating it under the provisions of 14 CFR Part 91. The airline transport pilot, the sole occupant, sustained fatal injuries. The airplane sustained substantial damage. Visual meteorological conditions prevailed and no flight plan was filed. The pilot departed from Carson Airport, Carson City, Nevada, about 1500 for the local area flight. The pilot was reported missing, and the accident site was located on February 8, at 1030. The day of the accident, a pilot who rented a hangar next to the accident pilot saw him preparing for a flight. According to the witness, the accident pilot indicated that he was going flying, "...up and down the river." He observed the accident pilot taxi from his hangar to runway 27, and approximately 10 minutes later at 1500, the flight departed westbound. The witness stated that the accident pilot usually flew the airplane for 30 minutes to 1 hour per flight. 1.2 Personnel Information 1.2.1 Pilot Information The pilot held an airline transport certificate for multi-engine airplanes and a commercial pilot certificate for single-engine airplanes. He also held a mechanic certificate for airframe and power plant, in addition to a ground instructor certificate. The pilot held an expired certified flight instructor certificate. The pilot's last medical certificate was a second class issued in March of 2006, and he reported a total time of 30,000 hours. Based on the maintenance logbooks, the pilot had accumulated over 700 hours in the accident airplane. The pilot was employed as a first officer for American Airlines, a Part 121 commercial air carrier. A review of law enforcement records showed that the pilot had been involved in three arrests. The first arrest involving driving under the influence occurred in 1989 and was dismissed. The second arrest on April 19, 2006, was initiated by the driver's failure to maintain a single traffic lane. A breath test taken approximately 1 hour after the accident showed a blood alcohol content of .250 percent. As a result, the pilot's driver's license was suspended. The third arrest was dated January 29, 2007, and involved an alleged hit-and-run accident. Witnesses reported seeing the driver of the vehicle [the accident pilot] step out of his car and dispose of a beer bottle, prior to leaving the scene of the accident. The driver then went home and contacted the local authorities regarding the event. Neither the second or third arrests had been adjudicated at the time of the aircraft accident. 1.3 Aircraft Information 1.3.1 General Aircraft History The airplane was certified as an experimental. The pilot built the airplane, and the FAA issued the special airworthiness certificate in 1990. The accident pilot maintained the airplane. Review of the maintenance logbooks for the airplane showed that the last continuous airworthiness inspection was completed on August 26, 2006, at a total time of 713.2 hours. The pilot participated in air shows and races using the airplane, which was known as Tonopah Low II. 1.4 Meteorological Information Reno International Airport, Reno, Nevada, was located about 22 nautical miles north-northeast of the accident site. At 1456, the following conditions were reported: sky conditions, scattered cloud layer at 20,000 and a broken cloud layer at 25,000, 10 miles visibility, the temperature was 66 degrees Fahrenheit, the dew point was 10 degrees Fahrenheit, the altimeter was 30.04 inches of mercury, and the winds were from 210 degrees at 16 knots, gusting to 22 knots. 1.5 Wreckage and Impact Information An FAA inspector responded to the accident site on February 9. The first identified point of impact was an 18-inch deep crater in the ice-covered lake surface in which a portion of the starter ring gear from the engine was identified. From this crater, on a general magnetic heading of 140 degrees, there was a skid mark approximately 50 yards in length. The airplane came to rest inverted. The empennage remained intact with the elevator and rudder surfaces in place. Portions of the wings, including the struts, guy wires, and wing panels were located either with the main wreckage, or in the surrounding debris field. The propeller and hub were offset 10 degrees from the main debris path, to the south-southeast, approximately 20 yards from the main wreckage. 1.6 Medical and Pathological Information The Washoe County Coroner completed an autopsy. The autopsy report indicated that a broken beer bottle was identified in the upper right pocket of the pilot's flight suit. The pilot was also carrying a fully loaded Smith and Wesson .38 caliber revolver. The FAA Bioaeronautical Research Laboratory completed toxicological testing on specimens of the pilot, including chest blood, for carbon monoxide, volatiles, cyanide, and tested drugs. The following positive results were recorded: 10 percent Carbon Monoxide detected in Blood 155 (mg/dL, mg/hg) Ethanol detected in Blood 279 (mg/dL, mg/hg) Ethanol detected in Urine 151 (mg/dL, mg/hg) Ethanol detected in Muscle 155 (mg/dL, mg/hg) Ethanol detected in Heart 96.34 (pmol/nmol) Serotonin Metabolite Ratio detected in Urine The report indicated that a ratio greater than 15 pmol/nmol was indicative of ethanol ingestion. The NTSB medical officer reviewed the pilot's medical records obtained from the FAA Aerospace Medical Certification Division. The pilot's most recent application for a medical certificate noted that the pilot's occupation was as a commercial pilot, and that he was employed by a Part 121 commercial air carrier. On April 26, 2006, the pilot submitted a letter to the FAA Security and Investigations Division (AMC-700) noting, in part, "I submit the following information in compliance with 14 CFR 61.15 (e) Type of violation: Alcohol Related Suspension/Revocation (Refuse to test, BAC over legal limit, etc.) Date of action: 4-19-06 State holding record: Nevada" The letter did not provide any additional details about the circumstances of the violation. There was no indication in the FAA medical records that any additional information regarding the suspension was requested or provided, or that any additional action was taken regarding the suspension. 1.7 Tests and Research The wreckage was examined on April 11, 2007, by the NTSB investigator, the FAA accident coordinator, and a representative from Textron Lycoming. The cockpit area and firewall were crushed aft. The wings were identified through portions still attached to the fuselage, and small sections recovered from the debris field. All control cables and torque tubes remained connected. Movement was obtained from the elevator and rudder control surfaces to the cockpit connections. Movement of the control stick produced corresponding movement to the aileron control surfaces. Examination of the canopy showed that the Plexiglass had broken, but the latching mechanism remained intact in the closed position. The engine was examined. The spark plugs were removed and showed similar gapping and coloration. The magnetos were removed and produced spark upon rotation. Investigators used a borescope to inspect the cylinders and drive train, and noted no anomalies. The oil screens and fuel screens were clean. Investigators removed the accessory case and noted that all of the gears were in place and coated with oil. 1.8 Additional Information 1.8.1 Regulations FAA regulation 14 CFR 91.17, alcohol or drugs, in part, stated: (a) No person may act or attempt to act as a crewmember of a civil aircraft -- (1) Within 8 hours after the consumption of any alcoholic beverage; (2) While under the influence of alcohol; (3) While using any drug that affects the person's faculties in any way contrary to safety; or (4) While having .04 percent by weight or more alcohol in the blood. The FAA defines substance (including alcohol) dependence as "evidenced by (A) increased tolerance, (B) manifestation of withdrawal symptoms, (C) impaired control of use, or (D) continued use despite damage to physical health or impairment of social, personal, or occupational functioning" (14 CFR 67.107(a)(4)(ii), 67.207(a)(4)(ii), and 67.307(a)(4)(ii)). FAA regulations cited above note that a history or clinical diagnosis of substance dependence is specifically disqualifying. The FAA requires that airmen report a history of substance (including alcohol) dependence on each application for airman medical certificate. The FAA additionally requires that airmen report any convictions involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug and performs a National Driver Register (NDR) inquiry for each application for medical certificate to verify that all such convictions are in fact reported. Once the initial conviction is reported, the FAA may or may not require a substance abuse evaluation. 1.8.2 Human Intervention and Motivation Study (HIMS) HIMS was originally a congressional study in the 1970s to establish a recertification process for airline pilots following a diagnosis of chemical abuse or dependency. It is now used as a common reference for the FAA airman medical recertification process following a chemical dependency diagnosis. Dependent upon the airline, the specific HIMS recertification process may be worked differently. According to the general HIMS program outline, HIMS is an occupational substance abuse treatment program, specific to commercial pilots, that coordinates the identification, treatment, and return to the cockpit of impaired aviators. The HIMS concept is based on a cooperative and mutually supportive relationship between pilots, their management, and the FAA. Personnel are trained to identify, and in many cases, conduct an intervention to direct the troubled individual to a substance abuse professional for a diagnostic evaluation. If deemed medically necessary, treatment is then initiated. Following successful treatment and comprehensive continuing care, the pilot is eligible to seek FAA medical re-certification. According to the HIMS program outline of American Airlines, all HIMS programs have the same basic components: treatment, an independent medical sponsor, corporate monitoring, and aftercare. 1.8.3 Allied Pilots Association The Allied Pilots Association is the pilot union of American Airlines. According to the HIMS program director at American Airlines, the airline has an open policy regarding chemical dependence. American pilots are advised through posters, annual training, videos, and articles, of how to seek assistance. In conjunction with the HIMS program, company pilots undergo medical treatment to eventually reinstate their medical certificate and continue chemical abstinence. American Airlines medical personnel had no record of the pilot's chemical dependency, and he had not undergone treatment through the HIMS program. 1.8.4 Wreckage Release The wreckage was released to the owner's representative on April 24, 2007. No parts or pieces were retained by the Safety Board.
The airplane collided with a frozen lake for undetermined reasons. Contributing to the accident was the pilot's intentional operation of the airplane while impaired by alcohol and the FAA's failure to obtain additional information about the pilot's self-reported driver's license suspension.
Source: NTSB Aviation Accident Database
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