Quincy, FL, USA
N4778M
PIPER PA-11
The pilot and his passenger flew the accident airplane earlier in the day when they observed a "dead cylinder" prior to takeoff. After 2 mechanics freed a sticking exhaust valve, a ground run was accomplished, followed by an uneventful 30-minute local flight. After breaking for lunch, the pilot and passenger returned to the airport for another local flight. Shortly after takeoff they again observed a "dead cylinder" and the engine was "shaking real bad." The pilot, who was at the controls at the time, "tried to turn the plane around so violently, it instantly stalled out and went into a spin and we went straight in." The airplane crashed into an open cotton field. Examination of the engine and airframe did not reveal evidence of a pre-existing mechanical malfunction or failure, and no physical evidence of a sticking exhaust valve was observed. The pilot had a history of advanced cirrhosis of the liver, severe emphysema, and the regular use of prescription narcotic painkillers. He had noted a history of lung problems and 6-year history of cirrhosis (with the use of two medications for complications of the disease) to a designated aviation medical examiner (AME) 3 days before the accident. The AME issued the pilot a 3rd class medical certificate without any additional information provided or requested. The pilot had not previously had a medical certificate issued for nearly 7 years, and the Federal Aviation Administration publishes guidance for AMEs to not issue medical certificates to pilots with histories of cirrhosis or emphysema. Because of extensive postaccident treatment, it was not possible to determine whether the pilot might have been impaired by narcotic medication, but post-mortem toxicological testing did reveal elevated levels of an over-the-counter sedating antihistamine, strongly suggesting impairment due to the use of that substance.
On September 7, 2009, about 1530 eastern daylight time, a Piper PA-11, N4778M, was substantially damaged after a collision with terrain shortly after takeoff from Quincy Municipal Airport, Quincy, Florida. The airplane was owned and operated by a private individual. The certificated private pilot was killed, and a passenger sustained serious injuries. Visual meteorological conditions prevailed at the time, and no flight plan was filed for the 14 Code of Federal Regulations Part 91 personal flight. The flight was originating at the time of the accident. According to the Gadsden County Sheriff's Office, the airplane crashed into a cotton field approximately 500 feet north of the departure end of runway 32. No eyewitnesses to the accident were located. The front-seat passenger, who possessed a student pilot certificate, reported that he had flown with the pilot “a handful of times.” He reported that on the morning of the accident, he went to the airport and performed a preflight inspection on the accident airplane. When the pilot arrived at the airport, the passenger assisted him into the aft cockpit, as the pilot had some difficulty walking and required some assistance getting into the airplane. After engine start and during taxi for takeoff, he recalled that they had a “dead cylinder” and the engine was “shaking real bad.” They shut down the engine and pushed the airplane back to the parking area. The front-seat-passenger further stated a couple of mechanics, who were reportedly friends of the pilot, assisted and freed a sticking exhaust valve, using a rope inserted into the cylinder. After a ground run of 20 to 30 minutes, with no anomalies noted, he and the pilot took off and flew the airplane for about 30 minutes, again with no anomalies noted. After breaking for lunch, he and the pilot returned to the airport and prepared for another flight in the accident airplane. After an uneventful preflight, engine start, and taxi, a takeoff was performed on runway 32. At about 100 to 150 feet above ground level (AGL) after takeoff, the cylinder “went dead again; the engine started shaking really bad.” The passenger reported that the pilot “tried to turn the plane around so violently, it instantly stalled out and went into a spin and we went straight in.” The passenger believed that the pilot was attempting a return to the airport. The passenger reported that the pilot, seated in the aft seat, was at the controls at the time of the loss of engine power and subsequent loss of airplane control. Although the passenger possessed a student pilot certificate, he reported that he was not taking instruction from the accident pilot and was not under the impression that the accident pilot was a flight instructor. Following the accident, the wreckage was examined by an inspector from the Federal Aviation Administration (FAA) and by an investigator with Teledyne Continental Motors. The wreckage was found in a cotton field in a steep, nose low attitude. Flight control continuity was confirmed from the cockpit to all flight control surfaces. Approximately two gallons of fuel were observed in each wing tank. The engine was turned through by hand and internal continuity was confirmed. The engine was transported to a hangar where a more detailed examination could be performed. The engine exhibited varying degrees of impact-related damage. The propeller, left magneto, and upper spark plugs were removed to facilitate rotation of the crankshaft. The cylinders were borescoped and no foreign objects or debris were noted in the cylinder bore areas prior to the rotation of the crankshaft. The aircraft battery was connected directly to the starter motor. The starter was engaged by hand and continuity was established to the accessory gears, valve train, and right magneto. Compression was observed on all 4 cylinders. During rotation of the engine with the starter motor, all 4 ignition leads from the right magneto exhibited a blue spark. The left magneto was rotated with a cordless drill and spark was observed on all 4 ignition leads. The carburetor separated free of the intake manifold and remained attached to the engine via the induction airbox support bracket and the throttle and mixture cables. The throttle arm was actuated manually and a stream of fuel exited the throttle bore. The carburetor was disassembled and a small amount of fuel and sediment was observed in the carburetor bowl. The carburetor accelerator pump assembly shaft was full of fuel. A review of the maintenance logbooks revealed documentation of an annual inspection that was accomplished on February 2, 2009. There were no logbook entries for engine or airframe maintenance on the day of the accident. The pilot held a private pilot certificate with a single engine land rating. Pilot logbooks were not located following the accident; documentation of a current biennial flight review was not located. According to FAA records, the pilot’s latest third class medical certificate was issued on September 4, 2009, 3 days prior to the accident. The pilot reported 4,000 hours total flight time, including 15 hours in the previous 6 months, on his most recent medical certificate application. The medical certificate application noted a history of medication use (furosemide and spironolactone), cirrhosis since 2003, a history of “asthma,” a history of medical disability benefits, and a most recent previous application of September 20, 2002. The certificate was noted as issued by the aviation medical examiner with no further documentation provided. Medical records maintained on the pilot by his primary care physician documented a visit to the physician on the same date as the most recent application for FAA Medical Certificate, at which time the pilot was noted to have a diagnosis of emphysema and cirrhosis, to be in a wheelchair, and to be regularly taking medications including a hydrocodone/acetaminophen combination (5mg/500mg every 4 hours), an acetaminophen/codeine combination (300mg/30mg every 8 hours), alprazolam (0.5mg each night), furosemide (40mg twice a day), and spironolactone (100mg per day). Personal medical records also noted a history of severe muscle pain “due to inactivity and sitting in the chair all day” and a history of “dyspnea [shortness of breath] when flying at approximately 5000-6000 feet.” The FAA Guide for Aviation Medical Examiners has noted since at least 2003 that a diagnosis of either emphysema or cirrhosis require that the examiner not issue a medical certificate and that additional documentation be provided to the FAA for a determination of medical certification. The report of autopsy on the pilot noted the “Cause of Death” as “Multiple blunt traumatic injuries” and identified, in part, “Extensive bilateral pulmonary hemorrhage.” Post mortem toxicology tests conducted by the FAA Forensic Toxicology Laboratory, Oklahoma City, Oklahoma, on specimens obtained from the pilot, were negative for carbon monoxide, cyanide, and ethanol. The tests were positive for acetaminophen, atrophine, chlorpheniramine, codeine, dextromethorphan, dextrorphan, dihydrocodeine, furosemide, hydrocodone, lidocaine, morphine, quinine, and salicylate. The records of the pilot’s post-accident emergency treatment note that the pilot had received atropine, lidocaine, blood, and substantial intravenous fluids during resuscitation attempts. The 1553 weather observation for Tallahassee, Florida, located 16 nautical miles southeast of the accident site, included the following: few clouds at 3,300 feet, surface winds from 040 degrees at 5 knots, 10 statute miles visibility, temperature 31 degrees Celsius, dew point 19 degrees Celsius, and an altimeter setting of 29.99 inches of mercury.
The pilot’s improper use of flight controls following a partial loss of engine power for undetermined reasons. Contributing to the accident was the pilot’s impairment from the use of an over-the-counter sedating antihistamine.
Source: NTSB Aviation Accident Database
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