Edgewater, MD, USA
N1521S
BEECH P35
The airplane was on final approach to land about 300 feet above the ground, when it stalled, banked right, and descended into trees about 1/2 mile from the approach end of the runway. A postcrash fire destroyed the cockpit and consumed a majority of the airframe. The engine separated and was located in a creek, about 100 feet east of the main wreckage. Examination of the wreckage did not reveal any preimpact malfunctions. It was noted that while witnesses reported they observed the airplane's landing gear and flaps extended during the beginning of the accident sequence, postaccident observations were consistent with the landing gear and flaps in the retracted position. The pilot had a history consistent with alcohol and prescription drug dependence, and had at least once previously failed rehabilitation treatment. He had been experiencing worsening back pain, and had undergone surgery about 6 weeks prior to the accident, with continuing pain after the surgery. He had been using prescription narcotic medications from multiple different providers for over a year prior to the accident, most recently filling a large prescription for prescription narcotic medications 3 days prior to the accident. Postmortem toxicology testing was consistent with recent use of a prescription anti-depressant, also used to treat nicotine dependence that can increase the likelihood of seizure activity, though that risk remains low. Toxicology testing also was consistent with the relatively recent use of a prescription narcotic medication, but the lack of such medication in the pilot's blood suggests the possibility that the pilot may have been experiencing the effects of opiate withdrawal, which can include agitation, anxiety, nausea, and abdominal cramping, among other symptoms. The pilot may also have been distracted by back pain. The FAA failed to identify the pilot's substance dependence, in spite of substantial differences in his and police reports regarding a Driving Under the Influence charge in 2005, and publicly available records that documented his misuse of prescription medications.
HISTORY OF FLIGHTOn February 27, 2010, about 1617 eastern standard time, a Beech P35, N1521S, owned and operated by a private pilot, was substantially damaged when it impacted terrain while on approach to the Lee Airport (ANP), Edgewater, Maryland. The certificated private pilot was killed. Visual meteorological conditions prevailed and a visual flight rules (VFR) flight plan had been filed for the local flight. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The airplane was based at ANP. According to a Federal Aviation Administration (FAA) inspector, the pilot filed a VFR flight plan with ANP listed as both the departure and destination airports. According to witnesses, the airplane departed from runway 30, a 2,500-foot-long, 48-foot-wide, asphalt runway, and flew over the airport without any problems. Shortly thereafter, the pilot reported over the airport common traffic advisory frequency that he was performing a "straight-in" approach to runway 30. One witness stated that he observed the airplane on final approach, about 300 feet above the ground, with the landing gear and flaps extended. The airplane was in a nose high attitude and appeared "a little slow," when it made a sudden steep right bank and descended into trees. The witness subsequently observed a "bright orange fireball" and black smoke. Radar data obtained from the FAA revealed the airplane's track was consistent with a departure from runway 30, followed by a left-hand traffic pattern. At 1617:11, the airplane was on a course consistent with a final approach to runway 30, at altitude of 600 feet and a ground speed of 74 knots. Twenty eight seconds later, the airplane had descended to an altitude of 300 feet, and had slowed to a ground speed of 64 knots when radar contact was lost. PERSONNEL INFORMATIONThe pilot, age 53, held a private pilot certificate, with ratings for airplane single-engine land and instrument airplane. His most recent FAA third-class medical certificate was issued on August 4, 2009. Review of the pilot's logbook revealed that at the time of the accident, he had accumulated about 1,125 hours of total flight experience, which included about 185 total hours in the accident airplane. He had flown the accident airplane for about 80 hours during the 1 year preceding the accident, which included and 8 and 3 hours, during the 90 and 30 days preceding the accident, respectively. AIRCRAFT INFORMATIONAccording to FAA records, the pilot purchased the airplane about 2 years prior to the accident. The four-seat, low-wing, retractable-gear airplane, serial number D-6963, was manufactured in 1962. It was powered by a Teledyne Continental Motors IO-470-N, 260-horsepower engine equipped with a Beech two-bladed, constant speed propeller. The airplane's logbooks were destroyed during the accident. Review of work orders revealed that the accident flight was the airplane's first flight after an annual inspection, which was completed on February 26, 2010. At the time of the accident, the airframe had accumulated approximately 7,205 total hours since new, and the engine had been operated for about 435 hours since it was overhauled. According to the Airplane Flight Manual, the recommended landing approach speed was 69 knots, and the indicated stall speed in the landing configuration was 52 knots. METEOROLOGICAL INFORMATIONA weather observation taken at 1654, at the U.S. Naval Academy, located about 5 miles northeast of ANP, reported, wind from 280 degrees at 9 knots; visibility 10 statute miles; sky clear, temperature 6 degrees Celsius (C), dew point minus 6 degrees C; altimeter 29.63 inches of mercury. Two pilots, who flew approaches to runway 30 about the time of the accident, reported they experienced a "significant downdraft" or "sink hole" while on short final approach. AIRPORT INFORMATIONAccording to FAA records, the pilot purchased the airplane about 2 years prior to the accident. The four-seat, low-wing, retractable-gear airplane, serial number D-6963, was manufactured in 1962. It was powered by a Teledyne Continental Motors IO-470-N, 260-horsepower engine equipped with a Beech two-bladed, constant speed propeller. The airplane's logbooks were destroyed during the accident. Review of work orders revealed that the accident flight was the airplane's first flight after an annual inspection, which was completed on February 26, 2010. At the time of the accident, the airframe had accumulated approximately 7,205 total hours since new, and the engine had been operated for about 435 hours since it was overhauled. According to the Airplane Flight Manual, the recommended landing approach speed was 69 knots, and the indicated stall speed in the landing configuration was 52 knots. WRECKAGE AND IMPACT INFORMATIONThe airplane impacted 60 to 75-foot tall trees, in a residential area about 1/2 mile from the approach end, and 1/4 mile to the right of runway 30. Several freshly broken tree branches were observed at heights below tree top level. The airplane came to rest upright, at the base of trees, on a heading of approximately 265 degrees, adjacent to a house. All major components of the airplane were located at the accident site. The engine and a portion of the airplane's nose section, which contained the nose gear assembly, separated from the airframe. The nose section was located at the edge of a creek, about 70 feet east of the main wreckage and the engine was located in the creek, at a depth of about 5 feet, about 100 feet east of the main wreckage. A postcrash fire destroyed the cockpit and consumed a majority of the airframe, with the exception of the empennage. The airplane was equipped with a "v-tail" configuration, which utilized an elevator-rudder combination (ruddervator) flight control. Flight control continuity was confirmed from the left and right ruddervator control surfaces to the mid-cabin area. The aileron cables remained attached to the right aileron bellcrank, which was pulled from its mount. The left aileron bellcrank was consumed by fire; however, the left aileron cable ends were intact. The airplane was equipped with a "throw-over" control yoke assembly, which was separated. The nose gear was observed partially extended from the nose gear wheel well. The left and right main landing gear were observed retracted into their respective wheel wells. Both the left and right flap actuators measured approximately 2.25 inches, which corresponded to a flap setting between 0 (flaps retracted) and 5 degrees. The engine was recovered from the creek by members of the Maryland State Police dive team. It was subsequently examined in a hanger at ANP. The two-bladed propeller assembly remained attached to the crankshaft flange and both propeller blades exhibited "S" bending and damage consistent with rotation. Examination of the engine did not reveal any catastrophic engine malfunctions. The No. 5 cylinder head exhibited impact damage. The fuel pump, fuel servo and both magnetos remained attached to the engine. The engine was rotated by hand via the crankshaft flange. Valve train continuity was observed and thumb compression was attained on all cylinders, except for the No. 5 cylinder. A lighted borescope examination of all cylinders did not reveal any preimpact malfunctions. All spark plugs were removed and their respective electrodes were intact. Both the left and right magnetos were removed and did not produce spark when rotated by hand. Subsequent disassembly of both magnetos did not reveal any mechanical malfunctions; however, it was noted that they both contained evidence consistent with being submerged in water. The fuel pump was removed. The drive coupling was intact and rotated freely when turned by hand. The fuel inlet filter and oil filter screens did not exhibit any obstructions or debris. MEDICAL AND PATHOLOGICAL INFORMATIONAn autopsy was performed on the pilot by the Office of the Chief Medical Examiner, Baltimore, Maryland. The autopsy report revealed the cause of death as "multiple injuries." In addition, toxicology testing noted the presence of an unquantified amount of bupropion, oxycodone, quinine, and acetaminophen in the urine, and the absence of bupropion, oxycodone, or acetaminophen in heart blood. Toxicological testing performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma, revealed the following: ">>16.61 (ug/ml, ug/g) Acetaminophen detected in Urine >>Bupropion detected in Urine >>Bupropion detected in Blood >>Naproxen detected in Urine >>0.098 (ug/ml, ug/g) Oxycodone detected in Urine >>Oxycodone NOT detected in Blood >>0.296 (ug/ml, ug/g) Oxymorphone detected in Urine >> Oxymorphone NOT detected in Blood >>Quinine detected in Urine" The pilot's application for FAA third-class medical certificate dated July 16, 2007, noted a "history of alcohol use with satisfactory recovery since April 2005." A letter submitted by the pilot in conjunction with that application noted, in part, an "incident involving drinking and driving" in May 1995, with a blood alcohol content that "was either 0.010 or 0.012" and an April 2005 arrest. The State of Maryland trooper's record of the April 2005 arrest, also included in the FAA records, noted in part, "...hit and run... [a driver of a vehicle] advised that he was bumped from behind...[the pilot]...got back into his vehicle and began to drive off... Also submitted was a letter from a psychologist and Licensed Clinical Alcohol and Drug Counselor noting, in part, that the pilot "has successfully completed his recommended portion of the Outpatient Treatment Program with me. The FAA requested and received a "current substance abuse evaluation," which was performed by the same psychologist and noted, in part, the pilot "has maintained continuous sobriety since April 2005...Based on the information reported in this interview...there is no indication of an employment problem that warrants attention at this time....Based on the information reported in this interview ... there is no indication of an alcohol problem that warrants attention at this time...."The Manager of the FAA Aerospace Medical Certification Division noted in a memo dated December 13, 2007, "a very good substance abuse evaluation that was negative for all aspects of substance abuse/dependence so certify and warn; no follow-up required" and in a letter to the pilot that "Our review of your medical records has established that you are eligible for a third-class medical certificate. ...You are cautioned that any further alcohol related offenses or evidence of alcohol abuse will require re-evaluation or possible denial of your medical certification. ..." The pilot's most recent application for an FAA third-class medical certificate (dated August 4, 2009), indicated "No" to "Do You Currently Use Any Medication," The application indicated "Yes" to "Alcohol dependence or abuse," "Admission to hospital" and "Other illness, disability, or surgery" and "No" to all other items under "Medical History." The application also indicated "Yes" in response to "History of ... any arrest(s) and/or conviction(s) involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug ..." and to "History of nontraffic conviction(s) (misdemeanors or felonies)." Under "Explanations" was noted "Previously reported no change." Under "Comments on History and Findings" was noted "... Knee surgery 1993/2003 ...." "Occupation" was noted as "Physician." There was no indication in the FAA medical records of actions taken against the pilot's State medical licenses (see below). Publically available records from the Maryland State Board of Physicians included a letter from the pilot dated April 9, 2003, that noted, in part, "Please be advised that I have decided to surrender my license to practice medicine in the State of Maryland ... My decision to surrender my license to practice medicine in Maryland has been prompted by an investigation of my license by the Maryland Board of Physician Quality Assurance ("the Board") concerning allegations that: I failed to notify the Board that I entered into a consent order with the Virginia Board of Medicine; I fraudulently attempted to obtain a license to practice medicine in the state of Maryland by not informing the Board that I was under investigation in Virginia and that my application for licensure in Texas was not accepted because I provided false information on that application; I failed to disclose treatment for behavioral health impairment; I failed to disclose to the Board the full extent of my substance abuse history; I failed to inform the Board on my Maryland licensure application that I was impaired due to abuse of drugs and alcohol and that I had provided medical services for patients while I was under the influence of drugs and alcohol." Also included in the records was a Final Order on Application for Reinstatement of Medical Licensure dated September 1, 2005 noting, in part, that the pilot "has not only abused alcohol and drugs, but he also abused his privilege as a doctor in order to fraudulently obtain controlled dangerous substances. ...[The pilot] participated in rehabilitation and monitoring. However, such efforts were met with varying degrees of success; while being monitored, [the pilot's] urine specimen tested positive for an opioid analgesic.... [The pilot] has not treated patients since 2002 and has not held an active license to practice medicine, in any state, since April 2003. ... it is ... ordered that the Board will not accept any further applications for reinstatement from [the pilot] for at least five (5) years from the date of this Order and unless and until [the pilot's] Virginia medical license is reinstated without any restrictions ...." The pilot's personal medical records documented treatment with a narcotic medication for an outpatient procedure on September 9, 2008, the filling of 5 prescriptions for narcotic-containing medications from 4 different providers between December 19, 2008 and December 23, 2009, inpatient back surgery on January 19, 2010, and the filling of 3 subsequent prescriptions for narcotic-containing medications from 3 different providers, with persistent back pain noted on January 31, 2010, and on February 24, 2010. The most recent prescription, filled for 90 oxycodone-acetaminophen at a pharmacy less than 1/2 mile from the pilot's reported address, was recorded as having been prescribed by the neurosurgeon who performed the pilot's back surgery. The hospital at which that surgery was performed and the office of the neurosurgeon were each more than 100 miles from the pilot's reported address.
The pilot's failure to maintain adequate airspeed while on approach, which resulted in an inadvertent stall. Contributing to the accident was the pilot's likely impairment due to back pain, symptoms of opiate withdrawal, or both.
Source: NTSB Aviation Accident Database
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