Gatesville, TX, USA
N4218J
PIPER PA-28-140
Witnesses saw the airplane make abrupt changes in directional flight, “first to the right at a bank angle of at least 60 degrees,” then it flew straight and level before entering a steep left climbing turn. The aircraft then started a descent with wings level at about a 45-60 degree nose-down angle. Other witnesses saw the airplane make several loops. The airport manager said this was “entirely out of the pilot’s character.” The pilot had a medical history that included a traumatic brain injury following an accident that put him in a coma in 1993. This was accompanied with persistent cognitive deficits and frequent intermittent episodes of amnesia, severe chronic lung disease that required him to use supplemental oxygen to avoid hypoxia during periods of activity, and depression for which he had been receiving therapy. He had specifically denied any history of unconsciousness, lung disease, neurological disorders, or depression on his most recent application for a Federal Aviation Administration (FAA) Airman Medical Certificate, and the FAA would have denied that application had they been aware of the full extent of the pilot’s medical conditions. The pilot also had a slowly expanding abdominal aortic aneurysm, and coronary artery disease with evidence of heart muscle abnormalities on echocardiogram performed two months prior to the accident. He was on a medication that would have reduced his tolerance to increased G-loading. Although an oxygen generator was found in the pilot’s parked automobile, no oxygen was found in the airplane wreckage.
On February 27, 2010, approximately 0905 Central Standard Time, a Piper PA-28-140 Cherokee, N4218J, registered to and operated by the pilot, was destroyed when it impacted terrain in the 1200 block of County Road 132, near Gatesville Texas. A post-impact fire ensued. Visual meteorological conditions prevailed at the time of the accident. The personal flight was being conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91 without a flight plan. The pilot, the sole occupant on board the airplane, was fatally injured. The local flight originated at City-County Airport (GOP), Gatesville, Texas, approximately 0845, and was en route to Mathis Field (SJT), San Angelo, Texas. According to the airport manager, the pilot was going to San Angelo to have the press-to-transmit button on the control yoke repaired. He watched the pilot take off on runway 35. Shortly thereafter, heard an airplane southwest of the airport. Walking outside the hangar, he observed an airplane approximately 1,000 feet agl (above ground level) “making some very abrupt changes in directional flight, first to the right at a bank angle of at least 60 degrees. The aircraft then started to fly in a straight and level attitude and then entered a very steep left climbing turn. The aircraft then started descent with wings level at about a 45-60 degrees angle towards the ground. During the descent the noise level of the engine appeared to increase.” The airport manager, who was a close friend of the pilot, said the maneuvers were “entirely out of his character.” There were three other known witnesses to the accident. The first witness “observed him do 3 loops.” The second witness to an FAA inspector the airplane made “2 or 3 high pitch attitude loops, coming out in a high angle of bank, (then) he looped it over and headed for the ground, (losing) altitude rapidly, engine was screaming at a high rpm. Hit the ground (and) exploded.” The third witness, a retired U.S. Army sergeant, observed the airplane “at about 500 feet altitude climbing steeply under full power…(he made) several full throttle dives with rolls and tight turns at the apex of each climb. He went into a steep (about 30+ degrees) dive…The engine sounds were steady at full throttle.” The pilot was 66-year-old retired pilot and captain in the United States Army. He held a commercial pilot certificate with airplane single/multi engine land, rotorcraft-helicopter, and instrument airplane-helicopter ratings. On his second class airman medical certificate, dated June 9, 2008, which expired in June 2009, the pilot estimated he had accrued 6,700 hours total flight time. The airport was equipped with an AWOS (Automatic Weather Observing System). At the time of the accident, VMC (visual meteorological conditions prevailed): the sky was clear, visibility 8 miles, and the wind was calm. On March 31, 2010, the airplane and engine were examined at the facilities of Air Salvage of Dallas (ASOD) in Lancaster, Texas. No anomalies were found. The left wing was fragmented and bore thermal and impact damage. Most of the skin was separated from the main spar. The fuel tank was fragmented. The landing gear was in place and secured to the spar. The aileron and flap were separated and linkages broken. The aileron bellcrank was in place between the main and aft spars with both the control and balance cables secure. The cables were continuous to the forward fuselage where both displayed broom straw appearance. The remaining portion of the left aileron control cable was secure to the control wheel chain and the remaining portion of the balance cable was secure to the right side aileron bellcrank. The right wing was fragmented and bore thermal and impact damage. Most of the skin was separated from the main spar. The fuel tank was fragmented. The upper landing gear strut was in place and secured to the spar, but the wheel brake assembly and tire were separated. The aileron and flap were separated and the linkages broken. The aileron bellcrank had been displaced from its normal position and pulled inboard and separated from the wing structure. Both the aileron control and balance cables were secure to the bellcrank. The aileron control cable was intact, continuous and secure to the aileron control wheel chain. The balance cable was continuous to the center fuselage area where it displayed a broom straw appearance. The empennage was intact but showed impact and fire damage. The vertical stabilizer and rudder were in place and secure. Both rudder control cables were secured to the rudder bellcrank and continuous to the forward fuselage area where both had been cut to facilitate transport. The remaining portion of the cables was found secured to the rudder bar. The stabilator was in place and secured at both hinge points. The balance tube was secured and both the upper and lower control cable attach points were in place with cables secured. Both cables were continuous to the forward cabin area where they had been cut to facilitate transport. The remaining portion of the cables was secured to the T bar. The trim drum showed 7 threads upper extension. According to Piper, this was consistent with a setting of about 2 degrees of the available 12 degrees nose up trim. The fuselage had been consumed by fire. Seat frames were evident as were parts from the main cabin door. The flap handle was in the full down (flaps up) position. The flap torque tube actuator arm was also in the full up position. Although an oxygen generator was found in the back seat of the pilot's parked automobile, no oxygen was found in the airplane wreckage. The engine bore impact damage to the bottom of the crankcase which interfered with a connecting rod. The crankshaft flange was bent and the propeller assembly was separated. Engine continuity was obtained with valve action. Compression was obtained on all cylinders. A bore scope inspection of the interior of the cylinders noted no anomalies. All engine components incurred substantial fire and /or impact damage. The magnetos incurred thermal damage and could not be tested. The carburetor was impact separated. The vacuum pump drive was intact and the pump rotated freely. The propeller assembly separated from the engine. One blade was bent aft approximately 90 degrees along the outboard span and twisted toward low pitch. The leading edge displayed nicks dents and cuts. The surface of the blade showed diagonal and chordwise surface scratches. The other blade was twisted about 90 degrees toward low pitch. The blade displayed substantial leading edge dents and nicks as well as surface scratches and gouges most heavy along the outboard span. An autopsy was performed by the Southwestern Institute of Forensic Sciences in Dallas, Texas. Cause of death was attributed to “multiple blunt force injuries,” and the manner of death was deemed “accident.” No soot was detected in the airways. Their drug screen noted 0.05 mg/L metoprolol and 2.2 mg/L hydroxychloroquine in the pilot’s body. The autopsy report noted (in part): “…Multiple full thickness lacerations involve the heart. …Multiple transections and lacerations involve both the thoracic and abdominal aorta…The intimal surface of the abdominal aorta has extensive ulcerative atherosclerotic plaque…The left anterior descending and right main coronary arteries are focally 80% stenosed by atherosclerotic plaque. The circumflex coronary arteries are free of significant atherosclerosis.…Sectioning of the myocardium reveals firm brown parenchyma…” The heart weight was noted as 340 grams. FAA’s Civil Aeromedical Institute (CAMI) toxicology report found hydroxychloroquine in lung, liver and heart tissue, and metoprolol in liver and kidney tissue. In addition, 0.166 (ug/ml, ug/g) and 0.098 (ug/ml, ug/g) oxazepam and 0.413 (ug/ml, ug/g) and 0.263 temazepam was detected in liver and kidney tissue, respectively. No ethanol was detected in muscle and liver tissue. Carbon monoxide and cyanide tests were not performed. On his most recent application for a second class airman medical certificate, dated June 9, 2008, the pilot indicated “Yes” in response to the question, “Do You Currently Use Any Medication.” He indicated he was taking tamsulosin, 0.4 mg per day; tolterodine, 4 mg per day; cyclosporine eye drops, twice a day, lubricating eye drops as needed; aspirin, 81 mg per day; simvastatin, 20 mg per day; fiber supplement, 1 tablespoon per day; magnesium oxide, 400 mg twice a day; calcium with vitamin D, 500 mg twice a day, and a multivitamin once a day. The application noted “No” to all items under “Medical History,” except for “Admission to hospital” and “Other illness, disability, or surgery.” The application specifically noted “No” in response to the questions “Unconsciousness for any reason,” “Eye or vision trouble except glasses,” “Asthma or lung disease,” “Heart or vascular trouble,” “Neurological disorders: epilepsy, seizures, stroke, paralysis, etc.,” “and “Mental disorders of any sort; depression, anxiety, etc.” A review of the pilot’s personal medical records revealed a history of multiple medical conditions. The records documented a “serious motor vehicle accident” with traumatic brain injury in 1993, which put him in a coma and resulted in “episodes of amnesia … usually once a week” for “an hour, all morning or several days” during which he “may conduct the same business three times as he does not remember it” and “can go places and not know why he went there or how he got there or even where he was.” The injury also resulted in “poor organizational skills,” leaving the pilot “chronically frustrated by the cognitive inefficiency he has experienced,” and “diplopia from head trauma” that was noted in October 2007 to “not usually bother him anymore, except when he is very tired or trying to do vision intensive tasks in low lighting situations….” The pilot had a “history of coccidiomycosis” with a “left upper lobectomy in 1976” and “restrictive lung disease secondary to severed left phrenic nerve” with a “history of pneumonia once per year.” The pilot had indicated in November 2008 that “if he is forced to wear portable oxygen then it is not worth living because he cannot do farm work,” and a pulmonary specialist noted in December 29, 2009 that the pilot’s “condition may be getting progressively worse and there is unfortunately not much more that can be done for his treatment. He…desaturates with exercise, but he is reluctant to use his oxygen on a regular basis…unable to get back to his baseline…two respiratory illnesses in the last year that have accelerated his decline…encouraging the patient to use his oxygen more…” The pilot had been receiving therapy for “depression manifested as depressed affect” since at least January 2007. He had difficulty sleeping for which he had been receiving clonazepam at night starting in 2006, and excessive daytime sleepiness for which he had been receiving modafanil through at least April 2007. He had a slowly expanding abdominal aortic aneurysm, noted during hospitalization for pneumonia in December 2009 to be 4.6 cm in largest diameter, and treated medically with metoprolol and simvastatin. He had been diagnosed with rheumatoid arthritis since complaining of joint pain in June 2009, and treatment with hydroxychloroquine was noted on February 21, 2010 to be “working extraordinarily well” with “hand pain and stiffness and swelling…no longer present,” though his right shoulder, which he had previously noted “after a couple of hours in flight” to have “a hard time moving,” was “still bothering him” at that time. He had undergone an echocardiogram on January 2, 2010, which noted, in part, “severe hypokinesis of the basal-mid wall” that had not been identified on a myocardial perfusion study performed in June 2007.
The pilot’s incapacitation as a result of one or more pre-existing medical conditions.
Source: NTSB Aviation Accident Database
Aviation Accidents App
In-Depth Access to Aviation Accident Reports
