Astoria, OR, USA
N7055D
NORTH AMERICAN AT 6A
The flight was intended for the dispersal of the passenger's deceased husband's ashes, which took place over a river. The dispersal procedure called for the ashes to be placed in a bag that was cinched at the top and tethered to the airframe inside the cabin. The pilot was required to slow the airplane and fly it in a banking maneuver, and the passenger in the aft cockpit would then throw the bag out through the opened aft canopy and retrieve the bag once the ashes had been released into the slipstream. Witnesses described the airplane flying low and slow over the river channel and then rolling left and nose-diving into the water. Examination of the wreckage revealed that the rear sliding canopy was most likely open at the time of impact. The ash dispersal bag was not located. Therefore, based on the accident location, the observed maneuver, and the open rear canopy, the accident likely occurred at some point during the ash dispersal sequence. Postaccident examination did not reveal any anomalies with the airframe or engine that would have precluded normal operation. Several maintenance discrepancies were found; however, none would have resulted in the flight maneuver observed. Although the airplane was required to have undergone an inspection on an annual basis, the last inspection had occurred 22 months before the accident. Additionally, the pilot's last flight review had occurred 29 months before the accident, rather than the 24 months required. The airplane was equipped with dual controls and a swiveling rear seat; the seat was found in the forward and locked position, and the rear control stick appeared to have been removed and stowed. Therefore, passenger interference with the flight controls was unlikely. The pilot's autopsy revealed significant coronary artery disease, which review of his medical records indicated was apparently undiagnosed. Therefore, he was susceptible to an acute cardiac event or stroke (although the degree of blunt force injury prevented the evaluation of his brain.) Toxicology testing on the pilot identified sertraline, its metabolite desmethylsertraline, and trazodone in urine and cavity blood. According to his medical records, the pilot had insufficiently treated sleep disorders and had been taking trazodone as a sleep aid. Trazodone can increase the potential for arrhythmias in patients with pre-existing cardiac disease. In addition, the pilot had longstanding depression, and he had sufficient neurocognitive symptoms the preceding year from a series of concussions that he had stopped flying, driving, and working for several months. While the pilot's depression and symptoms related to his concussion were described as in remission, he had not undergone formal psychometric testing to evaluate these issues, and he had been self-medicating with sertraline, which he had been obtaining from another country out of concern about Federal Aviation Administration (FAA) regulations. He did not report the use of sertraline and trazodone to his FAA medical examiner. Chronically insufficient sleep can lead to chronic fatigue, which results in impaired attentiveness and slowed hazard detection and response times. The use of sleep aids such as trazodone in patients with inadequately treated sleep apnea may worsen the effects of sleep apnea and both directly and indirectly increase the degree of fatigue. The pilot's failure to have obtained the required condition inspection of the airplane or his required flight review may indicate some difficulty in attention and organization. Thus, the pilot had a number of medical conditions which could have contributed to him becoming inattentive, distracted, or debilitated during flight. He could have had a stroke or sudden cardiac event leading to a loss of control. Further, the negative cognitive effects from chronic fatigue resulting from his inadequately treated sleep disorders, chronic depression, and neurocognitive deficits from postconcussive syndrome would have increased the likelihood of the pilot failing to effectively manage airplane control while either setting up for, or during performance of the ash dispersal maneuvers.
HISTORY OF FLIGHTOn March 23, 2016, about 1542 Pacific daylight time, a North American AT-6A, N7055D, impacted the Columbia River near Astoria, Oregon. The private pilot and the passenger sustained fatal injuries, and the airplane was destroyed. The airplane was registered to and operated by the pilot as a personal flight under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time and location of the accident, and no flight plan had been filed. The flight departed Pearson Field Airport, Vancouver, Washington, about 1506. The passenger was seated in the aft cockpit, and the flight was intended to be for the dispersal of her deceased husband's ashes. According to representatives of the passenger's family, the plan was to disperse the ashes along the Pacific coast near a beach house the passenger owned in Ocean Shores, Washington, and, if the weather along the coast was bad, they were going to drop the ashes over the Columbia River instead. The beach house was about 115 miles northwest of Pearson Field and about 45 miles north of the entrance to the Columbia River channel. A witness, who was the captain of a cargo ship moored at an anchorage in the river channel about 1 mile northeast of Astoria, was on the ship's bridge at the time of the accident. He observed the airplane flying about 300 ft above sea level, approaching the ship from the starboard quarter traveling on a north-northeast track. He walked outside to watch as it flew directly overhead and across the ship's port beam. It continued on the same track away from the ship, and, a short time later, he saw the left wing dip as the airplane began a left turn. A few seconds later the wings were almost vertical, and the airplane then rapidly transitioned into an aggressive steep vertical dive. The airplane hit the water in a nose-down attitude, and the captain saw a red tail section bob back into view and then sink. The airplane was flying level over the water surface leading up to the turn, and the captain could hear the engine operating throughout the flight. Another witness, located inside her apartment close to the southern shore of the waterfront in Astoria, was at a north-facing window with a view of the channel. She observed an airplane directly ahead flying over the water and east toward and over moored ships. She was familiar with the helicopter traffic of the Columbia Bar Pilots, and the airplane immediately seemed unusual to her because of its low altitude. It was flying at the same level as the ship's stacks relative to her position at an altitude typically flown by the helicopters. The airplane was flying at a speed she considered to be slower than normal, and it then began a slow and "graceful" turn to what appeared to be the left. She likened the maneuver to the way a large commercial airplane turns, and, as it progressed, she could eventually see the full wing profile. The turn continued, and, before completing 180°, the nose of the airplane aggressively dropped, and the airplane transitioned into an almost vertical dive, passing out of view behind a ship. The airplane was flying straight and level up until the turn that resulted in the accident. The witnesses reported that the airplane was not trailing smoke or vapor at any time and that the weather included good visibility, with overcast skies above the airplane's altitude. They further stated that it was not raining at the time of the accident, but rain began later that day. Due to the airplane's low altitude and the local terrain features, there were no radar data for the final portions of the flight. The witnesses guided search and rescue personnel from the Coast Guard and Clatsop County Sheriff's Department to the approximate accident location. No wreckage was observed floating in the water, and weather, fast water currents, and low water visibility hampered the search efforts. Two days later, divers from the Sheriff's Department located the wreckage in 15 ft of water in a 5-mile-wide section of the channel about 1.5 miles from the southern shore. The location was about 2 miles northeast of Astoria and 11 miles east of the river mouth to the Pacific Ocean. PERSONNEL INFORMATIONThe pilot held a private pilot certificate with a rating for airplane single-engine land issued in 1976 and an instrument airplane rating issued on June 16, 2005. He held a third-class medical certificate issued on July 1, 2014, with no limitations. At the time of the application for this medical certificate, he reported 1,140 hours of total flight time, 5 hours of which occurred in the 6 months before the examination. The pilot's logbook indicated that, since May 2007, he had accumulated about 168 hours of flight experience in the AT-6A airplane (all in the accident airplane). His last entry in the logbook was dated March 19, 2016, and he reported at that time a total flight experience of 1,282.4 hours. His last flight review took place on October 1, 2013. No logbooks with entries before 2007 were recovered. The pilot had been involved in an airplane accident in August 2004, during takeoff in a Taylorcraft DC-65 airplane (NTSB accident number SEA04LA156). The NTSB determined the cause to be his inadequate compensation for wind conditions and his failure to maintain airspeed, resulting in a stall. The NTSB cited the pilot's failure to use all of the available runway and the high-gusty winds as contributing factors. AIRCRAFT INFORMATIONThe tailwheel-configured airplane had retractable main landing gear and was powered by a nine-cylinder Pratt & Whitney R-1340-AN1 radial engine, which drove a two-blade constant-speed propeller. Maintenance records indicated that a disassembly and restoration of the airplane was completed in 2006, after which it was issued an experimental special airworthiness certificate in the exhibition category. According to the maintenance records, at that time, the airframe had accrued a total time of 2,931 flight hours. The last logbook entry was on May 23, 2014, and was for a condition inspection. The entry indicated a total flight time of 3,070.7 hours. The recording hour meter had fragmented during the accident, preventing an accurate determination of airframe and engine time. However, according to the pilot's logbooks, he had flown the airplane for 8.5 hours since May 24, 2014. The pilot reported to a friend before departure that he had recently fueled the airplane, and the last entry in the pilot's flight logbook indicated that the airplane had been fueled on the pilot's last flight, 4 days before the accident. According to the manager of Astoria Regional Airport, the airplane did not arrive at or obtain fuel from Astoria on the day of the accident. METEOROLOGICAL INFORMATIONThe closest weather reporting station was located at Astoria Regional Airport, Astoria, Oregon, about 5 miles southwest of the accident location. An automated report issued at 1455 indicated wind from 190° at 13 knots gusting to 24 knots and variable between 160° and 230°; visibility 10 miles; light rain beginning at 1421; scattered clouds at 4,500 ft, broken ceiling at 5,000 ft, and an overcast ceiling at 6,500 ft; temperature 11°C; dew point 7°C; and altimeter 30.20 inches of mercury. By 1555, the visibility had reduced to 4 miles with light rain, scattered clouds at 2,400 ft, and an overcast ceiling at 3,100 ft. The closest weather reporting station to the primary intended ash dispersal location was Bowerman Airport, Hoquiam, Washington, about 10 miles east of Ocean Shores. An automated report issued at 1453 indicated wind from 150° at 22 knots gusting to 25 knots; visibility 4 miles; light rain beginning at 1415; mist; scattered clouds at 1,600 ft, broken at 2,200 ft, and overcast ceiling at 3,100 ft. By 1553, the visibility had reduced to 1 3/4 miles with light rain and mist, broken clouds at 1,300 ft and 1,700 ft, and an overcast ceiling at 2,400 ft. A video of the airplane departing for the flight was taken by a friend of the pilot. The video revealed light rain and overcast ceilings. According to a representative from Lockheed Martin Flight Service, the pilot did not request any weather services. Additionally, there was no record of the pilot obtaining a weather briefing from any Direct User Access Terminal (DUAT) providers. AIRPORT INFORMATIONThe tailwheel-configured airplane had retractable main landing gear and was powered by a nine-cylinder Pratt & Whitney R-1340-AN1 radial engine, which drove a two-blade constant-speed propeller. Maintenance records indicated that a disassembly and restoration of the airplane was completed in 2006, after which it was issued an experimental special airworthiness certificate in the exhibition category. According to the maintenance records, at that time, the airframe had accrued a total time of 2,931 flight hours. The last logbook entry was on May 23, 2014, and was for a condition inspection. The entry indicated a total flight time of 3,070.7 hours. The recording hour meter had fragmented during the accident, preventing an accurate determination of airframe and engine time. However, according to the pilot's logbooks, he had flown the airplane for 8.5 hours since May 24, 2014. The pilot reported to a friend before departure that he had recently fueled the airplane, and the last entry in the pilot's flight logbook indicated that the airplane had been fueled on the pilot's last flight, 4 days before the accident. According to the manager of Astoria Regional Airport, the airplane did not arrive at or obtain fuel from Astoria on the day of the accident. WRECKAGE AND IMPACT INFORMATIONThe underwater debris field was about 150 ft long and 100 ft wide. The wreckage had broken into multiple sections and was recovered by a diving team. The sections included the fuselage, which was still attached to the empennage, the right wing outboard of the main landing gear, the wing center section, and the engine and propeller. Additionally, the fragmented left wing, along with cabin debris and airframe and control surface skins were recovered. (Photo 1, 2). Photo 1 – Airframe Following Recovery Photo 2– Wings Following Recovery ADDITIONAL INFORMATIONDuring the airframe examination, a 10-inch crescent wrench (with an opening set to about 9/16 inch), along with a 9/16-inch wrench, and a 3-inch-long 9/16-inch (head) bolt were found loose on the floor of the tailwheel strut box area, below the horizontal stabilizer main spar attach points. The rudder cables and lower elevator horn passed within the center of the box area. The errant items were well clear of (about 10 inches below) the flight controls, and no bolts were found to be missing in the tail section. MEDICAL AND PATHOLOGICAL INFORMATIONAccording to the autopsy performed by the Clatsop County Medical Examiner's Office, Clackamas, Oregon, the cause of death for the pilot was multiple blunt force injuries, and the manner of death was accident. Examination of the body for natural disease was limited by the severity of the pilot's injuries. The heart was lacerated, which complicated the evaluation, but severe coronary artery disease was identified. The proximal third of the left anterior descending coronary artery had about 90% occlusion that was described as a pinpoint lumen. Several millimeters of the proximal left circumflex coronary artery also had 90% or greater occlusion. The myocardium was otherwise grossly normal. No weights or other measurements were given, and microscopic evaluation of the myocardium did not identify any myocardial fibrosis or inflammation. Toxicology testing performed by the FAA's Bioaeronautical Sciences Research Laboratory identified sertraline, its metabolite desmethylsertraline, and trazodone in urine and cavity blood. Sertraline is an antidepressant prescription medication commonly marketed with the name Zoloft. It falls within the selective serotonin re-uptake inhibitors drug class and is not generally considered sedating. Although the use of antidepressant drugs is usually disqualifying for aeromedical certification purposes, FAA guidance indicates that the authorization decision is made on a case-by-case basis, when a pilot is taking one of four potentially allowable antidepressants. These are sertraline (which the pilot was taking), plus fluoxetine (Prozac), escitalopram (Lexapro), and citalopram (Celexa). Trazodone is a prescription antidepressant that can be sedating. It comes with this warning: "Trazodone hydrochloride tablets may cause somnolence or sedation and may impair the mental and/or physical ability required for the performance of potentially hazardous tasks. Patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that the drug treatment does not affect them adversely." In addition, trazodone can increase the potential for arrhythmias in patients with pre-existing cardiac disease. Pilot's FAA Medical Information The pilot had reported multiple eye conditions and procedures, multiple orthopedic procedures, chronic back pain, and sinus disease to his FAA medical examiner. He reported brief treatment for depression in 2000 but said that it had resolved. At the time of his most recent FAA medical examination, dated July 1, 2014, he reported frequent or severe headaches, hand surgery, and the use of intranasal steroids (fluticasone and beclomethasone) as well as ocular drops of cyclosporine (a treatment for dry eyes). He did not report his use of sertraline and trazodone, and he was issued a third-class medical certificate without limitations. Review of the pilot's personal, non-FAA medical records revealed that he had presented multiple times to physicians with complaints of fatigue. He was diagnosed with sleep apnea in 2011, which was treated with a continuous positive airway pressure (CPAP) machine. However, data downloaded periodically from his CPAP machine indicated that he was never compliant with the FAA frequency and duration usage requirements. The pilot was diagnosed with major depression in 1999 and was placed on sertraline. The records document remission of his symptoms, and he stopped receiving prescriptions for the drug sometime between 2002 and 2004. However, in 2014, he told one of his personal physicians that he had continued to use sertraline and had been obtaining it from India for many years out of concern about FAA regulations. After again complaining of fatigue, the pilot was prescribed and used trazodone for sleep from 2013 onwards. In 2014, he was diagnosed and treated for chronic lung disease (Valley Fever), and he had symptoms of post-concussive syndrome due to sports injures for several months in 2014 and 2015, and although these symptoms were later thought to have completely resolved, he had stopped flying, driving, and working during that period. TESTS AND RESEARCHAsh Dispersal Procedures Friends and fellow pilots gave similar descriptions of the ash dispersal procedures the pilot planned to use, stating that the bag had been used on multiple occasions by other pilots. One pilot stated that the bag was made of canvas, with a plastic inner liner that was cinched at the top, and tethered to the airframe from within the cabin. The procedures required slowing down the airplane, following which the passenger would throw the bag out of the window. The ashes would then release into the slipstream, and the bag would be pulled back in. The pilot's daughter flew with him in the airplane to disperse ashes over the water between downtown Seattle and Bainbridge Island in June 2015. She stated that on that occasion she was briefed by her father on the dispersal procedures both before and during the flight. Before takeoff, the ashes were placed in the bag, which she described as being about the size of a paper lunch bag. The bag was cinched closed with a rope, and tied by a longer rope to an interior airframe member on the right side. She sat in the rear seat, facing forward, and, when the time to disperse came, she slid the rear canopy open. The pilot then performed a shallow banking maneuver to the right, and she reached out with her hand holding the bag along the airframe side. She then let go of the bag
The pilot's loss of aircraft control during a low-altitude ash dispersal maneuver. Contributing to the accident was his degraded performance due to his medical conditions.
Source: NTSB Aviation Accident Database
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