Aviation Accident Summaries

Aviation Accident Summary CEN23FA050

Gage, OK, USA

Aircraft #1

N2710D

CESSNA 170

Analysis

The airplane departed from the turf airstrip, and according to data recovered from a handheld GPS, it proceeded about 1.5 miles south and then returned to overfly the airport before returning to land. The non-certificated pilot again departed from the turf airstrip. He appeared to return for a touch-and-go landing and then proceeded north about 0.80 mile before returning to the airport. The final GPS data point was positioned about 265 ft north of the accident site and about 34 ft above ground level. A witness observed the airplane taxi out for takeoff with the airplane owner seated in the right (co-pilot) seat and a friend of the owner in the left (pilot) seat. Neither the owner nor the left-seat occupant held a pilot certificate. They took off toward the south. It appeared that the wing flaps were extended, and the engine sounded “fine.” After lifting off, the airplane porpoised, entered a “steep” left turn, and flew out to the north. After returning to the airport, they appeared to be lined up on final approach for the turf runway. As the witness proceeded to open a hangar door, he heard the impact and turned to see the airplane. He responded to the accident site and notified local authorities. The airplane came to rest inverted along the west edge of the paved ramp area. An initial impact ground scar was located about 15 ft north of the main wreckage. The fuselage nose and engine were crushed aft and upward consistent with a nose-low impact. Postaccident airframe and engine examinations did not reveal any anomalies associated with a preimpact failure or malfunction. . The airplane owner’s toxicology was positive for ethanol. The consistency of ethanol levels indicates that the owner likely had consumed ethanol, and likely had a very high blood ethanol concentration at the time of the accident. Based on the high blood ethanol concentration, he likely experienced degradation of judgment and significant deficits in coordination, psychomotor skills, perception, and attention. In addition, toxicology results detected other central nervous system depressant medications including phenobarbital, cetirizine, hydroxyzine, and doxepin, all of which can adversely interact with one another and with ethanol to worsen impairment. The owner’s past flight experience and competency of piloting are unknown. However, the combination of his pre-existing cognitive conditions, identified during neuropsychological testing in 2015 that revealed evidence of a risk of compromised safety, and the impairing effects of his use of multiple substances, likely contributed to poor decision making. In addition, the combination of cognitive conditions and use of multiple substances would have diminished any baseline flying ability he may have possessed. Thus, effects of the owner’s use of ethanol and other depressants, in combination with his baseline cognitive impairment, likely contributed to the accident. The left-seat occupant’s toxicology was also positive for ethanol in all tested specimens at significant levels, including in vitreous fluid. This indicated that he likely had consumed ethanol and had an impairing blood ethanol concentration at the time of the accident. He, too, would have likely experienced degradation of judgment, and deficits in coordination, psychomotor skills, perception, and attention. In addition, the left-seat occupant’s toxicology testing detected the central nervous system depressing medication alprazolam and the antidepressant citalopram. It is likely that the combination of substances worsened his impairment. However, it is unknown if the left-seat occupant possessed any baseline skill or experience relevant to operating the airplane. Thus, whether effects of his impairment contributed to the accident cannot be determined. Both occupants sustained injuries to their hands, wrists, and arms consistent with holding the aircraft controls; the investigation was not able to determine which occupant was operating the airplane at the time of the accident.

Factual Information

HISTORY OF FLIGHTOn November 28, 2022, at 0820 central standard time, a Cessna 170B airplane, N2710D, was destroyed when it was involved in an accident near Gage, Oklahoma. The two occupants were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Data recovered from a handheld GPS unit revealed that the airplane departed from Vici Municipal Airport (5O1), Vici, Oklahoma, at 0652, and proceeded northwest. At 0726, the airplane landed on the turf airstrip at Gage Airport (GAG), Gage, Oklahoma. At 0803, the airplane departed southbound from the turf airstrip and proceeded about 1.5 miles south, then returned to overfly the airport before returning to land. At 0816, the airplane again departed from the turf airstrip southbound and returned for a takeoff and landing (touch and go), then proceeded north about 0.80 mile before returning to the airport. The final GPS data point was recorded at 0820:23 and was positioned about 265 ft north of the accident site. The altitude corresponding to the final data point was 2,238 ft. The approximate elevation at the accident site was 2,204 ft. A witness observed the airplane taxi out for takeoff with the airplane owner seated in the right (co-pilot) seat and a friend of the owner in the left (pilot) seat. They took off toward the south. It appeared that the wing flaps were extended, and the engine sounded “fine.” After lifting off, the airplane porpoised and entered a “steep” left turn. They flew out to the north and, after returning to the airport, appeared to be lined up on final approach for the turf runway. As the witness proceeded to open the hangar door, he heard the impact and turned to see the airplane. He responded to the accident site and notified local authorities. PERSONNEL INFORMATIONThe Federal Aviation Administration (FAA) reported no record of either the airplane owner or the left-seat occupant holding a pilot certificate. AIRCRAFT INFORMATIONAccording to FAA records, the owner purchased the airplane in September, 2015. The airplane registration lapsed in September 2021 and was subsequently cancelled when the required registration renewal was not submitted. Airplane maintenance records were not available for the investigation. AIRPORT INFORMATIONAccording to FAA records, the owner purchased the airplane in September, 2015. The airplane registration lapsed in September 2021 and was subsequently cancelled when the required registration renewal was not submitted. Airplane maintenance records were not available for the investigation. WRECKAGE AND IMPACT INFORMATIONThe airplane came to rest inverted along the west edge of the paved ramp area. An initial impact ground scar was located about 15 ft north of the main wreckage. The propeller was separated at the ground scar. The fuselage nose and engine were crushed aft and upward consistent with a nose-low impact. The center fuselage was deformed, and the aft fuselage was partially separated. The empennage remained attached to the aft fuselage. Both wings remained attached to the fuselage and exhibited leading edge crushing damage along the entire spans. The flight control surfaces remained attached to the airframe, and flight control continuity was confirmed. Postaccident airframe and engine examinations did not reveal any anomalies associated with a preimpact failure or malfunction. MEDICAL AND PATHOLOGICAL INFORMATIONRIGHT-SEAT OCCUPANT According to FAA records, the 30-year-old airplane owner’s only aviation medical exam was in August 2012. He reported a learning disability treated with methylphenidate (often marketed as Ritalin), a prescription medication that can be used to treat attention deficit/hyperactivity disorder and narcolepsy. He also reported taking the prescription medication phentermine for weight loss. According to the FAA medical case review, both medications were unacceptable. The FAA issued a general denial in July 2013 for a history of attention deficit disorder (ADD) requiring medication. According to the owner’s FAA medical certification file, in 2015 he requested reconsideration for an aviation medical certificate and underwent a formal neuropsychological evaluation. The evaluating clinical neuropsychologist concluded that the results of the evaluation revealed evidence of a risk of compromised pilot safety due to cognitive weaknesses and impairments on formal testing. Based on the evaluation results, the FAA sustained the July 2013 denial for ADD on disqualifying medication, due to the applicant’s disqualifying general medical condition (cognitive impairment as evidenced by abnormal neuropsychological testing). The Board of Medicolegal Investigations, Office of the Chief Medical Examiner (OCME) of Oklahoma City, performed the autopsy. According to the autopsy report, the cause of death was multiple blunt and sharp force injuries, and the manner of death was accident. The liver was noted to be enlarged and micronodular. The FAA Forensic Sciences Laboratory performed toxicological testing of postmortem specimens. Ethanol was detected in cavity blood at 0.378 g/dL, in vitreous fluid at 0.431 g/dL, and in urine at 0.471 g/dL. Methanol was detected at a low level in urine but not in cavity blood or vitreous fluid. Phenobarbital was detected in cavity blood at 396 ng/mL and in urine at 338 ng/mL. 6-beta naltrexol was detected in heart blood and urine. Cetirizine was detected in femoral blood at 8 ng/mL and in urine at 76 ng/mL. Hydroxyzine was detected in femoral blood at 6 ng/mL and in urine at 7 ng/mL. Bupropion was detected in femoral blood at 6 ng/mL and in urine at 9 ng/mL. Hydroxybupropion was detected in femoral blood at 14 ng/mL and in urine at 53 ng/mL. Doxepin was detected in urine at 20 ng/mL and was also detected in femoral blood. Nordoxepin was detected in femoral blood at 13 ng/mL and in urine at 57 ng/mL. Ethanol is a type of alcohol. It is the intoxicating alcohol in beer, wine, and liquor, and, if consumed, can impair judgment, psychomotor performance, cognition, and vigilance. Effects of ethanol can significantly impair pilot performance. While the acute effects of ethanol can vary depending on an individual's frequency of use, body weight, and tolerance, in general, at blood ethanol concentrations as low as 0.02 g/dL, there is relaxation and some loss of judgment. Ethanol levels of 0.05 g/dL have been found to further degrade judgment, psychomotor functioning, and alertness. At blood ethanol concentrations above 0.10 g/dL, there is prolonged reaction time, altered perception of the environment, lack of coordination, slowed thinking, and mood and behavioral changes. FAA rules impose strict limits on flying after consuming ethanol, including prohibiting pilots from flying with a blood ethanol level of 0.04 g/dL or greater. Once ethanol is consumed, it is rapidly absorbed from the gastrointestinal tract and distributed into total body water. As ethanol is distributed in total body water, it uniformly distributes across tissues and into the brain. Vitreous fluid, and to a lesser extent urine, generally are better protected from microbial spread, and thus generally are less susceptible to postmortem ethanol production, than are other specimen types. Phenobarbital is a prescription long-acting barbiturate medication. It is a central nervous system (CNS) depressant and is commonly used for sedation and as an anti-seizure medication. Phenobarbital usually carries a warning that it has the potential for abuse and dependence (requiring increasing doses over time for the same effects). The FAA stated that phenobarbital, even if used for non-seizure indications, is a Do Not Issue/Do Not Fly medication. In addition, phenobarbital usually carries a warning that barbiturate use may impair mental and/or physical abilities required for the performance of potentially hazardous task such as driving a car or operating machinery. Phenobarbital also usually carries a warning that alcohol, narcotics, tranquilizers and antihistamines should not be used in combination with phenobarbital, as the concurrent use of other CNS depressants may result in additive CNS depression. Cetirizine is a second-generation antihistamine medication that is available over the counter and is commonly used to treat allergy symptoms. Cetirizine typically carries a warning that users may experience drowsiness and should use caution when driving a motor vehicle or operating machinery. The FAA states that pilots should wait 48 hours after using cetirizine before flying, to allow time for the drug to be cleared from circulation. Cetirizine can also be an active metabolite of hydroxyzine. Hydroxyzine is a prescription medication that can be used to treat anxiety, as well as pruritis (itching) due to allergies. Hydroxyzine usually carries a warning that users may experience drowsiness and should use caution when driving a motor vehicle or operating machinery. Hydroxyzine will potentiate the effects of other CNS depressants, such as alcohol and barbiturates, and concurrent use of other sedating medications is not recommended. Norchlorcyclizine is a chemical that may be a metabolite of certain antihistamines including hydroxyzine. The FAA states that anti-anxiety medications are Do Not Issue/Do Not Fly medications both for their sedating effects and the potentially underlying conditions being treated. Bupropion is a medication prescribed as an antidepressant (commonly marketed as Wellbutrin) or for smoking cessation (commonly marketed as Zyban). Hydroxybupropion is the major active metabolite of bupropion. Bupropion use is contraindicated in users who consume alcohol. According to the FAA medical case review for this accident, bupropion was considered disqualifying for pilot medical certification. In May 2023, the FAA added extended-release and sustained-release (but not immediate-release) formulations of bupropion to the list of antidepressants that may be considered for FAA medical certification via special issuance. Doxepin is a prescription tricyclic antidepressant medication (commonly marketed as Sinequan) used to treat psychoneurosis-associated depression and anxiety. Doxepin is also used to treat depression anxiety associated with alcohol use disorders, and sleep disturbances associated with the depression and anxiety. Doxepin usually carries a warning that users may experience drowsiness and should use caution when driving a motor vehicle or operating machinery. Doxepin also carries a warning that use may increase risk of psychosis, mania, poor impulse control and should not be used in users who consume alcohol. Nordoxepin is a metabolite of doxepin. According to the FAA medical case review, use of doxipen for any reason is not acceptable for pilots. LEFT-SEAT OCCUPANT The Board of Medicolegal Investigations, OCME, Oklahoma City, performed the autopsy of the left-seat occupant. According to the autopsy report, his cause of death was multiple blunt force injuries, and his manner of death was accident. Due to the extent of the left-seat occupant’s injuries, examination of the heart and lungs was limited. Within these limitations, the remainder of the autopsy examination did not identify significant natural disease. The FAA Forensic Sciences Laboratory performed toxicological testing of postmortem specimens. Ethanol was detected in cavity blood at 0.109 g/dL. Ethanol was also detected in vitreous at 0.159 g/dL and urine at 0.199 g/dL. Alprazolam was detected in cavity blood at 51 ng/mL and in urine at 109 ng/mL. Alpha-hydroxyalprazolam was detected in urine at 58 ng/mL but was not detected in cavity blood. Citalopram was detected in cavity blood at 604 ng/mL and in urine at 3,334 ng/mL. N-desmethylcitalopram was detected in cavity blood at 78 ng/mL and in urine at 684 ng/mL. Metoprolol was detected in cavity blood and urine. The possible effects of ethanol have been described previously. Alprazolam (commonly marketed as Xanax) is a prescription benzodiazepine medication used to treat generalized anxiety disorders and panic disorders. Alprazolam generally carries a warning to use caution when operating machinery or driving a car due to CNS depression. The use of ethanol with alprazolam can produce additional CNS depressive effects including respiratory depression and respiratory failure leading to death. Alpha-hydroxyalprazolam is a less-potent metabolite of alprazolam. Citalopram (commonly marketed as Celexa) is a prescription medication generally used to treat depression. Citalopram sometimes carries a warning that any psychoactive drug may impair judgment, thinking, or motor skills, and that users should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that the drug does not affect their ability to engage in such activities.

Probable Cause and Findings

The non-certificated pilots’ loss of airplane control, resulting in an impact with terrain during final approach. Contributing to the accident was the airplane owner’s impairment due to his use of ethanol and depressant medications, in combination with his baseline cognitive impairment.

 

Source: NTSB Aviation Accident Database

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