Pilot Debrief

BEECH P35 near Edgewater, MD — 2010-02-27

Final reportERA10FA154
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Date
2010-02-27
Location
Edgewater, MD, USA
Airport
ANP
Aircraft
BEECH P35
Registration
N1521S
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

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.

Contributing factors

Contributing to the accident was the pilot's likely impairment due to back pain, symptoms of opiate withdrawal, or both.

NTSB narrative

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.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have aborted the approach when experiencing downdrafts.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 23 docket documents
View NTSB final reportView NTSB docket

Docket documents23

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