Pilot Debrief

PIPER PA-32-260 near Madisonville, TX — 2021-06-14

Final reportCEN21FA263
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Date
2021-06-14
Location
Madisonville, TX, USA
Airport
51R
Aircraft
PIPER PA-32-260
Registration
N3258W
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot’s failure to maintain a proper glidepath during final approach for landing, which resulted in impact with trees and terrain.

NTSB narrative

The pilot departed on a night cross-country flight. While on approach to the destination airport, the airplane impacted trees and terrain and came to rest about 550 ft from the runway threshold. Postaccident examination of the airplane revealed no anomalies that would have preclude normal airplane operation. The switches for the airplane’s landing light and rotating beacon were both found in the OFF position. Autopsy revealed that the pilot had 85% stenosis of one of his coronary arteries, which placed him at an increased risk for a sudden cardiac event; however, there was no evidence to suggest that occurred and based on the circumstances of this accident, it is unlikely that the pilot’s cardiovascular condition was a factor in the accident. Toxicological testing identified the antidepressant sertraline and its metabolite desmethysertraline in the pilot’s heart blood and urine. While the levels detected were above therapeutic levels, this medication can undergo postmortem redistribution. Sertraline is one of the four medications the Federal Aviation Administration will consider for treatment of depression. Special issuance is usually issued after 6 months of treatment when the applicant is clinically stable. It is unknown how long the pilot was taking sertraline and whether he was taking it for depression or some other condition. However, after a few weeks of use, sertraline does not impact psychomotor performance. Given the circumstances of this accident, it is unlikely that effects from the pilot’s use of sertraline were factors in the accident.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have chosen to divert or abort approach due to low visibility.

NTSB coding

Evidence available

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

Docket documents9

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