Pilot Debrief

AIR TRACTOR INC AT-602 near Kennett, MO — 2016-07-07

Final reportCEN16LA260
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Date
2016-07-07
Location
Kennett, MO, USA
Aircraft
AIR TRACTOR INC AT-602
Registration
N967JB
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot's failure to maintain clearance from power lines while maneuvering during the aerial application flight.

NTSB narrative

The pilot was performing an aerial application flight to a field that was intersected by powerlines. There were no witnesses to the accident, but the wreckage path consisted of broken power lines consistent with an in-flight collision. In addition, the ground scarring was consistent with the airplane operating at a normal speed before the collision, followed by an uncontrolled descent. Examination revealed no mechanical anomalies that would have precluded normal operation. The 48-year-old pilot had reported multiple orthopedic surgeries and use of medication for high cholesterol to the FAA. At the time of his last aviation medical examination, he was diagnosed with diabetes and began treatment with metformin. The aviation medical examiner (AME) who performed the examination questioned the pilot's records from a recent hospitalization that stated the pilot had anxiety/depression. The pilot told the AME this was not a current diagnosis and that he had not been on medication for these conditions in years. Toxicology testing identified acetaminophen, an over-the-counter analgesic; chlorpheniramine, a sedating antihistamine available over-the-counter in many cold, cough, and allergy preparations; citalopram, a prescription antidepressant medication; and dextromethorphan, an over-the-counter cough suppressant, in liver. Acetaminophen and chlorpheniramine were found in cavity blood and the rest were found in muscle. Acetaminophen was identified in urine. It is likely that the pilot did not see the power lines while spraying the field, which resulted in the in-flight collision with the power lines. While treated diabetes can result in hypoglycemia, this is an unusual occurrence when metformin is used as a single agent for the disease. Thus, it is unlikely that the pilot's diabetes or its treatment contributed to this accident. Because the status of the pilot's depression symptoms around the time of the accident were unknown, whether effects from it contributed to his inability to avoid the powerlines could not be determined from the available information. The pilot's use of chlorpheniramine, dextromethorphan, and acetaminophen suggests that he had cold or allergy symptoms and was using an over-the-counter product to treat them. When severe, such symptoms may be quite debilitating; however, the extent to which he had symptoms at the time of the accident and the effectiveness of the treatment could not be determined. As a result, whether his underlying symptoms or the use of medications contributed to the accident circumstances could not be determined.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot's medical condition and medication use should have been evaluated before flight.

NTSB coding

Evidence available

  • 5 docket documents
View NTSB final reportView NTSB docket

Docket documents5

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