Pilot Debrief

PIPER PA-32RT-300 near Memphis, TN — 2009-11-29

Final reportERA10LA082
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Date
2009-11-29
Location
Memphis, TN, USA
Airport
MEM
Aircraft
PIPER PA-32RT-300
Registration
N9243C
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot's failure to execute a timely missed approach and subsequent failure to maintain aircraft control, after he was unable to establish the airplane on the instrument approach. Contributing to the accident was the pilot's possible impairment due to his medical condition and/or medication use.

Contributing factors

Contributing to the accident was the pilot's possible impairment due to his medical condition and/or medication use.

NTSB narrative

The pilot was conducting an instrument landing system (ILS) approach, in instrument weather conditions, to his home airport after a 4 hour, 20 minute flight. According to air traffic control radar and voice data, the airplane maintained a parallel course, left of the runway centerline, for the entire approach, and when it was about 3 miles from the end of the runway, it descended below the glideslope. The air traffic controller issued two low altitude alerts over the next few minutes, after which the pilot acknowledged and initiated a climb. During the second climb, the ground speed decreased, and the pilot banked to the right and then sharply to the left. The groundspeed continued to decrease until the airplane stalled and impacted a grass area about 1 mile from the end of the runway. Witnesses reported the airplane appeared to be aligned with a parallel (center) runway, instead of the (left) runway the pilot was cleared for, when it descended from below the cloud layer. The pilot, who was also a co-owner of the airplane, had a significant amount of total and instrument flight experience. He flew the accident airplane exclusively for the previous 11 years, and had conducted numerous instrument approaches at his home airport. Weight and balance calculations revealed, at the time of the accident the airplane center of gravity was at about 99.26 inches aft of the airplane datum or approximately 3.26 inches aft of the rear center of gravity (CG) limit. The pilot had a long history of significant liver disease (cirrhosis) as a result of chronic hepatitis C, and was apparently experiencing symptoms of insomnia and lethargy possibly related to his liver disease. He was regularly prescribed (for sleep) an evening dose of a potentially impairing medication (clonazepam) typically contraindicated in significant liver disease and a daily dose of a wakefulness-promoting medication (modafanil). The pilot and his physician had omitted information regarding the pilot's known cirrhosis, symptoms, and use of medications in information submitted to the FAA. Evidence of actively worsening liver disease was noted on autopsy. It is possible that the pilot's judgment and/or performance were somewhat impaired by chronic effects of hepatitis C or by the effect of a sudden deterioration in his condition. It is also possible the pilot may have been impaired as a result of his use of a prescription medication for sleep, particularly given that the metabolism of that medication may have been adversely affected by his liver disease. An inactive marijuana metabolite was detected in the pilot's urine on post-mortem toxicological testing, suggesting only that the pilot had used marijuana sometime in the previous days or weeks.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot could have executed a missed approach when below glideslope.

NTSB coding

Evidence available

  • ATC audio
  • Photos
  • 23 docket documents
View NTSB final reportView NTSB docket

Docket documents23

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