Pilot Debrief

Gordon PEGAZAIR P 100 near Mt Vernon, IN — 2016-12-02

Final reportCEN17FA046
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Date
2016-12-02
Location
Mt Vernon, IN, USA
Aircraft
Gordon PEGAZAIR P 100
Registration
N129LZ
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Climb

Probable cause

The pilot's failure to maintain airplane control, which resulted in a collision with terrain. Contributing to the accident was the pilot's impairment resulting from the combination of his progressive degenerative neurologic condition and his use of alcohol.

Contributing factors

Contributing to the accident was the pilot's impairment resulting from the combination of his progressive degenerative neurologic condition and his use of alcohol.

NTSB narrative

The 64-year-old pilot, who was the airplane owner, departed on a local personal flight in the airplane about 45 minutes before the accident. Witnesses saw the airplane at 400-500 ft above ground level when it entered a descent, pitched up, rolled right, and then pitched nose down impacting the ground. Ground scarring surrounding the airplane was consistent with a near-vertical nose-down impact attitude, which resulted in the engine separating and coming to rest about 20 ft from the airframe. Postaccident examination of the airplane revealed no evidence of any mechanical anomalies that would have precluded normal operation of the airplane. According to his pilot logbook, the pilot had not completed a flight review since 2012, and the pilot's last Federal Aviation Administration (FAA) airman medical certificate was issued in 2012. At the time of the accident, he was operating an airplane that required a medical certificate, but his certification was no longer valid. The pilot's personal medical records showed a history of a chronic progressive neurodegenerative disease beginning in 2011 with intermittent worsening of symptoms. The disease and its symptoms likely impaired his ability to safely operate the airplane. Toxicology testing of samples from the pilot detected ethanol at 0.070 gm/dl in vitreous and 0.038 g/dl in blood. Although blood levels of ethanol can change after death, the vitreous from an intact eye is not subject to significant postmortem changes. Therefore, it is likely the ethanol detected in blood and vitreous was from ingestion. The vitreous blood level was well above the FAA prohibited level of 0.04 gm/dl, and mild impairment has been shown at blood levels as low as 0.020 gm/dl. It is likely that the pilot was experiencing some level of impairment from alcohol ingestion and that the combination of the pilot's progressive degenerative neurologic condition and his use of alcohol impaired his ability to safely operate the airplane and contributed to the accident.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have conducted a thorough preflight inspection and ensured fuel was available.

NTSB coding

Evidence available

  • Photos
  • 10 docket documents
View NTSB final reportView NTSB docket

Docket documents10

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