Pilot Debrief

PIPER PA-22-135 near White City, OR — 2021-06-20

Final reportWPR21FA233
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Date
2021-06-20
Location
White City, OR, USA
Airport
OR96
Aircraft
PIPER PA-22-135
Registration
N2618A
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot’s failure to maintain control of the airplane during a go-around, which resulted in a collision with trees. Contributing to the accident was the pilot’s impairment due to his medical conditions and the effects of his medications.

Contributing factors

Contributing to the accident was the pilot’s impairment due to his medical conditions and the effects of his medications.

NTSB narrative

The pilot was repositioning his airplane to the accident airport for an annual inspection. He had planned to have a friend meet him at the destination airport to drive him home. The friend waiting to pick the pilot up at the destination airport stated that the pilot initiated a go-around when the airplane was not aligned with the runway on the first landing attempt. The friend stated that the pilot attempted another landing and once again the airplane was not aligned with the runway, so the pilot initiated another go-around. The pilot made two landing attempts, and during the last attempt, the airplane contacted trees off the left side of the departure end of the runway. The airplane then impacted terrain and a postimpact fire ensued. At the time of the accident, the density altitude at the airport was over 4,000 ft. A witness located at a residential airpark about 5 nautical miles from the pilot’s intended destination, where the accident subsequently occurred, reported that the accident airplane had landed at their private airpark just before the accident. They were worried because the airplane’s approach was erratic, and fast, and touched down about midfield and bounced before it went out of their view. The witness went to find the airplane and found it parked in his front yard. The pilot seemed lethargic, confused, and slow to answer questions. The pilot asked multiple times if he was at his destination airport, and the witnesses replied that he was not. Witnesses reported that about 20 minutes later the pilot departed from their airport. The witness reported that, although the airplane’s engine was running and sounded normal, it also sounded like the pilot had only applied partial power on takeoff. The witness noted that the airplane did not appear to be under control during the takeoff. Postaccident examination of the airframe and engine revealed no mechanical anomalies that would have precluded normal operation. According to the pilot’s wife, the pilot had heart issues that included two previous heart attacks, one of which was 3 weeks before the accident. The pilot’s wife also stated that her husband was easily confused, irritable, and was in poor health. His two visits to the emergency room about 10 days before the accident suggest that the pilot’s condition was not well-controlled. The pilot’s toxicology testing detected gabapentin, doxylamine, dextromethorphan, torsemide and carvedilol in his system. In addition, the pilot’s autopsy identified severe cardiovascular disease, chronic kidney disease, and previous atrial fibrillation. Based on the operational evidence, the pilot had actively attempted several landings when the accident occurred; therefore, it is unlikely that the pilot experienced sudden incapacitation. However, operational evidence and witness reports indicate that the pilot was behaving in a confused manner. The pilot was taking a diuretic medication and other medications that decrease sweating and body cooling. He was also taking gabapentin, which is associated with dizziness and sleepiness. Even without a heat stressor, people with chronic heart failure can experience mental confusion and impaired thinking. The pilot also had moderate chronic kidney failure that would decrease his heat tolerance. Additionally, heat stress can further impact kidney function. Decline in kidney function with subsequent buildup of body wastes in the blood can lead to confusion. Given the high outside temperatures, the pilot’s medical conditions, as well as the prescribed medication detected in his system, it is likely that the pilot experienced mental confusion and impaired thinking/judgement, which resulted in his inability to safely operate the airplane.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have chosen not to attempt landing after initial go-around.

NTSB coding

Evidence available

  • 9 docket documents
View NTSB final reportView NTSB docket

Docket documents9

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