Pilot Debrief

PIPER PA-28-160 near Tacna, AZ — 2012-11-23

Final reportWPR13FA058
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Date
2012-11-23
Location
Tacna, AZ, USA
Aircraft
PIPER PA-28-160
Registration
N5076W
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

Probable cause

The pilot’s failure to maintain airplane control. Contributing to the accident was the pilot’s impairment due to acute psychosis with paranoid thoughts.

Contributing factors

Contributing to the accident was the pilot's impairment due to acute psychosis with paranoid thoughts.

NTSB narrative

Without clearance or communication with air traffic control, the pilot took off in the airplane from a taxiway and departed the airport area westbound. Five days later, the airplane wreckage was found 160 miles west of the departure airport. Postaccident examination of the wreckage determined that the airplane impacted the ground in a near vertical attitude. Further examination of the airplane and engine revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. The pilot had been treated in the past for depression, a seizure disorder, an opiate addiction, and she used lamotrigine to treat migraine headaches. Toxicology results detected a sedating antihistamine, diphenhydramine, lamotrigine, and tetrahydrocannabinol in the pilot, however, their effects on her performance at the time of the accident could not be determined. The pilot's husband reported that his wife had been displaying abnormal behavior about 3 to 4 weeks before the accident. In a phone conversation with her husband the night before the accident, the pilot expressed concern about men in black helicopters watching her, and, in a message left on his voicemail the day of the accident, her husband stated that she seemed to be "acting paranoid," stating she was going to take the airplane flying to get away from "them." The source of the pilot's psychosis could not be determined during the investigation. The pilot's acute psychosis with paranoid thoughts likely impaired her decision-making and judgment and contributed to the accident.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have chosen not to fly due to mental health concerns.

NTSB coding

Evidence available

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

Docket documents12

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