Pilot Debrief

MORRISEY 2150A near Honesdale, PA — 2017-07-06

Final reportERA17FA232
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Date
2017-07-06
Location
Honesdale, PA, USA
Airport
N30
Aircraft
MORRISEY 2150A
Registration
N917JL
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Initial climb

Probable cause

A total loss of engine power due to fuel exhaustion. Contributing to the accident was the pilot's use of two psychoactive substances, which led to his impaired decision to attempt to takeoff after engine issues became evident.

Contributing factors

Contributing to the accident was the pilot's use of two psychoactive substances, which led to his impaired decision to attempt to takeoff after engine issues became evident.

NTSB narrative

The private pilot was taking off in day, visual meteorological conditions. According to a witness who was both a pilot and a mechanic, the airplane took off and sounded "normal" and returned for landing. After touchdown, the airplane continued for a touch-and-go landing but the engine, "fumbled… faltered drastically for 3 or 4 seconds" before the pilot aborted the takeoff, taxied back to the beginning of the runway, and took off again. During that takeoff, the witness heard the engine "miss" and heard further power interruptions before his attention was diverted from the airplane. The witness did not see the accident. Airport surveillance video depicted the airplane on its takeoff roll, followed by an initial climb and a left turn in the vicinity of the crosswind leg of the airport traffic pattern. The airplane then entered a shallow descent and a shallow bank angle as it descended from view behind trees. Examination of the airplane at the accident site revealed no fuel odor and no evidence of fuel spillage at the scene. Three ounces of fuel were recovered from the airplane. Detailed examination of the airframe and engine revealed no preimpact mechanical anomalies that would have precluded normal operation; however, locking pliers were substituted for the trim actuator handle, and a bird's nest was found in the engine. In addition, the lap belt and shoulder harnesses were not buckled, and the shoulder harnesses were stowed behind the seat, the lap belts were stowed to either side of the seat pan, and the mold growth, dirt, and corrosion visible on the belts, buckle, and male tabs suggested they had not been used for an extended period of time. Examination of airplane records revealed that the airplane's most recent annual inspection was 5 years before the accident. Whether the pilot confirmed the amount of fuel onboard before departure could not be determined, but his failure to appropriately address the "faltering" engine before attempting another takeoff reflects poor hazard recognition and impaired decision making. Given the lack of fuel found onboard after the accident, the loss of engine power was likely the result of fuel exhaustion. Additionally, toxicology testing of the pilot identified the use of butalbital (a barbiturate) and marijuana, both of which can affect decision-making. Thus, it is likely that the effects from the pilot's use of two psychoactive substances contributed to his decision to conduct the takeoff after observing an engine anomaly. Because the pilot was over 40 years old, his medical certificate expired 2 years after issuance; thus it was not valid at the time of the accident.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have aborted the second takeoff after engine issues during the first takeoff.

NTSB coding

Evidence available

  • Video
  • Photos
  • 9 docket documents
View NTSB final reportView NTSB docket

Docket documents9

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