Pilot Debrief

PIPER PA-24-250 near Madison, IN — 2010-04-19

Final reportCEN10LA216
Sign in to save
Date
2010-04-19
Location
Madison, IN, USA
Airport
IMS
Aircraft
PIPER PA-24-250
Registration
N5425P
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Initial climb

Probable cause

The pilot’s failure to maintain control of the airplane. Contributing to the accident was the pilot’s decision to conduct the flight with known physiological impairment and his use of unapproved sedating medication, both of which likely impaired his ability to operate the airplane.

Contributing factors

Contributing to the accident was the pilot’s decision to conduct the flight with known physiological impairment and his use of unapproved sedating medication, both of which likely impaired his ability to operate the airplane.

NTSB narrative

A witness to the accident said that the he heard the airplane’s engine "rev up" then saw the airplane pitch up, roll to the right into an inverted position, and nose dive toward the ground. Impact evidence showed that the airplane struck the ground in a near vertical attitude at a high rate of speed. Postaccident examination of the wreckage did not reveal any preimpact malfunctions or failures; however, the amount of destruction to the airplane precluded a comprehensive determination of its preimpact condition. Review of the pilot’s medical history revealed that over the few weeks before the accident, the pilot had developed neurologic symptoms, including increasing memory problems. During a doctor’s visit, he reported at least one acute episode where he felt confused and had some instability or balance problems. The exact cause of these symptoms and their degree was not determined because a thorough medical evaluation was not completed before the accident. In addition, toxicological test results showed that the pilot had been taking sedating medications that could impair his mental and/or physical ability. The medications were not approved by the Federal Aviation Administration (FAA) for pilots’ use, and the pilot did not report using them to the FAA.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have refrained from flying due to reported fatigue and confusion.

NTSB coding

Evidence available

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

Docket documents11

Related mishaps