Pilot Debrief

CESSNA 421 near Canton, GA — 2017-03-04

Final reportERA17FA118
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Date
2017-03-04
Location
Canton, GA, USA
Airport
CNI
Aircraft
CESSNA 421
Registration
N421KL
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 night visual landing approach. Contributing to the accident was the pilot's impairment due to his use of a combination of medications.

Contributing factors

Contributing to the accident was the pilot's impairment due to his use of a combination of medications.

NTSB narrative

The 69-year-old commercial pilot was making a personal cross-country flight in the newly-purchased airplane. When the airplane was on final approach to the destination airport in night visual meteorological conditions, airport surveillance video showed it pitch up and roll to the right. The airplane then descended in a nose-down attitude to impact in a ravine on the right side of the runway. During the descent over the ravine the right wing came in contact with a powerline that briefly cut power to the airport. Postaccident examination of the airframe, engines, and their components revealed no evidence of mechanical anomalies or malfunctions that would have precluded normal operation. The pilot's toxicology findings identified five different impairing medications: clonazepam, temazepam, hydrocodone, nortriptyline, and diphenhydramine. Although the results were from cavity blood and may not accurately reflect antemortem levels, the hydrocodone, temazepam, and diphenhydramine levels were high enough to likely have had some psychoactive effects. While the exact effects of these drugs in combination are not known, it is likely that the pilot was impaired to some degree by his use of this combination of medications, which likely contributed to his failure to maintain control of the airplane.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have opted for a go-around earlier instead of continuing approach.

NTSB coding

Evidence available

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

Docket documents13

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