Pilot Debrief

PIPER J5A near Iola, WI — 2023-08-19

Final reportCEN23FA369
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Date
2023-08-19
Location
Iola, WI, USA
Airport
68C
Aircraft
PIPER J5A
Registration
N35417
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Preflight

Probable cause

The pilot’s failure to maintain control of the airplane after landing on a grass taxiway with a tailwind, which resulted in a nose over.

NTSB narrative

The 78-year-old pilot had flown his airplane to the destination airport where an annual inspection was to be performed. The airplane did not have a current annual inspection and did not have a ferry permit for the accident flight. No record of a current flight review for the pilot was found. In addition, the pilot did not possess current FAA medical certification or BasicMed qualifications. Recorded GPS device data showed the airplane made several turns around the airport and then proceeded in the direction of and onto a grass taxiway with a prevailing tailwind, where it was found nosed over. There were no witnesses to the accident. There were no indications of ground scars or rotational features on the propeller and spinner indicative of engine power production. Although the airplane’s right front brake master cylinder arm had a bungee cord tied around it that connected to the pilot seat frame, the brakes actuated and released without anomaly. Examination of the airplane revealed no useable fuel aboard; however, the airplane’s flight path indicated that it circled the airport multiple times before landing, indicating that the flight had adequate fuel to reach and land at the airport. No mechanical anomalies were found that would have precluded normal operation. Although the pilot’s cardiovascular disease placed him at increased risk of an impairing or incapacitating medical event such as heart attack, arrhythmia, or stroke, there was no autopsy evidence that such an event occurred, and such an event does not reliably leave autopsy evidence if it occurs just before death. Toxicology results indicated that the pilot had used the opioid pain medication tramadol and likely was experiencing some effects of tramadol at the time of the accident. Although details of the pilot’s tramadol use are unknown, there is no specific evidence that this use was significantly different from the pilot’s baseline use of tramadol, which had begun years previously. Toxicology results also indicated that the pilot had used venlafaxine and a cannabis product. The measured postmortem levels of the substances in the pilot’s system at the time of the accident neither exclude nor specifically predict any impairing effects, especially in combination with one another and considering the pilot’s age and medical conditions. Based on the evidence, the pilot likely did not maintain control of the airplane after landing on a grass taxiway with a tailwind. Whether the impairing effects of the pilot’s substance use and medical conditions contributed to the accident could not be determined.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot did not obtain a current medical certificate or ferry permit before flight.

NTSB coding

Evidence available

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

Docket documents13

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