The commercial pilot departed on a fire detection flight for a state fire commission using a predetermined flight route. He was receiving flight-following services from the dispatch center and was reporting his flight progress to a dispatcher.
He reported entering the eastern boundary of the forest district near Oden, Ark., and then turning north toward the next checkpoint. Five minutes later, he reported that he was turning back due to low cloud ceilings. About 14 minutes later, the Cessna 210 hit trees on a ridgeline, which had an elevation of 1,473 feet. The pilot was killed in the accident.
A post-accident examination of the propeller revealed damage consistent with a medium-to-high power setting at impact. Although the plane was equipped for flight in instrument meteorological conditions, the instruments required for instrument flight were not maintained to those standards, so the plane was limited to flight in visual flight rules conditions only.
Surface weather reports indicated low cloud ceilings of 700 to 1,100 feet above ground level along most of the route of flight. Wave clouds and associated turbulence also existed in the area about the time of the accident.
A surface weather reporting station located 21 nautical miles west of the accident site and within the planned route of flight was reporting clouds overcast at 500 feet at the time of the accident.
The fire commission’s aviation department did not use flight risk assessments.
No record was found indicating that the pilot received a preflight weather briefing, however, it could not be determined if the pilot obtained weather information using other sources.
Toxicological testing detected nortriptyline, which can be impairing, in the pilot’s liver; however, no evidence was found indicating that the nortriptyline impaired his decision-making or flying skills at or around the time of the accident.
The NTSB determined the probable cause of this accident as the pilot’s improper decision to fly into an area with reported marginal meteorological conditions in an airplane not maintained for instrument flight and his subsequent failure to maintain clearance from trees and terrain.
NTSB Identification: CEN14GA135
This January 2014 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.
The story told in the short GANews summary is incomplete. There was low level wind shear in the mountains. While airports located in the valleys at elevations around 600′ MSL reported winds 2-6 kts, winds reported from soundings were 25 kts at 2,000′ MSL. The pilot crashed on a 1400’ ridge. Based on terrain photos in the docket there were no ‘good’ or even marginal off airport landing sites in the vicinity. I’m amazed the State Forestry Dispatch launched aircraft into those conditions in JANUARY!?!
“….in an airplane not maintained for instrument flight.” What do you need but an attitude indicator and an altimeter to keep the airplane out of the trees while exiting the scud. Did the airplane not have that minimal instrumentation? If so that pilot was out of his mind to be out there tooling around in low ceiling and viz weather. Maybe the drug detected in his system did affect his judgement, something obviously did.
I don’t know how they can say there was no evidence the nortriptyline impaired his decision making or flying skills? Northriptyline is used to treat major depression but also for a few other maladies, such as TMJ syndrome, migraines and so forth. The latter utilizes one of the side affects, analgesic action, due to it being a sodium channel blocker.
I recall the day of this accident and no pilot with good sense would have been flying VFR, due to weather conditions, so something impaired his decision making.
The Docket includes a medical report that states the pilot was using at least two drugs that had potential issues with operating machinery and making complex decisions. An excerpt from the NTSB medical report says:
“At the time of the accident, the pilot’s medications included tramadol 50 to 100 mg four times a day as needed, meloxicam 15 mg daily and nortriptyline 50 mg at bedtime. Tramadol is an opioid pain medication marketed under the trade name Ultram. It carries the warning – may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery).4 Meloxicam is a non-steroidal anti-inflammatory medication marketed as Mobic.5 Nortriptyline is a medication used to treat depression and chronic pain marketed as Pamelor.6 It carries the warning “may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery).”7
The pilot’s primary care provider had started a trial of nortriptyline three weeks prior to the accident. A record from two days prior to the accident documented continued knee pain with no benefit or side effects from the nortriptyline 30 mg at bedtime and the dose of nortriptyline was increased to 50 mg that day.”
The NTSB Meteorology Report in the Docket (and NTSB Factual Report) indicated that, while surface winds were benign soundings showed a rapid increase in wind velocities with altitude. Wind speed at 2000′ MSL (only 600′ higher than the ridgeline elevation at the accident site) were at 25 kts. Mountain wave was evident in the overcast, as well as in satellite imagery suggesting turbulence may have been brutal.
It was a very bad day to fly given medical and weather issues.