ANC10FA038

NTSB accident investigation · Piper PA-18-135 · Willow, AK · May 14, 2010

Accident · FatalField investigationFinal report
Date
May 14, 2010, 14:00 local (22:00 UTC)
Place
Willow, AK
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N1123Piper PA-18-135
Defining event
Maneuvering-low-alt flying: Low altitude operation/event
Weather
Visual (VMC) · Day
Status
Completed · report March 16, 2011
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Parties
FAA
FAA report
20100514034239A
Case key
76011

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's failure to maintain clearance from a tree due to the effects of impairment from alcohol consumption.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Oversight: oversight of personnelOrganizational issues › Support/oversight/monitoring · FAA/RegulatorPiper PA-18-135: 1 caseAll aircraft: 26 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The flight departed a private airport about 3 miles south of the accident site. A witness reported seeing the airplane approaching at a low altitude. The witness observed the airplane's left wing strike a tree about 100 feet from his location. The airplane continued and passed overhead, crashing in a wooded area behind him. The witness recalled that the airplane's engine sounded as though it was producing power and that the airplane maintained level flight. The accident site was on a broad, flat expanse of tree-covered land. The airplane impacted a single tree located between the parking area and the park administration building; the top 8 feet of the 50-foot-tall tree was severed. The airplane subsequently impacted additional trees and terrain at the rear of the building. An examination of the airplane revealed no evidence of any preimpact mechanical malfunctions or failures. Within the wreckage, an open container of beer was found located in the cockpit at the base of the pilot's seat. Toxicological testing performed on the pilot's specimens detected 106 (mg/dL, mg/hg) ethanol in the blood, which is equivalent to a 0.106 percent blood-alcohol level. He had slightly higher vitreous and urine alcohol levels, consistent with the recent ingestion of alcohol and with impairment due to that ingestion. A review of law enforcement records revealed that the pilot had two alcohol and driving related convictions in 1994 and 1996. After the second conviction, the Federal Aviation Administration (FAA) requested that this pilot undergo psychiatric and neuropsychological evaluations, which did not formally result in a diagnosis of substance abuse or dependence, but noted that having the convictions gives an indication that the pilot does have problems with drinking and that alcohol consumption is an area of potential danger for him. Despite these concerns, the FAA issued a medical certificate to the pilot without any further follow-up required.

Factual narrative

HISTORY OF FLIGHT On May 14, 2010, about 1400 Alaska daylight time, tailwheel-equipped Piper PA-18-135 airplane, N1123, sustained substantial damage when it struck a tree in-flight, about 12 miles north of Willow, Alaska. The airplane was being operated by the pilot as a visual flight rules (VFR) local flight under Title 14, CFR Part 91, when the accident occurred. The solo commercial pilot died as a result of the accident. The airplane departed a private airport about 3 miles south of the accident site, about 1350. No flight plan or flight following procedures were in effect. During an interview with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on May 14, a manager for a state operated RV park said he was in his office at the park working, when he heard an airplane approaching the park. He said due to the park's location along a large river, airplanes frequently pass by at a low altitude. He said he walked outside onto the deck in the front of his office, and saw the airplane approaching the park from the south at a low altitude over the river. He said when the airplane reached the southern perimeter of the park along the river's edge, it altered course and headed straight toward the office. The manager said as it approached, he realized it was not going to clear a tree located about 100 feet in front of his office. He said he thought the airplane would alter course, but it did not, and struck the tree with its left wing. He said he thought the wing was going to come off, but it didn't, and the airplane passed overhead and impacted in a wooded area behind the office. The manager told the IIC that as the airplane approached, the engine sounded strong, and the airplane appeared to be in level flight. He said the pilot may have been an acquaintance of the previous manager, as he was told by the prior manager the pilot would occasionally "buzz" the office. INJURY TO PERSONS The solo pilot died as a result of the accident. DAMAGE TO AIRCRAFT The airplane received substantial damage to the wings and fuselage due to impact with trees and terrain. PERSONNEL INFORMATION The 58 year old pilot held commercial pilot and flight instructor certificates. His most recent FAA third-class medical certificate was issued on April 30, 2010, and contained no restrictions or limitations. No personal flight logbooks were discovered for examination, and the pilot's flight experience was obtained from his most recent application for an FAA airmen medical certificate. According to the application, the pilot had logged over 7,000 hours of flight experience, 10 hours of which were in the past 6 months. A review of law enforcement records showed that the pilot was cited in June 1994 for possession of an open alcoholic beverage in a vehicle, and in a separate incident in June 1994 the pilot was arrested for driving a motor vehicle while intoxicated. The pilot was arrested again in February 1996, for driving a motor vehicle while intoxicated.The pilot was convicted in each of the three incidents. AIRCRAFT INFORMATION The accident airplane was a model year 1954 tailwheel-equipped, single-engine, Piper PA-18 airplane. No airframe or engine logbooks were discovered for examination. Total time for the engine and airframe are unknown. No evidence of the required annual aircraft inspection was discovered. METEOROLOGICAL INFORMATION The closest weather reporting station was the automated weather station at the Willow Airport, about 12 miles south of the accident location. The automated weather observation at 1355 ADT reported the wind variable at 5 knots, visibility 10 statute miles, sky condition scattered at 5,000 feet, broken at 8,000 and 12,000 feet, altimeter 29.82 inches of mercury, temperature 48 degrees F, and dew point 39 degrees F. COMMUNICATIONS There were no known communications with the airplane. WRECKAGE AND IMPACT INFORMATION During an examination of the airplane by the IIC and an FAA aviation safety inspector at the accident site on May 14, the IIC noted that the site was on a broad flat expanse of tree-covered land, adjacent to a large braided river system. The airplane had flown from the river, and crossed a large recreational vehicle (RV) parking area at a state operated RV park. The airplane impacted a single tree located between the parking area and the park administration building. The IIC found the top 8 feet of the 50 foot tall tree laying in the parking lot between the tree and the administration building, along with a piece of acrylic plastic, which was later identified as part of the airplane's windscreen. The airplane impacted additional trees and terrain at the rear of the administration building. All of the airplane's major components were at the site, and control continuity was established for all the primary flight controls. Observing the airplane's position, crush lines, damage to surrounding trees, and using an inclinometer, the IIC determined that after hitting the initial tree, the airplane impacted additional trees and terrain at a 40-50 degree nose down angle. Both blades of the propeller were twisted and gouged. Fuel was present in the engine carburetor and fuel tanks. No evidence of any preimpact mechanical deficiencies were discovered. During the examination of the airplane at the accident site, the IIC removed an open beer can from the floor of the airplane at the base of the pilot's seat. During an interview with the IIC on May 14, an Alaska State Trooper said a neighbor of the pilot said he watched the pilot takeoff from the private airport shortly before the accident, but he had not spoken to the pilot. MEDICAL AND PATHOLOGICAL INFORMATION A postmortem examination of the pilot was conducted under the authority of the Alaska State Medical Examiner, 4500 South Boniface Parkway, Anchorage, Alaska, on May 17, 2010. The examination revealed the cause of death for the pilot was attributed to multiple blunt force injuries of the head. The FAA's CivilAeromedical Institute (CAMI) conducted a toxicological examination on July 6, 2010, which showed; 106 (mg/dL, mg/hg) Ethanol detected in Blood 117 (mg/dL, mg/hg) Ethanol detected in Urine 90 (mg/dL, mg/hg) Ethanol detected in Muscle 121 (mg/dL, mg/hg) Ethanol detected in Vitreous Toxicological testing performed on the pilot's specimens detected 106 (mg/dL, mg/hg) Ethanol in the blood [equivalent to a 0.106 percent blood-alcohol]. The NTSB medical officer reviewed the pilot's medical records obtained from the FAA Aerospace Medical Certification Division, and noted that FAA medical records documented a history of driving while intoxicated in 1994 and 1996. The FAA requested that the pilot undergo psychiatric and neuropsychological evaluation in 1996. The pilot reported to the FAA in the first case a blood alcohol level of 0.105 and noted that he “did not think I was under the influence of alcohol.” The pilot reported in the second case to a neuropsychologist a blood alcohol level of 0.12, and noted to the neuropsychologist that “he had three beers” and that “his driving was not erratic.” The neuropsychologist indicated that the pilot “…does not appear to meet the criteria for diagnosis of a formal substance abuse disorder at this time, [but] his history would suggest that he has exercised less than optimal judgment in the past with regard to alcohol consumption and the use of motorized vehicles. His history and test results would suggest that alcohol consumption is an area of potential danger for him. Consequently preventive measures should be initiated to minimize this possibility.” The psychiatrist indicated that “…it does not appear that he has any significant psychiatric disorder. My biggest concern is the fact that he has had two DWIs within two years.…having two DWIs raises a very large red flag that the individual does have problems with drinking. In the future should he not be able to stop drinking, then I would take this as proof that he has more of a concern with drinking than he feels and would then recommend that he involve himself in alcohol treatment.” The FAA subsequently medically certified the pilot without any further follow-up required. The autopsy report on the pilot noted the presence of “fatty liver, moderately severe.” The pilot's most recent application for a medical certificate dated April 30, 2010, noted that the pilot had reported a previous history of alcohol related arrests and/or convictions. ADDITIONAL INFORMATION AND RESEARCH Due to the pilot's incidents with alcohol, in July 1996 the FAA's Civil Aviation Security Division began an evaluation of the pilot's fitness to hold an airmen medical certificate. The pilot was requested to provide copies of all his arrest and court records, and undergo a psychiatric and psychological examination. In October 1996 the pilot submitted the requested documents including the results of two psychological evaluations. After a review of the documentation, the FAA determined that thepilot was eligible for an airmen medical certificate. In 2003 the pilot's reporting of events came into question by the FAA because it appeared that on an application for a pilot medical certificate the pilot had not disclosed all of the relevant events. After additional review, the FAA determined the pilot was eligible for his medical certificate. FAA regulation 14 CFR 91.17, alcohol or drugs, states in part; a) No person may act or attempt to act as a crew member of a civil aircraft -- (1) Within 8 hours after the consumption of any alcoholic beverage; (2) While under the influence of alcohol; (3) While using any drug that affects the person's faculties in any way contrary to safety; or (4) While having .04 percent by weight or more alcohol in the blood. The FAA defines substance (including alcohol) dependence as "evidenced by (A) increased tolerance, (B) manifestation of withdrawal symptoms, (C) impaired control of use, or (D) continued use despite damage to physical health or impairment of social, personal, or occupational functioning" (14 CFR 67.107(a)(4)(ii), 67.207(a)(4)(ii), and 67.307(a)(4)(ii)). FAA regulations cited above note that a history or clinical diagnosis of substance dependence is specifically disqualifying. The FAA requires that airmen report a history of substance (including alcohol) dependence on each application for airman medical certificate. The FAA additionally requires that airmen report any convictions involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug, and performs a National Driver Register (NDR) inquiry for each application for medical certificate to verify that all such convictions are in fact reported. Once the initial conviction is reported, the FAA may or may not require a substance abuse evaluation.

Aircraft

Registration
N1123
Reported as
Piper PA-18-135
Category
Airplane
Serial number
18-4034
Engine
Lycoming O-290 SERIES, 135 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Neal Burleson
Registered owner
Michael Zobel
Airworthiness certificate
Standard, Normal
Departed
Willow, AK
Destination
Willow, AK

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
58
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Seat
Front
Flight hours
7,000 total

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 5 knots
Visibility
10 statute miles
Lowest ceiling
8,000 ft broken
Temperature
48 °F, dew point 39 °F
Altimeter
29.81 inHg
Observed at
PAUO, 12 nm away

Docket · 7

The files NTSB released with the investigation on October 28, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.1 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N1123 · 1

Matched to the same aircraft by N-number and date.