# NTSB CEN10LA216: Piper PA-24-250, N5425P, Madison, IN, April 19, 2010 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: April 19, 2010, 10:38 local (15:38 UTC) - Place: Madison, IN - Coordinates: 38.749244, -85.380859 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.7492&lon=-85.3809&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report July 18, 2013 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA-Indianapolis FSDO - NTSB case key (mKey): 75821 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN10LA216 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/75821/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=75821 - Page: https://openairdocs.org/ntsb/CEN10LA216 ## 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. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-24-250, 6 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=7102404), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Impairment/incapacitation: illness/injury](https://openairdocs.org/ntsb-findings/02012010): Personnel issues › Physical · Pilot (probable cause); cases with it: [Piper PA-24-250, 1 case](https://openairdocs.org/ntsb-findings/02012010/cases.md?model=7102404), [All aircraft, 34 cases](https://openairdocs.org/ntsb-findings/02012010/cases.md) - [Impairment/incapacitation: prescription medication](https://openairdocs.org/ntsb-findings/02012025): Personnel issues › Physical · Pilot (probable cause); cases with it: [Piper PA-24-250, 2 cases](https://openairdocs.org/ntsb-findings/02012025/cases.md?model=7102404), [All aircraft, 77 cases](https://openairdocs.org/ntsb-findings/02012025/cases.md) - [Mental/emotional state](https://openairdocs.org/ntsb-findings/02022500): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-24-250, 1 case](https://openairdocs.org/ntsb-findings/02022500/cases.md?model=7102404), [All aircraft, 21 cases](https://openairdocs.org/ntsb-findings/02022500/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-24-250, 7 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102404), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-24-250, 34 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102404), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-24-250, 22 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102404), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-24-250, 55 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102404), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis 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. ## Factual narrative HISTORY OF FLIGHT On April 19, 2010, about 1038 central daylight time, a Piper PA-24-250, N5425P, was destroyed when it impacted the ground near Madison, Indiana. The private pilot, who was the sole occupant, was fatally injured. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight, which was not operated on a flight plan. The local flight originated from the Madison County Airport (IMS), Madison, Indiana, about 1030. A witness to the accident reported that he heard the airplane’s engine “rev up” and then he saw the airplane pitch up, roll to the right to an inverted position, and nose dive toward the ground. PERSONNEL INFORMATION The pilot held a private pilot certificate with single-engine land airplane, and instrument airplane ratings. He was issued a third-class airman medical certificate, with a restriction for corrective lenses, on June 3, 2009. Review of the pilot’s flight logbook indicated that the pilot had accumulated 6,006 hours as of the last entry dated March 23, 2010. All of the pilot’s recent flight entries were for flights in the accident airplane. The pilot’s most recent flight review, as required by 14 CFR 61.56, was completed on July 16, 2009. AIRCRAFT INFORMATION The accident airplane was a Piper model PA-24-250 Comanche, serial number 24-479. It was a four-place, low-wing, single-engine airplane, with a retractable tricycle landing gear configuration. The airplane was constructed predominately of aluminum alloy materials. The airplane was powered by a 250-horsepower Textron Lycoming model O-540-A1D5, six-cylinder, reciprocating engine, serial number L-20446-40A. Maintenance records indicated the most recent annual inspection was completed on November 19, 2009, and the airframe had 2,598.8 hours at the time of the inspection. The engine had accumulated 402 hours since overhaul at the time of the annual inspection. According to Federal Aviation Administration (FAA) records, the pilot had owned the airplane since June 3, 1974. METEOROLOGICAL INFORMATION At 1053, the reported weather at the Bowman Field Airport, Louisville, Kentucky, about 34 nautical miles south of the accident site were: Variable wind at 3 knots; 10 miles visibility; clear skies; temperature 16 degrees Celsius; dew point 4 degrees Celsius; altimeter setting 30.16 inches of mercury. WRECKAGE AND IMPACT INFORMATION The airplane impacted an open agricultural field about 4 miles northwest of IMS. The airplane was resting in the field about 500 feet south of a tree line along an east-west access road, and about 150 feet west of a north-south access roads that bordered the property. The only recognizable portion of the airplane was the empennage section. The remainder of the airplane was largely located in one area with the engine embedded about 4 feet into the ground. The firewall was approximately level with thesurrounding terrain. Examination of the airplane’s instruments and the debris field indicated that the impact occurred at a high rate of speed in a near vertical attitude on path of about 220 degrees magnetic. The airplane’s engine remained attached to the tubular engine mount structure. The propeller hub was shattered and all three propeller blades were found within the impact crater. The propeller blades exhibited chordwise . Examination of the debris field enabled identification of all major airframe and control surface components at the accident site. No preimpact anomalies were detected with respect to the airframe, control system, or engine; However, due to the extent of damage to the airframe, a comprehensive determination of the airplane’s preimpact condition was not possible. MEDICAL AND PATHOLOGICAL INFORMATION According to the pilot’s FAA blue ribbon medical file, his first third class certificate was awarded in 1956. The most recent aviation medical examination had been conducted on June 3, 2009, and a third class medical certificate awarded on that date, limited only for corrective lenses. At the time, the pilot denied any medication use except occasional Tylenol. Earlier evaluations document orthopedic procedures and the resection of a benign thyroid mass. The FAA records contain correspondence from his physicians between 2003 and 2005 which included mention of the pilot’s ongoing use of sedating medications including Darvocet (propoxyphene and acetaminophen, a narcotic pain medication) and Halcion (sleep aid). These are not included in the pilot’s report of medications on any visit. A week before the fatal crash, the pilot saw his personal physician who documented the pilot had complained of increasing fatigue and an episode of confusion and feeling unstable that had lasted about five or six minutes. He was accompanied on this visit by his daughter who expressed concern that the pilot appeared to be having more memory problems than previously. The physician recorded the patient’s active medical problems to include polymyalgia rheumatica, peripheral neuropathy, and arthritis. At that time his medications included Xanax (alprazolam, a benzodiazepine), Halcion (triazolam, a benzodiazepine sleep aid), aspirin, Darvocet (combination of propoxyphene and acetaminophen, a sedating narcotic pain medication), Ambien (zolpidem, another sleep aid), and prednisone (a steroid used to treat the muscle weakness associated with polymyalgia rheumatica). The physician noted the pilot had “decreased memory”; a significant change from February 2, 2010 when the pilot was described as “alert and in no distress”. The physician ordered blood work and an magnetic resonance imaging (MRI) of the brain to further investigate. He asked the pilot to decrease his use of sedating medications including Ambien, Darvocet, and Xanax. In addition, the physician recommended that the pilot, also a physician, refrain from working in his position at the local HealthDepartment for the next six weeks. The pilot’s last visit with the primary care physician occurred on the day of the accident. The pilot reported feeling somewhat better, but reported occasional palpitations. At that time, the physician and the pilot discussed the findings of the MRI. The radiologist had interpreted the images directly and described two small areas in the left brain (“9mm in length region in the left posteromedial occipital parietal lobe junction and a moderate sized area … in the left temporal lobe”) as having increased signal on the axial diffusion images that “do not have corresponding low signal on the axial apparent coefficient diffusion weighted images indicating these are not related to simple acute ischemic events”. It goes on to suggest “underlying necrosis or hemorrhagic transformation (are) not excluded as potential considerations. Other considerations can include neoplasm, inflammatory process, or recent insult.” The radiologist suggested a contrast enhanced MRI and a computerized tomography (CT) scan of the brain to further investigate the findings. An autopsy of the pilot was performed at The King's Daughters' Hospital, Madison, Indiana, on April 20, 2010. The autopsy report concludes that the cause of death was multiple blunt force injuries. No brain or blood was available for examination due to the severity of injury. Toxicology testing was performed by the FAA Civil Aerospace Medical Institute. The toxicology report was limited by the unavailability of blood; this precluded testing for cyanide or carbon monoxide poisoning. There was no ethanol found in muscle or brain. Dextromethorphan (an over the counter cough suppressant) was identified in liver and kidney; propoxyphene (sedating narcotic pain medication) was identified in liver (6.025 ug/ml) and kidney (0.779 ug/ml); norpropoxyphene was also identified in liver (25.594 ug/ml) and kidney (2.777 ug/ml); and phenobarbital (sedating anti-seizure medication) was identified in liver (0.299 ug/ml) and kidney (0.172 ug/ml). Both propoxyphene and phenobarbital carry a warning: “may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery).” Neither is FAA approved for use by pilots. ## Aircraft - Registration: [N5425P](https://openairdocs.org/deregistered/N5425P-2013-04-09), registration cancelled 2013-04-09, S/N 24-479, built 1959 (OpenAirDocs) - Reported make and model: PIPER PA-24-250 - Registry model: [Piper PA-24-250](https://openairdocs.org/model/piper-pa-24-250) (registry code 7102404) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 24-479 - Airframe hours: 2599 - Engines: LYCOMING 0-540-A1D5 250 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 19, 2009 - Departed: IMS, Madison, IN - Destination: IMS, Madison, IN - Airport: IMS, Madison Municipal Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 81; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review July 16, 2009; seat: left; toxicology performed; flight hours: 6,006 total ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 61 °F, dew point 39 °F - Altimeter: 30.13 inHg - Observed at: LOU, 34 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20100419032869A](https://openairdocs.org/incident/20100419032869A), Apr 19, 2010: Piper PA-24-250, Madison, IN, Destroyed, 1 fatal. (See attachment) at 1300 hours on April 19, 2010 the ind FSDO received a call from great lakes roc that an accident had occurred at 1135L (EDT) in a plowed… ## Docket (11 files) The files NTSB released with the investigation on May 9, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=75821. 12.3 MB in all. - Medical Factual Report (item 1, .PDF, 191 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389422&FileExtension=.PDF&FileName=Medical%20Factual%20Report-Master.PDF - Toxicological Report (item 2, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389426&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Pilot Logbook Excerpts (item 3, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389493&FileExtension=.PDF&FileName=Pilot%20Logbook%20Excerpts-Redacted.PDF - Aircraft Logbook Excerpts (item 4, .PDF, 636 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389498&FileExtension=.PDF&FileName=Aircraft%20Logbook%20Excerpts-Redacted.PDF - Witness Interviews and Statements (item 5, .PDF, 925 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389558&FileExtension=.PDF&FileName=Witness%20Interviews%20and%20Statements-Redacted.PDF - Accident Site Diagram (item 6, .PDF, 25 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389559&FileExtension=.PDF&FileName=Accident%20Site%20Diagram-Master.PDF - Photo 1. Main Wreckage (item 7, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389561&FileExtension=.PDF&FileName=Photo%201.%20Main%20Wreckage-Master.PDF - Photo 2. Main Wreckage (item 8, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389563&FileExtension=.PDF&FileName=Photo%202.%20Main%20Wreckage-Master.PDF - Photo 3. Main Wreckage (item 9, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389564&FileExtension=.PDF&FileName=Photo%203.%20Main%20Wreckage-Master.PDF - Photo 4. Propeller Blades (item 10, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389565&FileExtension=.PDF&FileName=Photo%204.%20Propeller%20Blades-Master.PDF - Photo 5. Engine (item 11, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389566&FileExtension=.PDF&FileName=Photo%205.%20Engine-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.