CEN15LA026

NTSB accident investigation · Stephenson Stol CH 701 · Mount Vernon, IN · October 24, 2014

Accident · FatalLimited investigationFinal report
Date
October 24, 2014, 19:00 local (23:00 UTC)
Place
Mount Vernon, IN
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N34WSStephenson Stol CH 701
Defining event
Maneuvering-low-alt flying: Low altitude operation/event
Weather
Visual (VMC) · Dusk
Status
Completed · report October 3, 2016
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration
FAA report
20141024019179A
Case key
90300

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 impairment due to the ingestion of alcohol and sedating medications, which led to her improper decision to conduct low-level flight, affected her ability to safety operate the airplane, and resulted in her failure to maintain clearance from power lines.

Findings · 6

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.

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 private pilot was conducting a local personal flight. A witness who was working in a field reported observing the pilot flying the airplane about 30 ft above ground level and 50 ft to his right. The airplane banked right and then impacted power lines. The power lines arced when the airplane contacted them, and the airplane subsequently caught on fire and was fully engulfed in fire when the witness arrived at the accident site. An examination of the airplane did not reveal any preimpact anomalies that would have precluded normal operation. Toxicological testing detected ethanol at 0.148 grams per deciliter (gm/dl) in the vitreous (Federal Aviation Administration regulations only allow 0.040 gm/dl of ethanol) and relatively similar levels of ethanol in the pilot's brain and blood specimens, which indicates that most of the ethanol was likely due to ingestion rather than postmortem production; therefore, she was likely intoxicated and impaired by ethanol at the time of the accident. In addition, the pilot had significant levels of diazepam and diphenhydramine in her heart blood. The detected levels for both drugs were likely therapeutic; however, in regular use, diazepam causes sedation and diphenhydramine causes marked sedation. Therefore, the pilot was likely impaired by both diazepam and diphenhydramine at the time of the accident. In summary, the pilot's judgment and psychomotor functions were likely significantly impaired by a combination of ethanol intoxication and the effects of both diazepam and diphenhydramine at the time of the accident. The combined effects of these impairing substances likely led to the pilot's improper decision to conduct low-level flight, affected her ability to safely operate the airplane, and resulted in her failure to maintain clearance from power lines.

Factual narrative

FAA regulation 91.17 Alcohol or drugs, in part, stated: (a) No person may act or attempt to act as a crewmember of a civil aircraft - (1) Within 8 hours after the consumption of any alcoholic beverage; (2) While under the influence of alcohol; … or (4) While having an alcohol concentration of 0.04 or greater in a blood or breath specimen. Alcohol concentration means grams of alcohol per deciliter of blood or grams of alcohol per 210 liters of breath. FAA regulation 91.119 Minimum safe altitudes: General, in part, stated: Except when necessary for takeoff or landing, no person may operate an aircraft below the following altitudes: ... (c) Over other than congested areas. An altitude of 500 feet above the surface, except over open water or sparsely populated areas. In those cases, the aircraft may not be operated closer than 500 feet to any person, vessel, vehicle, or structure. A Posey County Sheriff's Officer interviewed the witness. During the interview, the witness, in part, stated that he saw the accident airplane flying two or three days prior to the accident. The airplane "swooped" low and close to the combine where he was working. The airplane then climbed and flew away. He could not identify who had flown the airplane but confirmed it was the accident airplane. N34WS was an experimental amateur-built, two-seat, high wing, fixed landing gear Stephenson STOL CH 701 airplane with serial number 7-5218. It was issued a special airworthiness certificate on March 28, 2005. According to airworthiness records, the airplane was powered by a Rotax 912 ULS engine and equipped with a Warp Drive propeller. A witness reported that the airplane caught on fire when he saw it hit the power lines. The airplane subsequently came to rest on the ground and an image of the wreckage was consistent with an isolated fire that charred and discolored grass around the perimeter of the airplane. On October 24, 2014, about 1900 eastern daylight time, an experimental amateur-built Stephenson STOL CH 701 airplane, N34WS, struck powerlines and impacted terrain near Mount Vernon, Indiana. A ground fire subsequently occurred. The pilot, who was the sole occupant, was fatally injured. The airplane sustained substantial damage. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as personal flight. Visual flight rules conditions prevailed for the flight, which did not operate on a flight plan. The local flight originated from a private airstrip at time unknown. A witness, who was working farmland just north of the accident site, reported that he was traveling eastbound on his tractor when the airplane flew from behind and to the right of his position. The airplane was about 30 feet above ground level and about 50 feet to the farmer's right. When the airplane passed him, it pitched up and turned right heading southbound. He observed the airplane flying "right into the powerlines." The power lines arced and theairplane caught on fire. The power lines held the airplane aloft. The witness called 911 and drove to the accident site. The airplane was on the ground and the fire engulfed the airplane when he arrived at the site. An autopsy was performed on the pilot and toxicological samples were taken by the Posey County Coroner's Office. The autopsy ascribed the ground fire as the pilot's cause of death. The FAA Civil Aerospace Medical Institute (CAMI) prepared a Final Forensic Toxicology Accident Report following testing of the pilots toxicological samples. The report indicated: 148 (mg/dL, mg/hg) Ethanol detected in Vitreous 118 (mg/dL, mg/hg) Ethanol detected in Brain 121 (mg/dL, mg/hg) Ethanol detected in Blood (Heart) ... 0.164 (ug/ml, ug/g) Diazepam detected in Blood (Heart) 0.219 (ug/ml, ug/g) Diazepam detected in Liver 0.346 (ug/ml, ug/g) Diphenhydramine detected in Blood (Heart) Diphenhydramine detected in Liver Fluoxetine detected in Blood (Heart) Fluoxetine detected in Liver 0.07 (ug/ml, ug/g) Lorazepam detected in Liver 0.734 (ug/ml, ug/g) Nordiazepam detected in Liver Nordiazepam detected in Blood (Heart) Norfluoxetine detected in Blood (Heart) Norfluoxetine detected in Liver Oxazepam detected in Liver Oxazepam NOT detected in Blood (Heart) The CAMI website, in part, stated: Diazepam: A frequently prescribed antianxiety agent, muscle relaxant, and anticonvulsant. This drug is metabolized into nordiazepam, temazepam, and oxazepam, which are also active. [It is commonly marketed with the name Valium.] Diphenhydramine: Is a common over the counter antihistamine used in the treatment of the common cold and hay fever. [It is available over the counter under the trade names Benadryl and Unisom.] Ethanol: This is primarily a social drug with a powerful central nervous system depressant. After absorption, ethanol is uniformly distributed throughout all tissues and body fluids. The distribution pattern parallels the water content and blood supply of each organ. Postmortem production of ethanol also takes place due to putrefaction processes, but vitreous humor and urine do not suffer from such production to any significant extent in relation to blood. Vitreous humor would normally have about 12 [percent] more ethanol than blood if the system is in the post absorptive state, and urine would normally have about 25 [percent] more ethanol than blood. The average rate of elimination of ethanol from blood is 18 mg/dL (15-20 mg/dL) per hour. Fluoxetine: An atypical antidepressant (SSRI) with the selective serotonin reuptake inhibiting action. It is biotransformed to the active metabolite, norfluoxetine. [It is commonly marketed with the name Prozac.] Lorazepam: Is a tranquilizer used in the treatment of anxiety disorders. [It is commonly marketed with the name Ativan.] Nordiazepam: A metabolite of several different benzodiazepines which are used as a treatment for anxiety. Norfluoxetine: A metabolite of fluoxetine which is used as a treatment for depression.Oxazepam: Is a tranquilizer used in the treatment of anxiety disorders and a metabolite of Nordiazepam and Temazepam. The National Transportation Safety Board Chief Medical Officer reviewed the CAMI findings, FAA documents, and autopsy. According to these items, the pilot reported no chronic medical conditions and no medications to the FAA. The pilot was issued a third class medical certificate limited by a requirement to wear corrective lenses for distant vision and possess glasses for near vision. CAMI's toxicology testing identified ethanol at 0.148 gm/dl in vitreous, 0.118 gm/dl in brain, and 0.121 gm/dl in heart blood. After ingestion, at low doses, it impairs judgment, psychomotor functioning, and vigilance; at higher doses it can cause coma and death. The effects of ethanol on aviators are generally well understood; it significantly impairs pilots' performance, even at very low levels as reviewed and described in research papers articles published on alcohol and aviation. Ethanol may also be produced in body tissues after death by microbial action; when this occurs, levels from various tissues tend to vary widely. The CAMI report indicated that there was no putrefaction in the toxicological sample sent for testing. The medications found in the pilot's toxicological samples were on the FAA's Guide for Aviation Medical Examiners "Do Not Issue" list for aviation medical examiners; pilots who report "regular or intermittent use of any drug or substance classified under the Controlled Substances Act (Schedules I - V)" should not be issued a medical certificate. Fluoxetine is one of four antidepressants that may be allowed for pilot use by the FAA but special issuance medication certification is required and will only be issued after a favorable review of the effectiveness of the treatment by a Human Intervention Motivation Study aviation medical examiner. At 1855, the recorded weather at the Henderson City-County Airport, near Henderson, Kentucky, was: Wind calm; visibility 10 statute miles; sky condition broken clouds at 4,700 feet; temperature and dew point missing; altimeter 30.05 inches of mercury. The 69 year-old pilot held a Federal Aviation Administration (FAA) private pilot certificate with a single-engine land airplane rating. The pilot's most recent FAA airman medical certificate was a third class medical certificate, dated October 3, 2012. The certificate contained limitations to wear lenses for distant vision and possess glasses for near vision. The pilot reported on the application for that medical certificate that she had accumulated 987 hours of total flight time and 39 hours of flight time in the six months prior to the exam. An FAA inspector responded to the accident site, obtained a witness statement, examined the wreckage, and took photographs of the site. The wreckage was found about 15 yards from a local road. Power lines that paralleled the road were separated. The examination of the wreckage site revealed that thewreckage was discolored, charred, and melted. Flight control continuity was observed and no pre-impact anomalies were observed that would have precluded operation of the airplane.

Aircraft

Registration
N34WS
Reported as
Stephenson Stol CH 701
Category
Airplane, amateur-built
Serial number
7-5218
Built
2004
Engine
Rotax 912 ULS, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special); Special, Experimental light sport (Special)
Departed
Mount Vernon, IN
Destination
Mount Vernon, IN

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
69
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
987 total

Weather

Conditions
Visual (VMC) · Dusk
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
4,700 ft broken
Altimeter
30.04 inHg
Observed at
KEHR, 8 nm away

Docket · 9

The files NTSB released with the investigation on July 14, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.6 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.