WPR13FA058

NTSB accident investigation · Piper PA-28-160 · Tacna, AZ · November 23, 2012

Accident · FatalField investigationFinal report
Date
November 23, 2012
Place
Tacna, AZ
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Other
Aircraft
N5076WPiper PA-28-160
Defining event
Other: Miscellaneous/other
Weather
Visual (VMC) · Day
Status
Completed · report January 27, 2015
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Lycoming, Federal Aviation Administration, Piper Aircraft Inc.
FAA report
20121123026489A
Case key
85683

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

On this page

Probable cause

The pilot’s failure to maintain airplane control. Contributing to the accident was the pilot’s impairment due to acute psychosis with paranoid thoughts.

Findings · 3

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotPiper PA-28: 5 casesAll aircraft: 9,295 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA-28: 1 caseAll aircraft: 1,269 casesProbable cause
Mental/emotional statePersonnel issues › Psychological · PilotPiper PA-28: 1 caseAll aircraft: 21 casesProbable cause

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

Without clearance or communication with air traffic control, the pilot took off in the airplane from a taxiway and departed the airport area westbound. Five days later, the airplane wreckage was found 160 miles west of the departure airport. Postaccident examination of the wreckage determined that the airplane impacted the ground in a near vertical attitude. Further examination of the airplane and engine revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. The pilot had been treated in the past for depression, a seizure disorder, an opiate addiction, and she used lamotrigine to treat migraine headaches. Toxicology results detected a sedating antihistamine, diphenhydramine, lamotrigine, and tetrahydrocannabinol in the pilot, however, their effects on her performance at the time of the accident could not be determined. The pilot's husband reported that his wife had been displaying abnormal behavior about 3 to 4 weeks before the accident. In a phone conversation with her husband the night before the accident, the pilot expressed concern about men in black helicopters watching her, and, in a message left on his voicemail the day of the accident, her husband stated that she seemed to be "acting paranoid," stating she was going to take the airplane flying to get away from "them." The source of the pilot's psychosis could not be determined during the investigation. The pilot's acute psychosis with paranoid thoughts likely impaired her decision-making and judgment and contributed to the accident.

Factual narrative

The airplane was a Piper PA28-160, serial number 28-85. No maintenance or logbook records for the airplane were located. The engine was a Lycoming O-320-B2B, serial number L-4358-39. No maintenance or logbook records for the engine were located. Fueling records at Tucson International Airport established that the airplane was last fueled on November 23, 2012, with the addition of 15.0 gallons of 100LL-octane aviation fuel. On November 23, 2012, at an undetermined time, a Piper PA28-160, N5076W, impacted desert terrain 30 miles south of Tacna, Arizona. The owner/pilot was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The private pilot was fatally injured; the airplane sustained substantial damage. The personal flight departed Tucson International Airport (TUS), Tucson, Arizona, at 0957, with an unknown destination. Visual meteorological conditions prevailed, and no flight plan had been filed. On November 28, 2012, a US Customs and Border Patrol agent came across the aircraft accident site of a PA-28-160, N5076W. The accident site, located at 32 20 17.7N/-113 39 48.96W, was 28 miles south of highway 8, located inside the restricted area R-2301W and approximately 160 miles west of TUS. The pilot's husband reported that he had received a voicemail from her. He stated that she appeared to be "acting paranoid," stating she was going to take the airplane flying to get away from "them." Fueling records at Atlantic Aviation-Tucson established that the airplane was last fueled on November 23, 2012, with the addition of 15.1 gallons of 100LL-octane aviation fuel. At the pilot's request, the service technician also added air to the nose wheel tire. Afterwards he watched as the pilot taxied out, took off using taxiway "D," and flew southbound. According to FAA Mandatory Occurrence Report (MOR) TUS-M-2012/11/23-001, an unidentified Piper PA-28 aircraft departed the Tucson International Airport (TUS), Tucson, Arizona, from taxiway D at 0957/1757 coordinated universal time (UTC). The pilot did not communicate with air traffic control prior to, during, or after departure. The pilot departed to the south and turned right toward Victor Airway 66/106. The air traffic facility filed the MOR. According to the TUS air traffic control tower daily record of facility operation, FAA form 7230-4, dated November 23, 2012, the air traffic manager was notified of the event at 1006, and the domestic events network (DEN) 1 was notified at 1010. Postmortem examination of the pilot was conducted by the Yuma County Medical Examiner's Office on December 3, 2012. The Yuma County Arizona Medical Examiner determined the cause of death was multiple blunt force injuries and the manner of death was undetermined. The autopsy was limited due to the extent of injury and decomposition; no underlying natural disease was identified. Toxicology testing was performed by the FAA's Civil Aerospace Medical Institute, but no blood was available foranalysis. Testing detected ethanol in the liver (10 mg/hg) but did not detect ethanol in the muscle. The report stated, "The ethanol found in this case is from sources other than ingestion." Diphenhydramine and lamotrigine was detected in liver and muscle. Tetrahydrocannabinol was detected in the lung (0.0165 ug/g), and its metabolite, tetrahydrocannabinol carboxylic acid, was detected in the liver (0.026 ug/g), kidney (0.0142 ug/g) and lung (0.0034 ug/g). Diphenhydramine is a sedating antihistamine used to treat allergy symptoms and as a sleep aid. It is available over the counter under various trade names including Benadryl and Sominex. 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)." Lamotrigine is a prescription anticonvulsant used to treat epilepsy and bipolar disorder; it may also be used to reduce migraine attacks. Common side effects include loss of balance or coordination, drowsiness and double vision. A rare side effect of lamotrigine is psychosis. Tetrahydrocannabinol is the psychoactive compound found in marijuana. Effects of tetrahydrocannabinol range from euphoria, relaxed inhibitions, sense of well-being to disorientation, image distortion, and psychosis. Additional medical records information, as well as a copy the CAMI toxicology report, is included in the public docket. A review of Federal Aviation Administration (FAA) airman records revealed that the 49-year-old pilot held a private pilot certificate with ratings for airplane single-engine land. No personal flight records were located for the pilot. The pilot last obtained a third-class medical certificate on April 25, 2001. It listed no limitations or waivers. At the time of the issuance of the medical certificate, the pilot reported a total flight time of 250 hours with 45 hours logged in the previous 6 months. The pilot's husband reported that the pilot had been treated in the past for depression, a seizure disorder with no seizure in 3 to 4 years, and an opiate addiction. She used lamotrigine to treat her migraine headaches. He reported that his wife began acting strange about 3 to 4 weeks prior to the accident and made mention of seeing the face of god. In phone conversations with her husband the night prior to the accident, the pilot expressed concern about men in black helicopters watching her. According to the husband, on the day of the accident the pilot left a voice mail on his phone. He said that she appeared to be "acting paranoid," stating she was going to take the airplane flying to get away from "them." Examination of the recovered airframe and engine was conducted on November 30, 2012, at the facilities of Air Transport in Phoenix, Arizona. A report of the examination is attached to the accident docket. During the examination of the recovered airframe and engine, no evidence of pre-impact mechanical malfunction was noted that would haveprecluded normal operation. The leading edge of both wings displayed front impact compression damage consistent with a high velocity impact at about 75-80 degrees from horizontal. The compression damage was consistent and symmetrical with both wings. The fuel tanks displayed no significant hydraulic deformation. The fuel caps were in place and secure. Flight control continuity was established. The pitch trim drum showed an inner shaft upper extension of approximately 12 threads. This is consistent with a setting of about 75% nose up trim. The fuselage displayed substantial frontal impact damage consistent with an impact of approximately 75-80 degrees from horizontal. The engine and propeller assembly had been pushed aft, even with the leading edge of the wing. The tachometer displayed no case deformation, but the glass was missing. The register showed 3,625.60 hours, and the needle was at 750 rpms. The propeller was secure to the engine. Both blades displayed aft bending, one blade about 30 degrees and the other about 45 degrees. Both blades displayed face polishing, and the paint was worn off. Damage to the blades was consistent with little or no power at the time of impact. An Air Traffic Control Specialist with the National Transportation Safety Board submitted a factual report, which is attached to the public docket. Review of the ATC radar data from Tucson air traffic control and radar data from en-route radars in the area did not provide radar returns coincidental to the suspected flight path of N5076W. AMOC reviewed radar data from an aerostat sensor and provided a partial radar track that could have been that of N5076W. AMOC reviewed primary radar data that appeared to stop abruptly at the location of the crash site and evaluated radar returns that led up to the crash site. AMOC detection enforcement officers utilized their best judgment to assess the most probable correlation of the observed radar data to the accident aircraft, however, they make no assertion that the visual radar plot is all or part of the accident aircraft flight path. The accident site was located 28 miles south of highway 8, about 650 feet west of Papago Road, and located inside the restricted area R-2301W. Investigators responded to the accident site and documented the wreckage. Investigators examined the wreckage at the accident scene. The first identified point of contact (FIPC) was a ground scar. The debris path was along a magnetic heading of 140 degrees. The orientation of the fuselage was inverted facing 320 degrees. The wreckage was located approximately 30 miles south of Tacna, 650 feet west of Papago Road, in flat desert terrain. The terrain elevation was measured using a GPS receiver and recorded as 851 feet mean sea level (msl). The terrain was sparsely populated with desert scrub bushes. The airplane was orientated from tail to nose, on a bearing of 140 degrees magnetic. The wings were attached to the fuselage and in their generally normal positionrelative to the fuselage.

Aircraft

Registration
N5076W
Reported as
Piper PA-28-160
Category
Airplane
Serial number
28-85
Engine
Lycoming O-320-B2B, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Departed
TUS · Tucson, AZ

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
49
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
250 total

Weather

Conditions
Visual (VMC) · Day
Wind
30° at 13 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 28 °F
Altimeter
30.14 inHg
Observed at
NYL, 59 nm away

Docket · 12

The files NTSB released with the investigation on January 13, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.2 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.