# NTSB WPR14FA244: Grumman American Avn. AA 5B, N28718, Florence, OR, June 15, 2014 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 15, 2014, 09:45 local (16:45 UTC) - Place: Florence, OR - Coordinates: 43.976387, -124.106941 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.9764&lon=-124.1069&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report May 16, 2016 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 89439 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR14FA244 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89439/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89439 - Page: https://openairdocs.org/ntsb/WPR14FA244 ## Probable cause The noninstrument-rated pilot’s visual flight into instrument meteorological conditions, which resulted in his spatial disorientation and the subsequent loss of airplane control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Grumman American Avn. AA-5B, 2 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=3960105), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Grumman American Avn. AA-5B, 12 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=3960105), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Ceiling/visibility/precip: low ceiling](https://openairdocs.org/ntsb-findings/03035010): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Grumman American Avn. AA-5B, 2 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md?model=3960105), [All aircraft, 190 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md) - [Ceiling/visibility/precip: low visibility](https://openairdocs.org/ntsb-findings/03035015): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Grumman American Avn. AA-5B, 1 case](https://openairdocs.org/ntsb-findings/03035015/cases.md?model=3960105), [All aircraft, 175 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Grumman American Avn. AA-5B, 3 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=3960105), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/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 visual reference](https://openairdocs.org/ntsb-events/402); cases with it: [Grumman American Avn. AA-5B, 2 cases](https://openairdocs.org/ntsb-events/402/sequence.md?model=3960105), [All aircraft, 242 cases](https://openairdocs.org/ntsb-events/402/sequence.md) - [Maneuvering: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) (defining event); cases with it: [Grumman American Avn. AA-5B, 1 case](https://openairdocs.org/ntsb-events/401/sequence.md?model=3960105), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md) - [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Grumman American Avn. AA-5B, 8 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=3960105), [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: [Grumman American Avn. AA-5B, 10 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=3960105), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis A witness reported observing the noninstrument-rated private pilot departing the airport in marginal visual meteorological conditions; the pilot was conducting a personal flight. The witness further reported that, about 1 hour later, he could hear airplane engine noise approaching the airport but that he could not see the airplane due to low ceilings and visibility. The witness also noted that the weather conditions were quickly deteriorating. Another witness reported that, while he was walking along the beach, he heard airplane engine noise in the low clouds, which he estimated were about 100 ft above ground level (agl). This witness reported that a small airplane then emerged from the clouds above the river traveling westbound away from the airport and that the airplane then "pitched up and reentered the cloud[s]." Shortly after, he saw the airplane exit the low clouds about 400 yards offshore in a near-vertical attitude with the right wing low before it impacted the ocean. No radar data depicting the accident flight were available. A majority of the airplane was not located in the ocean; therefore, postaccident airframe and engine examinations could not be conducted. An automatic weather observation system located 2 1/2 miles from the accident site reported overcast clouds at 300 ft agl and visibility of 1 1/4 miles around the time of the accident. Witnesses estimated that the actual ceiling and visibility were lower near the accident site. In addition, a band of low stratiform-type clouds was present over the coast and the accident site. The low cloud ceiling and restricted visibility conditions would have been conducive to the development of spatial disorientation as the noninstrument-rated pilot maneuvered in the low-visibility conditions. The airplane's rapid descent from the clouds was consistent with the pilot's flight into instrument meteorological conditions and subsequent loss of airplane control due to spatial disorientation. Postaccident toxicology testing detected 6-ß-natrexol, the primary metabolite of naltrexone, in the pilot's blood and liver. Naltrexone alone is not known to be generally impairing, but early in treatment, its use can precipitate symptoms of withdrawal. Without more information about the underlying condition that led to the pilot's use of naltrexone, it could not be determined whether or not the condition contributed to the accident. ## Factual narrative The four-seat, low-wing, fixed-gear airplane, serial number AA5B-0772, was manufactured in 1978. It was powered by a Lycoming O-360-A4K 180-hp engine and equipped with a Sensenich model 76EM8S10-0-64 fixed-pitch propeller. Review of copies of maintenance logbook records revealed an annual inspection was completed on April 1, 2014, at a recorded tachometer reading of 1013.0 hours, airframe total time of 3062.4 hours, and 968.1 engine hours since major overhaul. The tachometer and the Hobbs hour-meter were not located at the accident site which precluded determining the current readings. On June 15, 2014, about 0945 Pacific daylight time, a Grumman American AA-5B, N28718, impacted the Pacific Ocean about 3 miles northwest of Florence Municipal Airport (6S2), Florence, Oregon. The private pilot and one passenger were fatally injured, and the airplane was destroyed. 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. Marginal visual meteorological conditions prevailed for the flight, and no flight plan was filed. The flight originated from 6S2 at about 0845. Witnesses reported that they observed the pilot depart the airport in marginal visual meteorological conditions. About one hour later a witness heard an airplane engine noise approaching the airport but could not see the airplane due to low ceilings and visibility, the witness also noted that the weather conditions were quickly deteriorating. Another witness reported that, while he was walking along the beach, he heard an airplane engine noise in the low clouds estimated to be 100 ft. above ground level (AGL). The witness reported that a small airplane then emerged from the clouds above the river traveling westbound away from the airport. The pilot then "pushed the throttle up, pitched up, and reentered the cloud[s]." Shortly after, he observed the airplane exit the low overcast about 400 yards offshore in a near vertical attitude with the right wing low before it impacted the ocean. There was no radar data available of the accident airplane or the departure airport. An autopsy was performed on the pilot on June 20, 2014 by the Oregon State Police Medical Examiner. The cause of death was reported as blunt force trauma. The pilot had reported no chronic medical conditions and no chronic medication use to the Federal Aviation Administration (FAA) or his personal physician. The autopsy identified moderate single vessel coronary artery disease without evidence of a pervious scar or muscle injury. Postaccident toxicology conducted by the FAA Civil Aerospace Medical Institute identified 6-ß-natrexol, the primarily metabolite of naltrexone, in the pilot's blood and liver. Naltrexone has only one use and it is an aid for people with alcohol or opioid abuse to maintain sobriety. Naltrexone alone is not known to be generally impairing, but early in treatment its use can precipitate symptoms of withdrawal. Despitemultiple attempts, the reason for the pilot's use of this drug was unable to be determined. A review of recorded data from the 6S2 automated weather observation station 2 ½ miles southeast of the accident site revealed that, at 0955, conditions were wind from 270 degrees at 5 knots, visibility of 1 ¼ mile, temperature and dew point temperature 13 degrees Celsius, and overcast clouds at 300 feet above ground level (agl). The Geostationary Operational Environmental Satellite 15 (GOES-15) infrared image at 0945 PDT (1645Z) depicted a band of low stratiform type clouds over the Oregon coast and the accident site with cloud tops near 13,500 feet. The pilot, age 69, held a private pilot certificate for airplane single-engine land issued December 19, 2008, and a third-class airman medical certificate issued July 29, 2013 with the limitation that he must wear corrective lenses. The pilot's logbook was not recovered for examination. On the application for his most recent medical certificate, he reported 660 total flight hours. The pilot was not instrument rated. The airplane was believed to have impacted the Pacific Ocean about ¼ mile from the shoreline. The main wreckage was not located; however, various components that washed up on shore were recovered. Some of the items recovered were the airplanes right wing flap, rudder, elevators, right landing gear wheel, pieces of airplane sheet metal, and various parts of the airplane's interior. The remainder of the airplane was not located. Due to the limited number of recovered airplane components, a postaccident airframe and engine examination was not completed. ## Aircraft - Registration: [N28718](https://openairdocs.org/deregistered/N28718-2018-04-19), registration cancelled 2018-04-19, S/N AA5B0772, built 1978 (OpenAirDocs) - Reported make and model: GRUMMAN AMERICAN AVN. CORP. AA 5B - Registry model: [Grumman American Avn. AA-5B](https://openairdocs.org/model/grumman-american-avn-aa-5b) (registry code 3960105) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: AA5B0772 - Year built: 1978 - Airframe hours: 3062.4 - Engines: LYCOMING IO360 SER 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Munger Richard S - Registered owner: Munger Richard S - Airworthiness certificate: Unknown - Last inspection: Annual, April 1, 2014 - Departed: 6S2, Florence, OR - Destination: 6S2, Florence, OR - Airport: 6S2, Florence Municipal Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; toxicology performed; flight hours: 660 total, 30 in the last 90 days ## Weather - Conditions: Instrument (IMC), Day - Wind: 270° at 5 knots - Visibility: 1 statute miles - Lowest ceiling: 300 ft overcast - Temperature: 55 °F, dew point 55 °F - Altimeter: 29.98 inHg - Observed at: 6S2, 3 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 20140615009429A](https://openairdocs.org/incident/20140615009429A), Jun 15, 2014: Grumman American Avn. Corp. AA-5B, Florence, OR, Destroyed, 2 fatal. The pilot in command of N28718 entered instrument meteriological conditions in his Grumman American AA-5B airplane. He subsequently lost control of the… ## Docket (7 files) The files NTSB released with the investigation on April 27, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89439. 2.0 MB in all. - NTSB Medical Factual Report (item 1, .PDF, 221 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439349&FileExtension=.PDF&FileName=NTSB%20Medical%20Factual%20Report-Master.PDF - Witness Statements (Courtesy of FAA) (item 2, .PDF, 501 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439350&FileExtension=.PDF&FileName=Witness%20Statements%20(Courtesy%20of%20FAA)-Master.PDF - Meteorological Report (item 3, .PDF, 489 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439351&FileExtension=.PDF&FileName=Meteorological%20Report-Master.PDF - Record of Email - Radar Information (item 4, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439352&FileExtension=.PDF&FileName=Record%20of%20Email%20-%20Radar%20Information-Master.PDF - Toxicological Report (item 5, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439353&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 6, .PDF, 146 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439354&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Photographs (item 7, .PDF, 3 photos, 570 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439355&FileExtension=.PDF&FileName=Photographs-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.