Aviation Accident Summaries

Aviation Accident Summary WPR17FA052

Port Orford, OR, USA

Aircraft #1

N81839

PIPER PA 28-236

Analysis

The 79-year-old private pilot was making a local personal flight in his airplane when he reported over the aircraft emergency frequency that he was losing vision in one of his eyes. About the same time, a radar target using the emergency transponder squawk code was acquired traveling northbound along the coastline. The airplane wreckage was subsequently located on a beach close to the last radar target. The damage to the airplane was consistent with a high-speed, left wing-low impact due to a loss of control. According to the pilot's son, the pilot had been diagnosed with multiple chemical sensitivity and had a history of sudden vision loss, sometimes in just one eye but at other times in both eyes, which had been attributed to his chemical sensitivity. He had not reported the episodes of vision loss or the chemical sensitivity on any of his Federal Aviation Administration (FAA) medical applications. His most recent FAA medical certificate had expired 5 years before the accident, and it had been 5 years since he had accomplished a flight review. The pilot continued to fly, and his flight instructor, who had given the pilot his last flight review and flew with him 1 year before the accident, reported a significant degradation in the pilot's flying skills.

Factual Information

HISTORY OF FLIGHTOn January 13, 2017, about 1125 Pacific standard time, a Piper PA28-236 airplane, N81839, impacted a beach near Port Orford, Oregon. The private pilot was fatally injured, and the airplane sustained substantial damage. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91.Visual meteorological conditions prevailed, and no flight plan had been filed. The local personal flight departed Southwest Oregon Regional Airport (OTH), North Bend, Oregon, at 1016. The pilot's son stated that earlier in the week, his father had told him he planned to fly the airplane along the Oregon coast once the weather had cleared. On the morning of the accident, having received his takeoff clearance from the OTH air traffic control tower, the pilot indicated his intention to depart to the north and fly along the coast. At 1019, about 3 minutes after takeoff, he advised being clear of the airport's Class D airspace. At 1046, he reported to OTH tower that he was 10 miles north of the airport at 1,500 ft. He requested and was granted a transition southbound along the coastline to the west, and the tower controller requested that he report crossing the extended centerline of runway 4; the pilot reported his position at 1052. The tower controller acknowledged and requested that the pilot report when he had exited the airport's airspace to the south. The pilot responded affirmative; however, by 1103, the tower controller had not received an update. The controller requested a position report, and the pilot responded, "I'm having trouble with err headphones err, say again." The controller asked that the pilot verify he was clear of the airspace, but only a muffled response was received. About 10 minutes later, controllers at the Seattle Air Route Traffic Control Center (Seattle Center) received reports from the crews of both a Coast Guard helicopter and an Air Force airplane that the pilot was transmitting on the aircraft emergency frequency (121.5Mhz), indicating that he had lost vision in one eye. Due to terrain, radar data was limited; however, at 1122, a radar target using the emergency transponder squawk code of 7700 was acquired traveling northbound along the coastline, just west of Port Orford, about 44 miles southwest of OTH. The target was present for 24 seconds, during which time it descended from 1,300 to 1,225 ft mean sea level while traveling at a groundspeed of about 100 knots. An Alert Notice was subsequently issued, and at 1307, a Coast Guard helicopter crew located the airplane wreckage on a beach, 4 miles north of the last recorded radar target and 3.5 miles south of Cape Blanco State Airport (5S6). PERSONNEL INFORMATIONThe 79-year-old pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. His most recent third-class medical certificate was issued on September 10, 2009, with the limitation that he must have available glasses for near vision; this medical certificate expired on September 30, 2011. At the time of the medical examination, he reported a total flight experience of 1,300 hours. The pilot's most recent flight review took place on October 27, 2011. The flight instructor who performed the review stated that, during the flight review, the pilot showed good judgement and flying skills but was a little "rusty." The flight instructor reported that he last flew with the pilot about 1 year before the accident and that during that flight he noticed a considerable degradation in the pilot's performance. He stated that the pilot had difficulty with basic flying skills, appeared confused during radio communications, and was flying "well behind the airplane." Following the flight, when the flight instructor relayed his concern about the pilot's flying skills, the pilot told the flight instructor that he was aware of his shortcomings but felt confident he could get current with a little more flight instruction. The instructor shared an adjacent hangar to the pilot's hangar and had known him for about 15 years. He was surprised that the pilot had flown on the day of the accident, as he was not aware of him taking any more flying lessons and was not sure that the pilot had flown again since the year before. AIRCRAFT INFORMATIONThe airplane was manufactured in 1980 and purchased by the pilot in 1992. The most recent maintenance event was an annual inspection that was completed on March 20, 2016, at a total airframe time of 2,725.8 flight hours. During the period between October 2011 and March 2016, the airplane received four annual inspections and had accrued 11.5, 1.7, 4.2, and 13.7 hours of annual flight time, respectively, between the inspections. The airplane was maintained by the pilot's flight instructor, who also performed the annual inspections. He stated that to the best of his knowledge, the pilot was the only person who flew the airplane. AIRPORT INFORMATIONThe airplane was manufactured in 1980 and purchased by the pilot in 1992. The most recent maintenance event was an annual inspection that was completed on March 20, 2016, at a total airframe time of 2,725.8 flight hours. During the period between October 2011 and March 2016, the airplane received four annual inspections and had accrued 11.5, 1.7, 4.2, and 13.7 hours of annual flight time, respectively, between the inspections. The airplane was maintained by the pilot's flight instructor, who also performed the annual inspections. He stated that to the best of his knowledge, the pilot was the only person who flew the airplane. WRECKAGE AND IMPACT INFORMATIONDue to rising tides, the airplane was expeditiously removed from the accident site by a local automobile towing and recovery company. An FAA inspector performed a brief visual assessment of the airplane wreckage after it had been loaded onto the recovery trailer; however, the recovery company disposed of the airplane before the National Transportation Safety Board was able to perform a more thorough examination. Therefore, the following information was derived from photographs provided by the Oregon State Police. The airplane came to rest surrounded by water in the middle of the northern tip of a sandspit, about 50 ft from the ocean and 600 ft from the beach cliffs to the east (Photo 1). A debris field consisting of the nose landing gear and small composite fragments led from the ocean swash to the main wreckage. Beyond the wreckage, sand and cabin contents had been ejected about 50 ft east. Photo 1 – Location of Wreckage on the Sandspit The cabin was on a north heading and had sustained crush damage from the firewall through to the leading edge of the vertical stabilizer. The left wing had folded back parallel to the tailcone and was resting on top of the left horizontal stabilizer. The left wing had sustained leading edge crush damage through to the main spar along its entire length with the damage deeper and more pronounced at the tip. The right wing remained attached to the cabin and had sustained leading edge crush damage through to the main spar along its entire length (Photo 2). All flight control surfaces remained attached to their respective attach points. Photo 2 – Accident Site Facing North The engine remained partially attached to the firewall and was submerged in the sand. The three blades of the propeller remained attached to the hub, which had broken away from the crankshaft. MEDICAL AND PATHOLOGICAL INFORMATIONAccording to the pilot's son, the pilot had a longstanding diagnosis of "multiple chemical sensitivity." In addition, he had episodes of sudden vision loss, sometimes in just one eye but at other times in both eyes, which had been attributed to his chemical sensitivity. The most recent event had occurred while he was driving on a highway about 1 year before the accident. During that event, he lost all vision and was only able to exit the highway by feeling the vibration of the rumble strips. Regarding the chemical sensitivity, the pilot's son stated that his father was particularly sensitive to odors such as perfumes and soaps. This condition had been present for as long as he could remember but came to a head in 2007, when the pilot began to experience strong and rapid onset of flu-like symptoms and hives. When driving, he would always drive with the windows open, in a specific vehicle, because other vehicles could trigger his symptoms. He was able to fly without experiencing any symptoms and attributed this to the fresh air at altitude. His son had also noticed a recent deterioration of the pilot's hearing. He was regularly misinterpreting words the week before the accident, and his son recommended that he have his hearing checked. The flight instructor stated that the pilot was hesitant to discuss his medical condition but had stated a few years before the accident that he was not going to fly anymore because his medical certificate had expired. The flight instructor was not aware of issues with the pilot's eyesight, but about 5 to 6 years prior, he had seen the pilot's face go very red and become inflamed. The pilot told him that this was due to chemical sensitivities. According to the autopsy performed by the Curry County Medical Examiner, Curry County, Oregon, the pilot's cause of death was massive blunt trauma. Due to the severity of damage to the body, the eyes could not be examined. There were no obvious signs of natural disease in the brain, but the cerebral vessels were described as having "diffuse, moderate to focally severe atherosclerosis." The heart was described as having "concentric hypertrophy measuring approximately 2 cm in thickness. The right ventricle averages 0.8 cm in thickness." The coronary arteries showed areas of multivessel, moderate to severe calcific atherosclerosis approaching 70 to 80% narrowing. Toxicology testing performed by the FAA's Bioaeronautical Sciences Research Laboratory did not identify the presence of any screened drug substances or ingested alcohol. At the time of the pilot's last medical certificate application in 2009, he reported occasional heartburn and the use of over-the-counter medication to treat it. He did not disclose the chemical sensitivity diagnosis nor his vision problems on any of his FAA medical certificate applications.

Probable Cause and Findings

The pilot's loss of vision during cruise flight, which resulted in a loss of aircraft control. Contributing to the accident was the pilot's decision to fly with a known medical condition.

 

Source: NTSB Aviation Accident Database

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