NTSB Factual Report

HISTORY OF FLIGHT

On July 30, 2001, about 1435 Alaska daylight time, a wheel-equipped Piper PA-32-300 airplane, N39586, was destroyed when it impacted mountainous terrain about 5,500 feet msl, adjacent to the Davidson Glacier, approximately 13 miles southwest of Haines, Alaska. The airplane was being operated as a visual flight rules (VFR) on-demand air tour flight under Title 14, CFR Part 135, when the accident occurred. The airplane was owned and operated by LAB Flying Service, Inc., of Haines. The certificated commercial pilot and the five passengers were fatally injured. Instrument meteorological conditions were reported in the area at the time of the accident, and a company VFR flight plan was in effect. The flight departed Skagway, Alaska, about 1400, and was en route to Glacier Bay National Park via the Davidson Glacier.

During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on July 30, the chief pilot for the operator reported that the accident airplane departed Skagway as the first of two airplanes conducting air tour flights over the Glacier Bay National Park. He added that the standard route of flight, after departing Skagway, would be to proceed southbound along the Taiya Inlet, cross the Chilkat Inlet, climb over the Davidson Glacier, and descend into the Glacier Bay area. He added that when the first of the two airplanes failed to return to Skagway, an aerial search was initiated.

During an interview with the NTSB IIC on August 1, the pilot of the second tour airplane stated that as both airplanes climbed up the Davidson Glacier, it was apparent that low clouds, rain, and fog within the pass would not allow them to fly through the pass. He said that he and the other pilot discussed optional flight routes. The accident pilot said that he was going to take a heading of 240 degrees, and fly through to the other side. The pilot of the second airplane said he replied to the accident pilot that he thought that this was a real bad idea, and that he was not going to follow him. The second pilot stated that the accident pilot's final radio transmission was, in part: "...I'm sure that it's clear on the other side. I'll see you on the other side." No further radio communications were received from the accident airplane. The pilot of the second company airplane took an alternate route, completed his tour, and returned to Skagway.

CREW INFORMATION

The pilot held a commercial pilot certificate with an airplane single-engine land rating. The most recent first-class medical certificate was issued to the pilot on September 21, 2000, and contained no limitations.

According to the operator, at the time of the accident, the pilot's total aeronautical experience consisted of about 1,788 hours, of which about 1,031 hours were accrued in the accident airplane make and model. In the preceding 90 and 30 days prior to the accident, the operator listed a total of 323.7 and 88.9 hours respectively.

The operator initially hired the pilot on March 9, 2000. At that time, the pilot reported he had accrued 694.4 hours of total aeronautical experience. His pilot-in-command experience consisted of 655.4 hours in single-engine airplanes, 123 hours at night, 56.8 hours of actual instrument flight, and 65.8 hours of simulated instrument flight.

Due to the seasonal nature of the company's business, the accident pilot's employment was terminated on September 28, 2000. He returned to work on February 15, 2001.

The accident pilot's most recent CFR Part 135 check ride, including an instrument proficiency check, was conducted on April 23, in the same make and model as the accident airplane. The company's chief pilot administered the check ride.

AIRCRAFT INFORMATION

The airplane had accumulated a total time in service of 7,760.0 hours. The airplane is maintained on an Approved Airworthiness Inspection Program (AAIP). The most recent inspection was accomplished on July 18, 2001, 42.0 hours before the accident.

The engine had accrued a total time in service of 4,121.0 hours. The operator reported that a major overhaul was accomplished 954.4 hours before the accident.

METEOROLOGICAL INFORMATION

The closest official weather observation station is Haines, Alaska, which is located about 13 nautical miles northeast of the accident site. On July 30, at 1354, an Aviation Routine Weather Report (METAR) was reporting in part: Wind, 100 degrees at 10 knots; visibility, 10 statute miles; clouds, 6,000 feet overcast; temperature, 60 degrees F; dew point, 51 degrees F; altimeter, 29.97 inHg.

COMMUNICATIONS

At 1411, the pilot contacted the Juneau Automated Flight Service Station (AFSS), and reported that he had departed Skagway, and then filed a VFR flight plan. The Juneau AFSS specialist reported to the accident pilot, in part: "LAB five eighty six roger, airmets for mountains obscured and moderate turbulence below five thousand, your ah flight plan is active."

WRECKAGE AND IMPACT INFORMATION

Continuous poor weather conditions prevented the NTSB IIC, along with members from the Juneau Mountain Rescue Team, Alaska State Troopers, and Federal Aviation Administration representatives, from reaching the accident site until August 1. The accident site was located in an area of steep, mountainous, glacial terrain. The main wreckage came to rest about the 4,700 feet msl level, on an area of about 40 degree downsloping, snow-covered terrain.

The area of the mountain that appeared to be the first point of impact was a vertical rock wall. After initial impact, the airplane wreckage fell onto an area of rock-covered terrain, then continued to slide downslope on snow-covered terrain, and finally came to rest about 800 feet below the initial impact point. A postimpact fire burned the fuselage center section of the wreckage.

During the IIC's on-site investigation, portions of airplane wreckage debris, including the accident airplane's propeller assembly, broken Plexiglas, passenger seats, and two of the airplane's occupants, were located about 75 feet below the initial impact point, in an area of large boulders.

The propeller bolts attaching the propeller to the engine crankshaft remained attached to the crankshaft flange, but the propeller hub-mounting surface was fractured. Both propeller blades were loose in the propeller hub, but remained attached to the propeller hub assembly. Both of the propeller blades displayed multiple leading edge gouges, substantial torsional "S" twisting, and chordwise scratching.

Scattered downslope, in a line between the initial impact point, and the final resting point of the main wreckage, were small portions of airplane wreckage debris, including engine cowlings, paint chips, broken Plexiglas, and passenger personal effects.

The engine assembly was torn free from the engine firewall, and located about 25 feet upslope from the main wreckage site. The engine sustained substantial impact and fire damage to the front and underside portion. Both exhaust tubes were crushed upward against each of the cylinders. The crushed and folded edges of the exhaust tubes did not exhibit any cracking or bending.

The wings remained attached to the fuselage, but were extensively distorted, and fire damaged. The flight control surfaces remained connected to their respective attach points. Due to impact and postaccident fire damage, continuity of the flight control cables could not be established.

The instrument panel sustained extensive impact and fire damage. The airplane's directional gyro and airspeed indicator were the only two surviving panel mounted instruments that were not destroyed by impact and fire related damage.

The airspeed indicator was retained by the NTSB's IIC for laboratory examination.

The airplane's directional gyro sustained extensive impact damage to the outer case, and faceplate. This damage in turn, wedged and jammed the rotating compass card. During the IIC's on-site investigation, upon examination of the directional gyro revealed that the compass card read 245 degrees, about the same as the pilot's last reported heading.

MEDICAL AND PATHOLOGICAL INFORMATION

A postmortem examination of the pilot was conducted under the authority of the Alaska State Medical Examiner, 4500 South Boniface Parkway, Anchorage, Alaska, on August 3. The cause of death for the pilot was attributed to multiple blunt force injuries.

The FAA's Civil Aeromedical Institute (CAMI) conducted a toxicological examination on November 27, 2001.

The toxicological examination revealed that 0.049 ug/ml of codeine, in conjunction with 1.658 ug/ml of morphine, was detected in the pilot's urine. Morphine is an inactive metabolite of codeine. No codeine or morphine was detected in the pilot's blood. Codeine is a narcotic painkiller, used for control of moderate to severe pain. Codeine is found in various prescription painkillers, as well as in some over-the-counter cough suppressants.

Additionally, the toxicological examination revealed that 0.355 ug/ml of paroxetine was detected in the pilot's blood, and unspecified levels of paroxetine were detected in liver tissue and urine samples. Paroxetine (trade name Paxil) is a prescription antidepressant medication commonly prescribed to patients suffering from social anxiety disorders, and panic attacks.

During a telephone conversation with the National Transportation Safety Board investigator-in-charge on January 3, 2002, the pilot's personal physician reported that he had prescribed the accident pilot's prescription for Paxil, but had not prescribed any medication that contained codeine. The physician added that he first started treating the accident pilot on May 9, 2001, after the pilot complained of ongoing chest and throat tightness. According to his physician, the pilot explained to him that he had a longstanding history of anxiety that was previously treated with other anxiety medication. The pilot told the physician that he had to discontinue use of the medication since he was a pilot.

The NTSB medical officer reviewed the medical records obtained from the accident pilot's physician, and extracted, in part, the following information.

May 9, 2001, the physician wrote in the pilot's medical records, in part: "26-year-old male comes in today for "years" of ongoing chest and throat tightness. ... He says it often comes on when there is bad weather and he has to fly, or when he has to give his briefing talk to several people." The medical records note that the pilot was scheduled for an Upper GI Series, to be conducted within the next two weeks. Additionally, the physician prescribed 10 mg of Paxil to be taken once per day, and provided the pilot with a one-month supply of Paxil sample packages.

On May 23, the accident pilot underwent an Upper GI Series examination. According the physician's notes, the examinations findings were, in part: "There is moderate large distal sliding hiatal hernia with minor gastroesophageal reflux." Additionally, the physician writes: "...He [the pilot] also says he feels slightly better on Paxil 10 mg, so tomorrow he is starting 20 mg per day. He says he'll phone when he needs more meds."

On June 19, the accident pilot visited the physician for a follow-up appointment. The physician's notes state: "... comes in with progress report on his Paxil trial... He notices that he has less anxiety while flying his plane and less subjective shortness of breath while speaking to people in the airplane. It was getting to be enough of a bother that he was real unhappy with his job. Now he says that's being reversed. ...He complained of a little grogginess upon waking in the morning, but feels that it clears rapidly and is not present at the time of his going to work. ... will increase the Paxil from 20 mg to 30 mg a day. Told him again to expect a subtle increase in his early morning grogginess. He understands that he's not to work if he feels that this is impairing him at all. I also was clear that his records would have to be surrendered if an employer requested them. He agrees and understands. He'll increase to 30 mg for next three weeks and see if he feels in optimal control of anxiety. If not, he'll increase to 40 mg and notify me - samples given today for about 6 weeks."

On July 25, five days before the accident, the pilot's physician made the following entry in the pilot's medical records: "By the way - Request for refill of samples today. Feels 30 mg is good dose of Paxil..."

The FAA's 1999 Guide for Aviation Medical Examiners states, in part: "The use of a psychotropic drug is considered disqualifying. This includes all sedatives, tranquilizers, antipsychotic drugs, antidepressant drugs , analeptics, anxiolytics, and hallucinogens." The drug Paroxetine (Paxil) is considered a mood-ameliorating drug and requires a review by the FAA's medical certification division before being used by pilots. The prescribing physician was not an FAA certified medical examiner.

SEARCH AND RESCUE

After being notified of an emergency locator transmitter (ELT) signal, search and rescue personnel from the U.S. Coast Guard Air Station Sitka, the Civil Air Patrol, along with other LAB Flying Service aircraft in the area, began a search for the missing airplane. The search was initiated about 1600. The Coast Guard helicopter was unable to search the upper levels of the mountainous areas due to low ceilings and poor visibility. The airplane wreckage was ultimately located about 1859, on an area of steep, snow-covered terrain.

TESTS AND RESEARCH

The accident airplane's airspeed indicator was retained by the investigator-in-charge, and sent to the National Transportation Safety Board's material laboratory for an incandescent and ultraviolet light examination. A senior Safety Board metallurgist reported that the instrument faceplate contained no evidence of an impression mark from the airspeed needle indicator.

WRECKAGE RELEASE

The Safety Board released the wreckage, located at the accident site, to the owner's insurance representative on August 2, 2001. The Safety Board retained the airspeed indicator until November 13, 2001, when it was released to the operator's chief pilot.

NTSB Probable Cause

The pilot's continued flight into known adverse weather conditions, and his poor in-flight decision making. Factors associated with the accident were clouds and mountainous terrain. A finding is the pilot's use of FAA prohibited drugs.