NTSB Factual Report

HISTORY OF FLIGHT

On July 21, 2003, about 0739 central daylight time, a Piper PA-28-235, N33774, was destroyed on impact with terrain at Jackson Municipal Airport (MJQ), Jackson, Minnesota. The private pilot was fatally injured. The 14 CFR Part 91 flight was operating in visual meteorological conditions without a flight plan. The flight originated from MJQ, at an unknown time.

A witness reported seeing the airplane over the airport at an altitude of 600-800 feet above ground level. This witness reported the airplane was flying "normal" on a east-southeasterly heading and "all of a sudden it turned to the left and straight down to the ground." Two other witnesses, who were about one mile away from the airport, reported seeing the airplane heading straight down toward the ground.

PERSONNEL INFORMATION

The pilot held a private pilot certificate for airplane single-engine land and instrument airplane operations. The pilot was issued a third class airman medical certificate on April 9, 2003, with "Must wear corrective lenses" printed in the limitations section.

According to the pilot's personal flight logbook, he had accumulated a total flight time of 657.6 hours as of his last entry, dated June 26, 2003, of which 442.5 hours were in the accident airplane. This last entry in the pilot's logbook was the satisfactory completion of a biennial flight review.

AIRCRAFT INFORAMTION

The accident airplane, serial number 28-7510061, was registered to the pilot and three other individuals in March of 1993. The Piper PA-28-235 is a production built, single engine, low wing airplane. The accident airplane was powered by a Lycoming O-540 series engine rated at 235 horsepower.

According to Federal Aviation Administration (FAA) records, the airplane was issued a Standard Airworthiness Certificate on August 15, 1975. The airplane received an annual inspection dated March 10, 2003. According to the airplane's maintenance records it accumulated approximately 3,156.4 hours as of the inspection date.

METEORLOGICAL INFORMATION

The recorded weather at MJQ reported the weather at 1236 as:

Wind: 320 degrees at 9 knots

Visibility: 10 statute miles

Ceiling: Clear

Temperature: 15 degrees Celsius

Dew Point: 14 degrees Celsius

Altimeter: 29.90 inches of mercury

WRECKAGE AND IMPACT INFORMATION

The airplane was resting on a magnetic heading of 283 degrees, approximately 150 feet prior to the approach end of the sod runway 22. The airplane was slightly right of the extended centerline of the runway. Fuel blight of the grass was visible in front of the airplane. The blight area extended for a distance of 78 feet in front of the wreckage. There was a smell of fuel in the area.

The fuselage was resting with its longitudinal axis perpendicular to the surrounding terrain. The entire nose section of the airplane was buried approximately three feet below ground level, and the leading edges of the wings were resting on the ground. The fuselage was bent just aft of the rear seats with only the lower skin attaching the cockpit to the empennage. The empennage was bent forward and to the right, with a lower section of the vertical stabilizer touching the top of the cabin. The horizontal stabilator and rudder had minimal damage.

The cockpit was destroyed. The accessory case of the engine was visible, as was about three inches of one propeller blade. The top of the fuselage was completely opened. The mixture, propeller, and throttle controls were forward.

The entire length of the right wing was crushed reward. The leading edge of the right wing from the tip to the first splice in the skin, was crushed rearward into the main spar. The leading edge of the inboard section of the right wing was crushed. The portion of wing skin that was over the fuel tank was split open and pushed outward, exposing the fuel tank. The fuel cap was in place. A ground impact scar was visible for the entire length of the wing. The wing tip was crushed and separated from the airplane. An 8-inch deep ground scar was visible under the wing tip area. This scar contained pieces of green glass. The right wing aileron bellcrank was torn away from its mounting structure inside the wing. The aileron cables were still attached to the bellcrank assembly.

The damage to the left wing was similar to that of the right wing. The entire length of the left wing was crushed accordion style. The outboard leading edge section of the wing was crushed rearward into the main spar. A ground impact scar was visible for the entire length of the wing. The wing tip was crushed and separated from the airplane. A 7-inch deep ground scar was visible under the wing tip area. This scar contained pieces of red glass. The left aileron bellcrank was partially torn away from its mounting structure inside the wing. The aileron cables were still attached to the bellcrank assembly.

Both main landing gears were attached to the airplane. Impact marks approximately 3 inches deep were visible under both gears. The nose gear had separated from the airplane.

The right side of the fuselage was split open to the empennage. The continuity of the stabilator and rudder control cables was established from the flight control surfaces to the cockpit controls.

MEDICAL AND PATHOLOGICAL INFORMATION

The National Transportation Safety Board (NTSB) issued subpoenas for the pilot's medical records from two medical facilities and his psychiatrist. The NTSB Medical Officer extracted the following information from those records.

The pilot had a history of depression. The pilot had two psychiatric hospitalizations in the past first in 1991 then again in 1995. He was placed on Prozac [fluoxetine] in 1993. The pilot had stopped taking the Prozac approximately five months prior to the accident. Two weeks before the accident, the pilot began taking Prozac again. The pilot reported he was experiencing a progressive decline in mood, increased irritability, obsessive tendencies, worries, anorexia, and he had been under a significant amount of stress for various reasons. On July 14, 2003, the pilot's psychiatrist changed his medication to Lexapro [escitalopram]. On July 18, 2003, the pilot took 8 Ambien 10 mg pills with suicidal intentions. The pilot stated he wanted to get the courage to kill himself. He was admitted to a medical facility on that same day. The following day the pilot was transferred to an acute psychiatric inpatient facility.

According to the pilot's son, there were no beds available at the psychiatric facility, so his father was taken to another regional medical center.

Records from the center where the pilot was admitted on July 19, 2003, state in part, "Chief Complaint: Suicide attempt. ...no prior suicide attempts...it does not appear to be appropriate to initiate a 72 hour hold at this time since the patient appears to be cooperating with treatment and does not have any active suicidal thoughts at this time...his risk of suicide at this time would certainly be considered high and it is my recommendation that he consider staying a few more days so that at least his sleep stabilizes. ...Should he decide to leave today, I will proceed with discharge...and he will see [his psychiatrist] tomorrow..."

The pilot's son stated his father was released from the regional medical facility on Sunday afternoon, July 20, 2003, and that he had an appointment to see his doctor the following morning. At 0600 on the day of the accident, the pilot told his wife that he as going to go help with the chores at the hog farm. The family became concerned when they found out the pilot failed to arrive at the hog farm. They were in the process of looking for him when they were informed of the accident.

An autopsy was performed on the pilot at the LCM Pathologists, P.C., in Sioux Falls, South Dakota, on July 22, 2003.

A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aeromedical Institute (CAMI), Oklahoma City, Oklahoma.

The toxicology results for the pilot were:

* 23 (mg/dL, mg/hg) Ethanol detected in Brain

* 14 (mg/dL, mg/hg) Ethanol detected in Muscle

* 10 (mg/dL, mg/hg) Isopropanol detected in Brain

* 1 (mg/dL, mg/hg) 2-Butanol detected in Brain

The CAMI report indicates that putrefaction had occurred.

The toxicology report also detected traces of the following drugs in the kidney and/or liver of the pilot:

* Diphenhydramine

* Citalopram

* N-Desmethylcitalopram

* DI-N-Desmethylcitalopram

* Flouxetine

* Norfluoxetine

With the exception of diphenhydramine, all of the substances would be expected from the pilot's recent documented use of the antidepressants. Diphenhydramine (commonly known as Benadryl) can have measurable effects on performance of complex cognitive and motor tasks.

On his 1999, 2001, and 2003 FAA Medical Certificate applications, the pilot did not report that he was taking any medications. Also, the pilot reported that he has never had any type of mental disorder, such as depression.

ADDITIONAL INFORMATION

The FAA, The New Piper Aircraft Company, and Textron Lycoming were parties to the investigation.

NTSB Probable Cause

The pilot's intentional flight into terrain as an act of suicide.