On July 21, 1995, approximately 1428 Pacific daylight time, a Piper PA-28-161, N83125, registered to Bobkat Aviation, Inc. of Boise, Idaho, received substantial damage in an inflight collision with terrain approximately 30 miles northeast of Lakeview, Oregon. The private pilot received minor injuries; his passenger was seriously injured. The 14 CFR 91 flight was on a visual flight rules (VFR) flight plan from Boise to Lakeview. Visual meteorological conditions prevailed in the accident area.

The pilot stated in his report of the accident:

My passenger...wanted to do some sightseeing...enroute to Lakeview...[The passenger] recognized...rangeland where he had herded cattle. There were no people or obstructions in the area so I told him we could descend lower if he wanted to. He agreed, so we descended to between 50 and 100 feet AGL [above ground level]....We then headed toward Hart [Mountain] at the same altitude. At some point I became concerned about flying into the Hart Mtn. National Wildlife Refuge. I asked [the passenger] to check the map and he said we were about to enter it. [At] that point I asked him to raise the map above the yokes so that I could see the ground and the map at the same time. I intended to scan back and forth between the ground and map while flying. I apparently fixated on the map while the aircraft nosed over and impacted the ground. I had tried to fly with slightly nose-up trim earlier, but it made maintaining our low altitude increasingly difficult. I believe that we descended because of neutral or slightly nose-down trim or an [inadvertent] downward pressure on the yokes while looking at the map.

The pilot indicated in his accident report that there was no mechanical malfunction or failure involved.

In a phone interview conducted on July 26, 1995, the passenger stated they were cruising at an altitude which he estimated at 100 to 200 feet above ground level when they flew over a water hole where they spotted a coyote. He stated that the pilot then maneuvered the airplane to look at the coyote. He stated that he and the pilot then began to look at their map, with the intention of overflying Hart Mountain, and started to discuss the altitude at which they should overfly the mountain (which was located in the National Wildlife Refuge.) The next thing the passenger remembered was the ground impact.

A team of investigators from the FAA, The New Piper Aircraft Corporation, and Textron Lycoming examined the aircraft wreckage at Independence, Oregon, on August 31, 1995. The team discovered no evidence of aircraft or engine malfunction, fuel exhaustion, or fire.

In a section of the pilot accident report which solicits operator recommendations as to how the accident could have been prevented, the pilot indicated: "don't look at the map while flying low."

Post-accident toxicology testing conducted at Lake District Hospital, Lakeview, Oregon, on the evening of the accident confirmed the presence of butalbital (323 ng/ml), codeine (1,260 ng/ml), and morphine (960 ng/ml) in the pilot's urine. The laboratory report indicated that the specimen was collected at 2230 on the day of the accident. In telephone inquiries by the investigator, emergency medical personnel who treated the aircraft occupants after the accident stated that they had not administered any medications to the pilot. According to the pilot's treatment records, the pilot stated to medical personnel that he had undergone a hair transplant operation one week before the accident. In a letter to the investigator dated November 27, 1995, a deputy regional flight surgeon for the FAA Northwestern Mountain Region stated the following concening these drugs:

Butalbital is a barbiturate. All barbiturates...[produce] some degree of depression of the central nervous system.

Codeine and morphine are both narcotic analgesics with similar adverse reactions. The most common adverse reactions are euphoria, drowsiness, mental confusion and respiratory depression.

Because of these adverse central nervous system effects, neither butalbital, codeine nor morphine should not [sic] be used individually or in combination by an airman on flight status.

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