CHI08FA135
CHI08FA135

HISTORY OF FLIGHT

On May 12, 2008, about 1700 central daylight time, a Piper PA-28-140, N1813T, owned and piloted by a private pilot, sustained substantial damage when it impacted terrain south of runway 12 (3,635 feet by 75 feet, dry, asphalt) at the Stevens Point Municipal Airport (STE), near Stevens Point, Wisconsin. A post-impact fire occurred. The personal flight was operating under 14 CFR Part 91 and no flight plan was on file. Visual meteorological conditions prevailed at the time of the accident. The pilot and passenger were fatally injured. The flight was originating from STE at the time of the accident and was destined for the J. Douglas Bake Memorial Airport (OCQ), near Oconto, Wisconsin.

A refueling receipt showed that the airplane was serviced with 27.4 gallons of "auto" fuel at OCQ on May 12, 2008, prior to its departure to STE.

A witness at the fixed base operator (FBO) at STE recalled that the pilot and passenger checked the weather computer prior to their departure from STE. Another witness flying on downwind for runway 12 said that he heard a pilot announce on the common traffic advisory frequency a takeoff from runway 12. He heard no further transmissions as he turned base on approach to runway 12. He saw smoke off the departure end of runway 12 and advised the FBO of a possible airplane down. He flew over the area and observed the accident airplane. The airplane's center section was "engulfed in fire." The pilot radioed the FBO and confirmed that it was a "downed" airplane.

Review of a video record from a ramp camera at STE showed an airplane was departing runway 12 about 1659. About 1700, a plume of smoke is observed in the recording.


PERSONNEL INFORMATION

The 56 year old pilot held a Federal Aviation Administration (FAA) private pilot certificate with a single-engine land airplane rating. A review of a copy of the pilot's logbook indicated that his most recent flight review was completed on July 27, 2007. The last recorded entry was dated April 20, 2008, and the logbook showed that the pilot had accumulated 278.2 hours of total flight time.

The following medical information was extracted by the National Transportation Safety Board (NTSB) Medical Officer from records maintained on the pilot by the FAA Aerospace Medical Certification Division:

11/1/04 - An application for 3rd class Airman Medical Certificate
indicates "Yes" for "Do you currently use any medication" and
notes the use only of atorvastatin. The application notes "Yes" to
"Diabetes" and "No" to all other items under "Medical History."
Under "Comments on History and Findings" is noted, in part, "...
Recent diagnosis of Type II diabetes, recently started on Actos
[pioglitazone] and glyburide. Random sugar today 250 mg%. ..."
Total pilot time is noted as 67 hours with 2 hours in the previous 6
months. Also noted is "No Certificate Issued - Deferred for
Additional Evaluation."

11/3/04 - Personal physician's note indicates, in part, that the pilot
"...works as a truck driver and is also pursuing a pilot's license and
he saw [another doctor] for a DOT exam 2 days ago, who called me
indicating he was off his meds and his nonfasting glucose was 500. ...
he has been pulled off the road for now."

12/7/04 - A letter from the Manager of the Aerospace Medical
Certification Division notes, in part, "We have received FAA Form
8500-8, Application for Airman Medical Certification, dated
November 1, 2004. For further consideration regarding your diabetes
mellitus requiring oral hypoglycemic medication for control, please
submit ... A current status report from your treating physician
regarding your diabetes mellitus in accordance with the enclosed
specification sheet. Upon receipt of this information, we will notify
you regarding your eligibility for medical certification."

1/14/05 - A letter from the Manager of the Aerospace Medical
Certification Division notes, in part, "A careful review of your
application and physical examination performed on November 1,
2004, discloses that you do not meet the medical standards ... By
virtue of your failure to provide requested information as outlined
in our letter dated December 7, 2004 ... we have no alternative
except to deny your application for Aerospace Medical Certification."

1/9/06 - Personal physician's note indicates, in part, that the pilot "...
has a history of poor compliance. Note when last seen in June his
hemoglobin A1c was elevated and I increased his glyburide ... and
he was told to return for a recheck in 3 months which he did not do.
He states his Accu-Checks typically range 180 to 210. He states that
when he gets a low reading in the 120s his feet will sting or tingle. ...
He gets no regular exercise ... has apparently been unable to fly
because of his poorly diet controlled diabetes ...Have tried again to
emphasize the necessity of good diabetic control ... emphasized the
fact that his diabetes has never been well controlled. ..."

2/15/06 - An internal FAA electronic memo from the Manager of
the Aerospace Medical Certification Division (AMCD) notes, in part,
"I see that the airman's treating physician mentions history of poor
control but based on the hemoglobin A1c levels given to AMCD he
can be issued a time-limited certificate and a 6 year Authorization."

2/23/06 - An Authorization for Special Issuance of a Medical
Certification from the Manager of the Aerospace Medical Certification
Division notes, in part, "I have reviewed the information submitted
by you in support of your request for an airman medical certificate.
The medical information reveals a history of diabetes mellitus
requiring oral hypoglycemic medication. You are ineligible for
medical certification .... I have determined, however, that you may
be granted an Authorization for special issuance of a third-class
airman medical certificate ... Enclosed is your medical certificate
with the restriction 'Not valid for any class after November 30, 2006.'
You must promptly report any adverse changes in your medical
condition to the AMCD at the above address. ... Because of your
history of diabetes mellitus, operation of aircraft is prohibited at any
time new symptoms or adverse changes occur or if you experience
side-effects from, or require a change in medication."

3/19/07 - A letter from the pilot's personal physician notes, in part,
that the pilot "... was last seen by me on March 5, 2007. He continues
to take glyburide 5 mg tablets one twice a day, Actos 45 mg every
day, Byetta [exenatide] 10 micrograms twice a day. Reviewing his
Accu-Check readings the 14 and 28 day average is 129. He has had
no significant hypoglycemic episodes and has been instructed on how
to deal with these should they occur, always have some type of sugar
available. His hemoglobin A1c was 7.0 which is considerably
improved from his previous Hemoglobin A1c of 10.2 on December
4, 2006. There is no evidence of any cardiovascular, neurologic, renal,
or ophthalmologic complications. I note that his most recent diabetic
eye examination was on February 24, 2006 ... and there was no
background retinopathy noted at that time. ..."

3/30/07 - The pilot's most recent application for 3rd class Airman
Medical Certificate indicates "Yes" for "Do you currently use any
medication" and notes the use of pioglitazone, atorvastatin, exenatide,
and glyburide. The application notes "Yes" to "Diabetes,"
"Admission to hospital," and "Other illness, disability, or surgery."
Under "Comments on History and Findings" is noted, in part, "...
shoulder surgery ... good control of Type II diabetes ..." Height is
noted as 70 inches and weight as 223 pounds. Total pilot time is
noted as 231 hours with 17 hours in the previous 6 months.

5/11/07 - A letter to the pilot from the Manager of the Aerospace
Medical Certification Division notes, in part, "Our favorable review
of your interim follow-up reports regarding your history of diabetes
has established that you are eligible for continued Authorization for
Special Issuance of a third-class airman medical certificate ... The
certificate issued by your AME is "Not valid for any class after
March 31, 2008". ... Please be advised, you must demonstrate more
consistent glycemic control on future evaluations. Failure to do so
may jeopardize continued special issuance medical certification. ...
Because of your diabetes, operation of aircraft is prohibited at any
time new symptoms or adverse changes occur or if you experience
side effects, or require a change in medication, or for 2 hours after
use of the medication Byetta. ..."


AIRCRAFT INFORMATION

N1813T, a 1971 Piper PA-28-140, serial number 28-7125165, was a single-engine, low wing, four-place airplane, with fixed tricycle landing gear. The airplane was powered by a 150-horsepower Lycoming O-320-E2D engine, serial number L-21766-27A, which was a four-cylinder, normally aspirated, reciprocating engine. Its propeller was a fixed pitch, two-bladed, Sensenich 74DM6-0-58, with serial number K31196.

Review of the maintenance logbooks indicated the airplane's most recent annual inspection was completed on May 15, 2007. The entry for that inspection showed that the airplane had accumulated 3,185.35 hours of total time and that the engine had accumulated 1,061.35 hours since major overhaul.


METEOROLOGICAL INFORMATION

At 1655, the recorded weather at STE was: Wind 180 degrees at 7 knots; visibility 10 statute miles; sky condition clear; temperature 17 degrees C; dew point 0 degrees C; altimeter 29.91 inches of mercury.


AIRPORT INFORMATION

The airport elevation at STE was 1,110 feet above mean sea level. STE was an uncontrolled airport with two runways, 3/21 and 12/30. Runway 3/21 was 6,028 feet by 120 feet wide. Runway 12/30 was 3,635 feet by 75 feet wide. Both runways' surfaces were composed of asphalt. The airport listed a Unicom frequency of 122.7 megahertz as its common traffic advisory frequency.


WRECKAGE AND IMPACT INFORMATION

The airplane was found about 250 yards south of the departure end of runway 12. Its fuselage, empennage, and left wing came to rest upright on about a 15-degree magnetic heading. The right wing was detached from the fuselage and it was found inverted. An aileron control cable was found intact between the right wing and fuselage. The fuselage was melted, deformed, charred, and consumed consistent with a ground fire. The wings, cowling, and engine sustained fire damage consistent with a ground fire. A ground scar was found 60 feet from the center of the fuselage. Green glass like media was found in the area of that scar. A depression consistent with the frontal shape of the cowling was found 38 feet from the center of the fuselage. The magnetic heading from that scar and that depression to the center of the airplane's fuselage was 270 degrees magnetic.

Control cables were traced from the flight controls in the cockpit to their respective flight control surface. All breaks in the cables were consistent with overload. The engine control cables were traced from the cockpit to the engine. Engine control and flight control continuity was established. The flap handle position was found near the first notch of flaps. The flap handle was not engaged in that first notch. A cabin door hinge was found intact. The cabin door latch was found intact and extended in the locked position. The propeller remained attached to the engine's crankshaft propeller flange. One propeller blade was bent rearward and the other blade did not reveal any damage. The propeller flange was bent rearward on the same side that the propeller was. Removal of the propeller allowed the engine crankshaft to be rotated. The top sparkplugs were removed and they exhibited no anomalies. Each cylinder produced a thumb compression when the crankshaft was rotated. Valve rockers operated when the crankshaft was rotated. Disassembly of the carburetor and fuel pump revealed no anomalies. Both magnetos sustained fire damage and did not produce a spark when they were rotated. Examination of the muffler's baffles revealed that they were intact. The fuel selector valve allowed air pressure to flow through the fitting for the right fuel tank and the air was felt discharging from the valve's fitting to the engine. Air pressure was applied to the valves fitting for the left fuel tank and no air was felt at the fitting to the engine. No pre-impact airframe or engine anomalies were detected.


MEDICAL AND PATHOLOGICAL INFORMATION

The Office of Coroner, Portage County, Wisconsin, performed an autopsy on the pilot.

The FAA Civil Aerospace Medical Institute prepared a Final Forensic Toxicology Accident Report. The report stated:

PIOGLITAZONE detected in Blood
PIOGLITAZONE detected in Urine

The following medical information was extracted by the NTSB Medical Officer, from the report of autopsy:

Cause of death is noted as "Massive Blunt Force Chest Trauma."
Under "Gastrointestinal Tract" is noted, in part, "The stomach
contains approximately 100 cc of a partially digested food matrix
with tan-white fragments of unrecognizable food particles admixed
with a brown yellow-tan mucoid matrix."

An e-mail from the coroner notes, in part, that the pilot was "a type II
insulin dependent diabetic and in his medical records described as
being 'poor controlled.' Was last seen Dec. 07, 2007 and was started
on a long acting insulin (U-100)."

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