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Aviation Accident

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NTSB Identification: WPR16FA178
14 CFR Part 91: General Aviation
Accident occurred Sunday, September 11, 2016 in Reno, NV
Probable Cause Approval Date: 02/26/2019
Aircraft: PIPER PA 28R-201T, registration: N821ET
Injuries: 3 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

The private pilot and two passengers were departing on a cross-country flight to transfer the rear-seat passenger to California, where a series of warrants had been issued for her arrest. A California-based bail bondsman was seated in the front right seat and the pilot was seated in the front left seat. The arrested passenger was restrained on the rear left seat by the lap belt.

Witnesses, surveillance camera footage, and recorded data from on board the airplane indicated that the airplane began its takeoff roll and climbed to about 200 ft above ground level (agl) before leveling off. One witness stated that the airplane immediately began to rock its wings, and the nose pitched up to a high angle and remained in that attitude as the airplane continued to fly over the runway. About 2/3 of the way down the runway, the airplane began to veer right of the runway centerline and entered a right, descending turn. The last recorded data showed the airplane in a 41° right bank with a 64° nose-down attitude. The airplane impacted a lamppost, vehicles, and the ground in a parking lot with the landing gear extended.

Postaccident examination did not reveal any anomalies with the airframe or engine that would have precluded normal operation. Sound spectrum analysis of the background noise recorded during the pilot's radio transmissions, along with examination of the propeller's internal and external witness signatures, revealed that the engine was likely producing takeoff power throughout the flight. The rear-seat passenger was found buckled in her seat after the accident; her legs were cuffed by leg-chains, and her hands were cuffed to her waist through a belly chain, thus, there was no evidence to suggest that the rear seat passenger interfered with the flight.

The pilot fueled the airplane almost to capacity before he definitively established the total weight of all occupants for the accident flight. Furthermore, he added more fuel than originally requested to avoid paying a facility fee to the fixed base operator (FBO). Further, the pilot's statements to FBO personnel indicated that he was concerned about the airplane being overweight. Although the pilot could have defueled the airplane in order to remain within weight and balance limitations, this would have been a time-consuming process, and it is likely that he felt pressured to proceed with the flight as planned in order to return the passenger to California that evening. Also, the time spent defueling would have resulted in the flight taking place in night conditions over mountainous, dark, uninhabited terrain.

The airplane was about 178 lbs over its maximum gross weight and loaded at or just beyond its aft center of gravity limit when it departed on the flight. Under such conditions, the airplane likely encountered longitudinal instability during takeoff and altitude and pitch oscillations. Strong gusty wind conditions and high density altitude (6,900 ft) further exasperated the situation and likely resulted in the pilot's difficulty controlling the airplane during the initial climb, which ultimately led to a loss of control.

The airplane was fitted with an aftermarket turbo intercooler system. Its manufacturer did not provide specific performance data, instead stating that the engine performance would have been "equal to or better than" standard equipment. It is possible that the pilot felt this system would have given the airplane increased performance capability.

Toxicology testing indicated the pilot had recently used 3 separate opioid drugs in addition to a sedating benzodiazepine (diazepam), and either meprobamate or its parent drug, carisoprodol. Although medical records indicated that the pilot had at one point been prescribed one opioid (oxycodone) and carisoprodol, the nearly simultaneous use of three separate opioids strongly suggests that he was misusing these substances. All of these medications are sedating and carry specific warnings against using them in combination. While the levels identified in cavity blood may be higher or lower than antemortem drug levels, the toxicology tests suggest that the pilot had 4 impairing substances in his blood at the time of the accident, and it is likely that his use of the combination of impairing medications contributed to his poor decision-making and willingness to attempt/proceed with the flight as planned.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
  • The pilot's decision to depart with the airplane loaded above its maximum gross weight and at or just beyond its aft center of gravity limitations, which resulted in a loss of control during the initial climb. Contributing to the accident was the pressure to complete the flight as planned, and the pilot's use of multiple impairing drugs, which degraded his decision-making.