Probable Cause #15: IFR & Meds -- A Deadly Mix

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This article originally appeared in IFR Refresher, March 2005.

Probable Cause

Though you may possess a valid medical certificate, as an FAA-licensed pilot you are expected to ground yourself whenever you do not meet the standards of that certificate. When a pilot has a bad cold or some other similar ailment, and especially if he or she is taking prescription or over-the-counter medication that may be on the FAA's "no-fly" list, flying around in instrument conditions is not the place to be.

It's a mixture of drugs and poor weather that the NTSB believes contributed to the fatal accident of a Piper PA-32R as the pilot was attempting to execute a missed approach at the Westchester County Airport (KHPN) in White Plains, N.Y.


Under The Weather

The fateful trip began on a June morning in 2001 when the pilot contacted the Millville, N.J., Automated Flight Service Station shortly after 7 a.m. for a briefing from Atlantic City's Bader Field to KHPN. The pilot was in a taxicab on his way to the airport and told the briefer that he planned to depart in 15 minutes. When he asked about the weather at KHPN, the briefer told him it was "zero-zero," adding, "I don't think you want to go right now."

The pilot then asked for the forecast, which called for variable winds at three knots, a half-mile visibility in fog and mist and a vertical visibility of 100 feet until 10 a.m. The forecast also called for temporary conditions of a quarter-mile visibility with fog and mist and a vertical visibility of 200 feet during that time. The rest of the day, the weather was forecasted to improve only marginally. The pilot also asked about the weather in the Albany, N.Y., area, stating he wanted to land at a small airport there although he didn't know the name of the facility. The briefer couldn't find the airport in his system but told the pilot that the Albany weather was VFR and was going to stay that way throughout the day.

At some point during the briefing, the pilot told the briefer that he had arrived at the airport and would call back. He did so about eight minutes later and received an updated forecast from a new briefer. This time, the pilot was told that the weather at KHPN was forecast to be two miles visibility with a 500-foot ceiling, a slight improvement to what he had been told earlier.

"OK. So, we can get in there all right," the pilot told the briefer, and filed an IFR plan to KHPN with Albany as his alternate.

The pilot departed Atlantic City at 7:51 a.m. The flight was uneventful until he contacted New York Approach at 8:38 a.m. The controller informed the pilot that the runway visual range (RVR) at White Plains was 800 feet. He also asked the pilot if he had the ATIS at White Plains. The pilot responded that he was in the process of receiving it.

The pilot asked the controller if any airplanes had landed at White Plains that morning. The controller replied that no one had tried the approach, although a corporate jet held for a while but then elected to go somewhere else.

At 8:42 a.m., the pilot said he'd like to try the ILS approach and that he would proceed to his alternate if he didn't get in. The controller told the pilot the RVR was now 1,400 feet. Four minutes later the controller told the pilot that the RVR was now 1,000 feet "touchdown and roll-out." The pilot acknowledged the information.

At 8:47 a.m. the Approach controller cleared the airplane for the ILS 16 at White Plains and told the pilot to switch over to the Tower controller. The pilot contacted the Tower two minutes later and was cleared to land.

At 8:54 a.m. the controller asked the pilot twice if he was going around. The pilot said, "Affirmative," and the controller told him to climb and maintain 2,000 feet and turn left to a heading of 090 degrees. At first, the pilot didn't respond, so the controller repeated the instructions. Again, the pilot failed to respond. When the controller asked him what his intentions were, the pilot replied, "I'm going 090, but 090 is to the right." The controller told the pilot to fly a 090 heading, omitting the direction of the turn, and cleared him to 2,000 feet.

What the tower controller didn't know was that when the pilot initiated the missed approach, he had turned left towards a northerly heading. With no radar in the tower, she logically assumed he was still facing south and therefore instructed him to turn left to 090. But that only added to the confusion that the pilot was now experencing, since to him, 090 was to the right.

Meanwhile, the Approach controller was watching the scenario unfold on his radar screen. Concerned about the plane's erratic path, he called up the Tower controller to ask her what was going on. She replied that she didn't "know what [the pilot] was doing" and that she thought that he was "a little confused."

At 8:55 a.m. the controller told the pilot to contact New York Approach on 126.4, to which the pilot replied: "Out of control. We're gone." The controller then tried to contact the airplane and after three attempts the pilot said, "Flight director is out of control." That was the last transmission from the Saratoga.

Impact

The aircraft crashed in wooded terrain in Greenwich, Conn., about one mile north of the airport. The pilot was killed in the crash. A witness, who lived directly across the street from the accident site, reported that he was in his home when he heard a low-flying airplane. He went outside to see if he could see the airplane but it was "very foggy." The witness said he heard the airplane circling overhead and that its engine sounded like it was operating normally. He then heard the airplane hit the ground.

The weather report at White Plains at the time of the accident showed that the wind was from 100 degrees at six knots, the visibility was zero in fog, and there was a vertical visibility of 100 feet. The temperature and dew point were both 64 degrees. The weather at Albany, located about 100 miles north of White Plains, was VFR.

Investigators found no defects in the airplane that might have caused the accident, nor were any anomalies found with the ILS 16 approach at White Plains.

The private pilot reported 5,865 total flight hours on his previous medical certificate application, which was dated one week before the accident occurred. His logbooks were not located so no other information regarding his currency to fly on instruments is known.

Erratic Track

An NTSB radar specialist reviewed the aircraft's flight path. It appeared that the aircraft had drifted to the right of the localizer at about 1.4 miles from the runway threshold. It then started to correct to the left and was almost on the localizer course when it began to drift to the right again. Then it turned left and flew across the localizer at about 0.4 miles from the runway. It drifted back to the centerline and about half a mile from the runway began a turn to the left for the missed approach procedure.

The aircraft then turned to the north and that is where the pilot heard the controller's transmission telling him to turn left to 090 degrees and climb to 2,000 feet. He made a right turn followed by several more turns in both directions. The aircraft dropped off the radarscope about a half mile east of the localizer and about a mile north of the runway.

Interpolation of the radar tapes showed that in the last three minutes of flight, the airplane climbed and descended 18 times, reaching vertical speeds of plus 4,600 feet per minute and minus 6,000 feet per minute between an altitude of 600 and 1,800 feet.

Adverse Effects

So, what happened to cause this pilot to lose control of his aircraft during a low approach? We'll never know for sure, but looking at some of the facts surrounding the flight we can speculate as to what might have happened.

The toxicology study done following the accident indicated that the pilot had a number of chemicals in his blood and urine, including Clorpheniramine, an antihistamine used to treat a variety of allergic reactions; Ephedrine, a stimulant that opens airway passages and is used to treat asthma and bronchitis and can also be used as a decongestant; and Phenylpropanolamine, which is a blood-vessel narrowing drug that is used to relieve a stuffy nose and other cold symptoms.

Side effects of these drugs include drowsiness, an increase in the central nervous system activity, headaches, a rapid heart rate, an inability to sleep, loss of appetite and high blood pressure.

So it would seem that the pilot was treating a cold or was suffering from allergies. In any case, the combination of these drugs would indicate that he was "under the weather" the day of the flight.

The radio transcripts indicate that there was some level of confusion or disorientation on the pilot's part as he began the missed approach. For example, his transmission to the tower controller, "Out of control. We're gone ..." appears to have been made when the aircraft was in a tight turn and in the middle of the altitude deviations.

The radar plot then shows that the pilot may have recovered at least partial control and flew a short distance to the southwest before beginning another series of turns, climbs and descents. It's clear that he fought with the aircraft for another three minutes or so before it disappeared from the radar.

Although we will never know, the medications in the pilot's system point to the very real possibility that a bad cold or allergies might have affected his inner ears, in turn causing or exacerbating his spatial disorientation.

Remember, the pilot made the statement that the "flight director is out of control." He could have meant that the attitude indicator and flight director did not appear to be working properly based on his false "sensing" of what the airplane was doing.

It has to be up to the pilot in command to decide whether he is fit to fly an airplane on a given day. At times pilots take liberties with their fitness and fly when they should not. We don't know for a fact that is what happened with this pilot, but the signs are, given the drugs found in his system, that he probably should not have been flying that day.

Rx For A Safe Flight

The rules regarding airmen medical certificates require that you ground yourself if you are not feeling well on the day of a flight. That means that if your situation requires that you take any unapproved medications, you shouldn't be flying. Medications do not have to be prescribed by a doctor to fall into that category. There are some that you can buy in any store that you can't take if you plan to go flying. This self-grounding policy applies even if you're not taking medicine. If you are not feeling 100 percent and your condition could interfere with your ability to fly, then you should ground yourself. It's that simple.

In the end, the NTSB determined that the cause of this accident was the pilot's failure to maintain control of his airplane while maneuvering in instrument meteorological conditions, due to spatial disorientation. Contributing factors in the accident were the fog and the pilot's use of a sedating medication.


More accident analyses are available in AVweb's Probable Cause Index. And for monthly articles about IFR flying including accident reports like this one, subscribe to AVweb's sister publication, IFR Refresher.