28 Apr 2008: TROMSNESS ENTERPRISES INC TURBINE LE — TROMSNESS ENTERPRISES INC

28 Apr 2008: TROMSNESS ENTERPRISES INC TURBINE LE (N747CT) — TROMSNESS ENTERPRISES INC

1 fatality • Miami, OK, United States

Probable cause

The pilot's failure to maintain control of the airplane for undetermined reasons. Contributing to the accident included his extensive use of medications and/or his multiple medical conditions and the failure of the FAA to follow up on his reported medication use.

— NTSB Determination

Accident narrative

On April 28, 2008, at 1430 central daylight time, an experimental Tromsness Enterprises, Incorporated Turbine Legend, N747CT, a single-engine turbo prop airplane, was destroyed by post-impact fire when it collided with a concrete barrier in the center median of Interstate 44 in Miami, Oklahoma. The certified private pilot, and sole occupant, was fatally injured. The airplane was registered to and operated by the pilot. No flight plan was filed for the local flight that departed the Miami Municipal Airport (MIO), Miami, Oklahoma, between 1400 and 1415. Visual meteorological conditions prevailed for the personal flight conducted under 14 Code of Federal Regulations Part 91.

Several witnesses observed the airplane prior to the accident and stated that it was spiraling as it descended to the ground. One witness said the airplane was approximately 500 feet above the ground and was heading southeast as it descended in an approximately 80 degree nose down attitude before it hit the median barrier and exploded into flames.

A second witness was traveling westbound on the interstate when he first observed the airplane. He said. "I saw the airplane moving in an unstable manner when it went totally out of control heading in a [southwest] direction. It started losing altitude fast, rolled over three times then hit the road left wing first, nose slightly upward. The plane burst into flames upon impact as it hit the center road barrier."

A third witness was also traveling west on the interstate when he first noticed "a small single engine airplane" that seemed to be "too low." The witness said, "I watched as the airplane suddenly dipped right then dipped left and did a complete roll. It managed to get upright just when it hit the interstate...."

An on-scene examination of the airplane was conducted by the Federal Aviation Administration (FAA). According to an FAA inspector, the airplane, which is comprised mostly of composite material, was destroyed by fire. The only identifiable parts of the airplane that remained were the propeller, the engine, a flap, a section of the vertical stabilizer, the elevator, the landing gear and both wing spars. The three-bladed propeller remained attached to the engine; however, one blade had separated from the hub. Examination of the blades revealed that they were curled aft, exhibited leading edge damage and deep gouging from impact with the concrete barrier. The cockpit area, including the instrument panel, avionics and radios, were also destroyed by fire. External examination of the engine revealed no pre-mishap anomalies.

The pilot held a private pilot certificate for airplane single-engine land and glider. His last FAA third class medical was issued on November 27, 2007. At that time, he reported a total of 3,012 flight hours.

Toxicological testing was conducted by the FAA Accident Research Laboratory, Oklahoma City, Oklahoma. Blood submitted for that testing is noted in the pilot's autopsy report to have been collected from the chest cavity. The toxicology report noted:

>> 3.126 (ug/mL, ug/g) TRAMADOL detected in Blood >> TRAMADOL present in Urine >> 0.343 (ug/ml, ug/g) HYDROCODONE detected in Urine >> HYDROCODONE NOT detected in Blood >> 0.084 (ug/mL, ug/g) DIHYDROCODEINE detected in Urine >> DIHYDROCODEINE NOT detected in Blood >> GABAPENTIN present in Urine >> GABAPENTIN NOT detected in Blood >> BUPROPION detected in Blood >> BUPROPION present in Urine >> BUPROPION METABOLITE present in Blood >> BUPROPION METABOLITE present in Urine >> 0.011 (ug/mL, ug/g) TRAZODONE detected in Blood >> TRAZODONE present in Urine >> 8.403 (ug/ml, ug/g) ACETAMINOPHEN detected in Blood >> 55.48 (ug/ml, ug/g) ACETAMINOPHEN detected in Urine

Review of the pilot's personal medical records revealed a history of anxiety, depression, muscle pain, severe headaches most mornings, obstructive sleep apnea (OSA), and memory loss since at least 1999. He noted "spells" of weakness during this period, and episodes of "shaking" in February of 2007. He had been regularly using multiple medications, including tramadol, gabapentin, trazadone, and flurazepam since at least 2006, and hydrocodone and bupropion since at least early 2007, with prescriptions documented for each of the medications in the months leading up to the accident. He had intermittently used a CPAP (continuous positive airway pressure) device to treat his OSA.

The pilot had specifically denied any history of "Frequent or severe headaches," "Mental disorders of any sort; depression, anxiety, etc.," "Admission to hospital," and "Other illness, disability, or surgery" on his two most recent applications for airman medical certificate in October 2005 and November 2007. He indicated the use only of "Excedrin - over the counter" in response to "Do You Currently Use Any Medication" on his 2007 application. In response to the same question on the 2005 application, the pilot had noted the use of tramadol "occasionally," without any other indication of the frequency, amount, or reasons for its use, and the FAA did not request any additional information regarding the use of the medication.

Weather reported at Grove Municipal Airport (KGMJ), about 20 miles south of the accident site, at 1432, was reported as wind from 330 degrees at 11 knots gusting to 15 knots, visibility 10 miles, clear skies, and a barometric pressure setting of 30.12 inches of Mercury. The temperature was 63 degrees Fahrenheit and the dewpoint was 41 degrees Fahrenheit.

Contributing factors

  • factor Pilot
  • cause Pilot
  • cause Performance/control parameters — Not attained/maintained
  • factor Pilot
  • factor FAA/Regulator

Conditions

Weather
VMC, wind 330/11kt, vis 10sm

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