Loss of control Accident Piper PA-22-135 Tri-Pacer N2618A,
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ASN Wikibase Occurrence # 264341
 
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Date:Sunday 20 June 2021
Time:14:40
Type:Silhouette image of generic PA22 model; specific model in this crash may look slightly different    
Piper PA-22-135 Tri-Pacer
Owner/operator:Private
Registration: N2618A
MSN: 22-902
Engine model:Lycoming O-290-D2
Fatalities:Fatalities: 1 / Occupants: 1
Aircraft damage: Destroyed
Category:Accident
Location:near Beagle Sky Ranch Airport (OR96), White City, OR -   United States of America
Phase: Approach
Nature:Private
Departure airport:Medford-Rogue Valley International, OR (MFR/KMFR)
Destination airport:Beagle Sky Ranch Airport, OR (OR96)
Investigating agency: NTSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
On June 20, 2021, at 1440 Pacific daylight time, a Piper PA-22-135, N2618A, was destroyed when it was involved in an accident near White City, Oregon. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

The pilot was repositioning his airplane to the accident airport for an annual inspection. He had planned to have a friend meet him at the destination airport to drive him home. The friend waiting to pick the pilot up at the destination airport stated that the pilot initiated a go-around when the airplane was not aligned with the runway on the first landing attempt. The friend stated that the pilot attempted another landing and once again the airplane was not aligned with the runway, so the pilot initiated another go-around. The pilot made two landing attempts, and during the last attempt, the airplane contacted trees off the left side of the departure end of the runway. The airplane then impacted terrain and a postimpact fire ensued. At the time of the accident, the density altitude at the airport was over 4,000 ft.

A witness located at a residential airpark about 5 nautical miles from the pilot’s intended destination, where the accident subsequently occurred, reported that the accident airplane had landed at their private airpark just before the accident. They were worried because the airplane’s approach was erratic, and fast, and touched down about midfield and bounced before it went out of their view. The witness went to find the airplane and found it parked in his front yard. The pilot seemed lethargic, confused, and slow to answer questions. The pilot asked multiple times if he was at his destination airport, and the witnesses replied that he was not. Witnesses reported that about 20 minutes later the pilot departed from their airport. The witness reported that, although the airplane’s engine was running and sounded normal, it also sounded like the pilot had only applied partial power on takeoff. The witness noted that the airplane did not appear to be under control during the takeoff.

Postaccident examination of the airframe and engine revealed no mechanical anomalies that would have precluded normal operation. According to the pilot’s wife, the pilot had heart issues that included two previous heart attacks, one of which was 3 weeks before the accident. The pilot’s wife also stated that her husband was easily confused, irritable, and was in poor health. His two visits to the emergency room about 10 days before the accident suggest that the pilot’s condition was not well-controlled.

The pilot’s toxicology testing detected gabapentin, doxylamine, dextromethorphan, torsemide and carvedilol in his system. In addition, the pilot’s autopsy identified severe cardiovascular disease, chronic kidney disease, and previous atrial fibrillation. Based on the operational evidence, the pilot had actively attempted several landings when the accident occurred; therefore, it is unlikely that the pilot experienced sudden incapacitation. However, operational evidence and witness reports indicate that the pilot was behaving in a confused manner. The pilot was taking a diuretic medication and other medications that decrease sweating and body cooling. He was also taking gabapentin, which is associated with dizziness and sleepiness. Even without a heat stressor, people with chronic heart failure can experience mental confusion and impaired thinking. The pilot also had moderate chronic kidney failure that would decrease his heat tolerance. Additionally, heat stress can further impact kidney function. Decline in kidney function with subsequent buildup of body wastes in the blood can lead to confusion. Given the high outside temperatures, the pilot’s medical conditions, as well as the prescribed medication detected in his system, it is likely that the pilot experienced mental confusion and impaired thinking/judgement, which resulted in his inability to safely operate the airplane.

Probable Cause: The pilot’s failure to maintain control of the airplane during a go-around, which resulted in a collision with trees. Contributing to the accident was the pilot’s impairment due to his medical conditions and the effects of his medications.

Accident investigation:
cover
  
Investigating agency: NTSB
Report number: WPR21FA233
Status: Investigation completed
Duration: 2 years and 3 months
Download report: Final report

Sources:

https://jacksoncountyor.org/sheriff/News/sams-valley-plane-crash-kills-pilot-update-photo
https://www.google.com/amp/www.kdrv.com/templates/AMP%3fcontentID=574674011

https://data.ntsb.gov/Docket?ProjectID=103294
https://registry.faa.gov/AircraftInquiry/Search/NNumberResult?nNumberTxt=N2618A

https://www.airport-data.com/images/aircraft/000/246/246506.jpg (photo

Location

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Revision history:

Date/timeContributorUpdates
21-Jun-2021 17:49 Captain Adam Added
21-Jun-2021 18:34 harro Updated [Aircraft type, Embed code]
21-Jun-2021 19:14 RobertMB Updated [Time, Aircraft type, Registration, Cn, Operator, Location, Phase, Nature, Source, Narrative]
21-Jun-2021 19:22 RobertMB Updated [Time, Location, Destination airport, Source, Narrative]
21-Jun-2021 19:29 Captain Adam Updated [Narrative]
21-Jun-2021 20:00 RobertMB Updated [Aircraft type, Location, Narrative]
21-Jun-2021 20:01 RobertMB Updated [Narrative]

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