Fatigue, Drugs and WX don't mix
CESSNA 525, BRANSON, MO., DEC. 9, 1999–Two pilots and four passengers were killed in the crash of a CitationJet owned and operated by The College of the Ozarks. The NTSB found that the accident resulted when the pilot descended below the minimum altitude on a GPS approach. “Factors relating to the accident were low ceilings, rain and pilot fatigue,” investigators said. They also found the pilot was taking Doxepin to treat a gastrointestinal problem, a drug that can cause drowsiness.
On the day of the accident the pilot and copilot prepared for their flight from St. Louis with a call to flight service around 1339 CST. After receiving weather information, the pilot filed an IFR flight plan and called the operations manager at his home base, M. Graham Clark Airport (PLK) in Point Lookout, Mo. The operations manager said the weather was “pretty poor.” His observation showed 300 ft overcast, rain and mist, with three-quarter-mile visibility. The pilot asked the ops manager to monitor the Unicom so he could provide the pilots an updated observation before they started their approach.
They departed St. Louis at 1411, had an uneventful flight and checked in with Springfield Approach at 1447. Because the weather was so poor at PLK, the pilot filed to Springfield-Branson Regional (SGF) and, after descending, was cleared for the ILS to Runway 2. Before starting the ILS approach, he requested a change to PLK, receiving a GPS approach to Runway 11.
Springfield Approach told the crew of N525KL at 1501:32 to “descend and maintain 3,000 feet until rawbe, cleared GPS 11 approach.” N525KL responded, “Okay, we’re down to three and direct rawbe, and we’re programming that now.” Seven minutes later the controller approved the change to the advisory frequency and told the crew to call back with the cancellation or the missed approach. The crew acknowledged and there were no further transmissions to ATC.
The PLK operations manager heard the pilot call inbound from rawbe on the approach and went to the door of the building to listen for the jet to go missed-approach. He didn’t hear anything, even though he waited 15 to 20 min. He later told the NTSB he thought he missed hearing the airplane and assumed it flew back to Springfield. He heard Springfield Approach trying to contact the Citation at 1530 and at 1600 and called The College of the Ozarks to report it missing. The operations manager then drove around the perimeter of the airport to see if the jet landed nearby.
Radar data showed N525KL crossed rawbe at 1507:08 at 3,000 ft on a 116-deg heading. Its descent started nine seconds later. N525KL leveled off at 2,500 ft at 1508:04 and a minute later began the next descent segment. At 1509:46 another aircraft called Springfield Approach looking for N525KL’s cancellation. ATC responded that the Citation was still on the approach nearing the FAF. The last radar contact was two seconds later showing the jet on a 296-deg bearing from the airport, some five nautical miles out at 2,100 ft.
The chart for the GPS Runway 11 approach shows an initial minimum altitude of 3,200 ft to rawbe intersection, followed by a descent to 2,500 ft to the garyy intersection (FAF). After passing garyy, a pilot can descend to 2,000 ft with a local altimeter setting until 3.2 nm from brenl (MAP). The step-down fix provides clearance for a 1,601-ft tower, just inside the five-mile point, along the approach path. With a local altimeter setting the MDA yields 522 ft agl. N525KL came to rest on a hill roughly 3.75 nm northwest of the airport at an elevation around 1,100 ft.
The NTSB confirmed the flight-control continuity, engine, avionics and GPS unit integrity and found no anomalies existed before the crash. The FAA flight tested the approach and found it met all standards. N525KL’s altimeters were examined after the crash and were determined to be properly set.
In determining that pilot fatigue was a factor in this accident, the NTSB did not have to go much beyond position descriptions of the many hats the pilot wore while working for The College of the Ozarks. He was the director of aviation science for the school and oversaw a program that “prepares students to become aviation maintenance technicians, qualifies students for certification by the FAA as aviation maintenance technicians with airframe and powerplant ratings, and assists those students involved in the aviation industry with additional training as necessary to meet current demands in the field of air transportation.”
Approximately 72 students are enrolled in the course, with 24 entering each fall. As the director, the pilot was responsible for overseeing faculty and staff, counseling and advising students, running a Part 61 flight school, managing the maintenance program and curriculum development and implementation.
He was also manager of PLK, where his duties included “parking and servicing transient aircraft, facilities’ management, hangar rentals, car rentals, fueling of aircraft, rental of the college’s airplanes, oversight of the Part 145 aircraft repair station, weather observation, fire and emergency operations, managing airport staff and overseeing special airport projects.” He was accountable to the college for both the aviation science program and the airport’s budget. In his spare time, he was involved in preliminary contract negotiations to move and extend the runway.
He was also the designated pilot examiner who administered all students’ private checkrides and also gave checkrides for additional ratings in airplanes. The pilot had approximately 10,150 hr TT and was ATP and CFI in single- and multi-engine land airplanes with instrument privileges on both tickets. He logged 328 hr in the CitationJet and held a type rating in the airplane since the college purchased it 17 months before the accident. He was the only person at the college qualified to fly the jet.
The Kansas City FSDO inspected the college’s Part 145 repair station on March 10, 1999, and discovered “several deficiencies on the college’s part to monitor, document and perform required maintenance on its airplanes.” The pilot responded to the FAA on behalf of the college, and he intervened in an enforcement action taken against one of the school’s mechanics.
According to the NTSB, on March 24, 1999, the pilot received a letter from the Kansas City FSDO stating, “On March 10, 1999, an inspector from this office reviewed the maintenance records of several aircraft under your control. The result of the review gives reason to believe that a reexamination of your airman competency is necessary. The examination will consist of appropriate airline transport pilot practical test areas with emphasis on determining the maintenance requirements, test and appropriate records applicable to the proposed flight operation.” After appealing the action later that month, the pilot was notified that the FSDO rescinded the letter.
Fifteen days before the accident the pilot received another letter from the Kansas City FSDO saying that two of the multi-engine checkrides he administered were done without the appropriate class rating on his certificate of authority and without a letter of authorization for the specific make and model of airplane. As a result, the FSDO requested his logbooks.
The NTSB interviewed the pilot’s wife who described him as being “distressed by the FAA harassment.” She said he had contacted an aviation attorney to respond to the situation, and was upset about the request for his logbooks. He felt persecuted by the FAA, according to her testimony, and believed the situation would bring about disgrace to the college and himself.
On the day before the Citation accident, a student from the college was involved in an incident involving one of its Cessna 172s. Two passengers received minor injuries in the accident and a witness told the NTSB the incident “weighed heavily” on the pilot’s mind.
Witnesses at the college felt the pilot was calm and in a good mood the day of the accident. However, a corporate operator, who was friend of the accident pilot, met with him in St. Louis the same day and felt the pilot “wasn’t himself.” This operator told the NTSB that his friend (the accident pilot) believed that the Kansas City FSDO was “out to destroy him and his position at the college.” The friend felt the pilot showed the lack of sleep he endured and that he was “visibly upset and antsy.”
Autopsy results on the pilot found Doxepin in the kidney and its metabolite, Nordoxepin, in the liver. The NTSB found the 1998 Physician’s Desk Reference described the drug as “one of a class of psychotherapeutic agents known as dibenzoxepin tricyclic compounds.” It is recommended for the treatment of psychoneurotic patients with depression and/or other anxiety-related disorders.
The reference also contains the warning that the drug may cause drowsiness and caution is given against operating dangerous machinery while under its influence. The doctor who prescribed the medicine believed its mood-elevating properties were minimal and that the secondary effects of the drug would help with an irritable bowel syndrom the pilot suffered.
The copilot (pilot-rated-passenger in the front seat) held commercial and CFI certificates for single- and multi-engine airplanes with an instrument rating. Insurance records provided to the NTSB showed the copilot had slightly less than 1,000 hr TT and 75 hr in type. Autopsy results of the copilot showed the presence of marijuana in the liver and the urine. The manager of the FAA toxicology and accident research laboratory said that based on the volatile concentration in the system, the drug was likely ingested two to eight hours before the accident.