What a sad accident I’ve got for your consideration this month. Typically, we explore accident chains with links comprising bad weather, complex system failures, inexperienced crews and difficult ATC transactions. In this month’s accident — the loss of a Premier I (N50PM) — we find great weather, a well-maintained, beautifully equipped aircraft, competent systems and a helpful controller. Indeed, there seems to be only one link in this accident chain — the use of medications and recreational drugs that can depress judgment and situational awareness.
The jet was destroyed when it struck trees and the ground, and was consumed by an explosion and post-crash fire. The pilot had been attempting to return for landing at Fulton County Airport — Brown Field (FTY) in Atlanta. The personal (FAR Part 91) flight had departed at 1924 EST on Dec. 17, 2013. Visual conditions prevailed and an IFR flight plan had been filed for the trip to New Orleans Lakefront Airport (NEW). The private pilot and sole passenger were killed. Weather in the area included wind from 240 at 4 kt.; visibility, 10 mi.; clear skies; temperature, 13C; and dew point, 0C.
The crash sequence began with tree strikes at 80 ft. AGL. Elevation of the crash site was 867 ft. MSL. The airplane had exploded and burned. Credit: NTSB


The aircraft was completed in September 2003 and registered to the accident pilot’s company. The small executive jet, powered by two Williams-Rolls FJ44-2A engines, had accumulated 712 hr. and was up to date on inspections and maintenance.
The 67-year-old pilot held a private certificate with single-engine and multiengine land, instrument ratings and had a Raytheon 390 type rating. He had accumulated 7,700 hr. total including 1,030 hr. of “jet” experience; however, investigators were unable to determine how many of those hours were in the accident aircraft make and model. He had flown 35 hr. in the previous six months.
His third-class medical certificate issued seven months prior to the incident carried a restriction validating it for only one year, rather than 24 months, which is the standard duration for a certificate holder over 40 years of age. He had been diagnosed with coronary artery disease and had had a heart attack in April 1996, which was treated with angioplasty and stent placement. The pilot’s stress test, conducted on April 11, 2013, revealed no evidence of ischemia. He further reported to his AME that his medications included aspirin, atenolol, losartan and simvastatin.
The 23-year-old passenger was not a rated pilot but, according to the CVR transcript, helped with portions of the checklist.
The Flight
FBO personnel told investigators they towed the Premier from a nearby maintenance facility and parked it on their ramp about 1720. At 1738, the pilot called to request 250 gal. of fuel with Prist and the aircraft was fueled about 1755.
The pilot and passenger arrived at the FBO about 1900 and parked their vehicle next to the airplane. Baggage was loaded on the airplane and the pilot told FBO personnel, as was his custom, that a marshaler would not be necessary.
Security cameras and witnesses observed the pilot walk around the aircraft and board the aircraft with his passenger. The airplane’s strobe lights were illuminated. Several moments later, the airplane’s taxi lights were illuminated and the airplane was observed taxiing from the parking ramp. It could not be determined conclusively who was seated in the pilot seat or copilot seat; however, the silhouette that was observed appeared to be that of an individual wearing a ball cap. The pilot was observed wearing a ball cap as he entered the airplane prior to closing the door; the passenger was not wearing a hat.
The CVR captured the pilot contacting Fulton County ground controller at 1902:12 requesting his IFR clearance. The ground controller issued the clearance and, at 1903:12, the pilot read it back and acknowledged a clearance to taxi.
The recorder picked up various personal conversations between the pilot and passenger. It also overheard the pilot missing a turn during the taxi and the ground controller providing him a modified taxi clearance. At 1908:54, the pilot requested “a couple of minutes here at the end . . .”
From 1909:10 to 1916:07, various test tones were recorded including several “lift dump fail” test tones. During that time, the pilot also asked the passenger if she had his phone. Investigators found a photograph of the warning light configuration in the pilot’s phone. Metadata revealed that the photograph was recorded at 1906; however, it could not be conclusively determined if the noted time was accurate. At 1916:36, the pilot requested takeoff clearance. The accident timeline follows:
At 1919:19, takeoff clearance was issued by the tower controller and acknowledged by the pilot.
At 1920:15, the cockpit area microphone recorded the sound of two engine igniters, which continued until the end of the recording.
At 1920:47, the passenger asked “Did you put heat on?” to which the pilot replied, “Why is that?”
At 1920:55, the ground proximity warning system (GPWS) warned “too low terrain too low terrain.”
At 1921:02, the pilot notified the Fulton tower that “We’re gonna need to come back now. We’ve got a problem here.” The controller cleared the airplane to enter right traffic for Runway 26 and asked if the pilot needed emergency assistance.
At 1921:32, the pilot replied “negative” on the assistance.
At 1921:33, the controller stated, “Premier Five Zero Papa Mike, they put a hold message on your flight plan. That way you can reuse it if you want to go later. Just let me know.”
At 1921:39, the pilot replied, “Sounds good; appreciate it.”
At 1922:42, the flight was issued landing clearance and traffic to follow.
At 1922:51, the pilot replied, “Cleared to land number two fifty five Mike thank you,” which was the last recording from the airplane to the ATCT.
From 1922:53 until the end of the recording, several GPWS audible warnings were given including “pull up pull up pull up” and the pilot stating “I don’t know what that’s sayin’.” The airplane crashed while on the downwind leg for Runway 26.
The wreckage was located about 3 mi. on a 043-deg. course from the threshold of Runway 26. The debris path was approximately 250 ft. in length and on a heading of 095 deg.
The main portion of the airplane came to rest upright and in a moderately wooded area within a drainage ditch. An impact crater was located approximately 45 ft. from the main wreckage along the debris path. Within the crater was the windscreen section, and the left pilot side window was spider-webbed but remained intact.
The crash sequence began with tree strikes at 80 ft. AGL. Elevation of the crash site was 867 ft. MSL. The airplane had exploded and burned. Investigators established control continuity and determined that the flaps had been set at 10 deg. The landing gear had been fully extended.
The composite and aluminum fuselage was thermally destroyed. Parts associated with five of the six seats were located; however, investigators could not determine what, if anything, was on the seats at the time of impact. No seat belts were located, but the seat belt attachment points remained secured at the aft side of their respective seat pans.
The cockpit separated at impact and exhibited thermal damage. The overhead panel, which included light switches, was found near the main wreckage but had little thermal damage. The center pedestal was located with the main wreckage. The thrust levers were found in the full forward positions. The ground lift dump lever was in the full forward or “stowed” position and was in the gated or detent position. The ground lift dump arm switch was in the full aft or “armed” position. The spring-loaded flight spoiler lever was in the forward position and operated smoothly at the pedestal. The right side of the center pedestal was thermally damaged and the flap lever was located; however, due to thermal damage a flap selection position could not be ascertained. The windscreen windows and cockpit crown were located within the initial ground impact crater.
Both engines were located in the main wreckage area. Engineers and technicians disassembled the engines and found no abnormalities or malfunctions.
Forensic Analysis
As NTSB investigators were able to cross off the usual suspects — weather, aircraft systems, communications, ATC, etc. — they turned to pilot performance factors. As it turned out, important causal factors were developed at autopsy and during laboratory fluids analysis.
The Fulton County Medical Examiner’s findings included atherosclerotic cardiovascular disease, post-mortem thermal burns and “multiple blunt force injuries.” The cause of death was reported as “multiple blunt force injuries of the head, torso and extremities.”
Forensic toxicology was performed on specimens from the pilot by the FAABioaeronautical Sciences Research Laboratory at Oklahoma City. The toxicology report stated no carbon monoxide or ethanol was detected in the blood. However, the following drugs were detected in his system:
Atenolol
Sildenafil
Methylone
Tetrahydrocannabinol (marijuana)
Zopiclone
A plastic baggie, containing a blue powder substance, was located in the front pocket of the pilot’s pants. The powder was also sent to the FAA Bioaeronautical Sciences Research Lab in Oklahoma City. The report listed the following drugs:
Amphetamine detected in blue powder
Cocaine detected in blue powder
Lidocaine detected in blue powder
Methylone detected in blue powder
Sildenafil detected in blue powder
Cocaine detected in white powder
Lidocaine detected in white powder
Methylone detected in white powder
According to the NTSB Medical Factual report, zopiclone is a short-acting prescription sleep aid marketed as Imovane. The half-life of zopiclone ranges from 3.5 to 6.5 hr. and therapeutic levels range from 0.076 to 0.140 ug/ml.
Tetrahydrocannabinol (THC) is the psychoactive compound found in marijuana and has effects at levels as low as 0.001 ug/ml. THC has mood-altering effects causing euphoria, relaxed inhibitions, sense of well-being, disorientation, image distortion and psychosis. The ability to concentrate and maintain attention is decreased during marijuana use. Tetrahydrocannabinol carboxylic acid is the inactive metabolite of tetrahydrocannabinol.
Methylone is a synthetic illicit stimulant with similar effects to cocaine, methamphetamine and MDMA (ecstasy or Molly). Methylone’s side effects are reportedly similar to those of MDMA and range from relaxation, euphoria and excited calm at lower doses to agitation, panic attacks and illusory or hallucinatory experiences at higher doses. Elevated body temperatures of up to 107F have been reported, where post-mortem blood methylone levels have ranged from 0.056 ug/ml to 3.3 ug/ml.
Analysis
The Safety Board offered this analysis of the accident:
The pilot and passenger departed on a night personal flight. Immediately after departure, the passenger asked the pilot if he had turned on the heat. The pilot subsequently informed the tower air traffic controller that he needed to return to the airport. The controller then cleared the airplane to land and asked the pilot if he needed assistance. The pilot replied “negative” and did not declare an emergency.
The pilot acknowledged to the passenger that it was hot in the cabin. The CVR recorded the enhanced ground proximity warning system (EGPWS) issuing 11 warnings, including obstacle, terrain and stall warnings; these warnings occurred while the airplane was on the downwind leg for the airport. The airplane subsequently impacted trees and terrain and was consumed by post-impact fire. Post-accident examination of the airplane revealed no malfunctions or anomalies that would have precluded normal operation.
During the attempted return to the airport, possibly to resolve a cabin heat problem, the pilot was operating in a high workload environment due to, in part, his maneuvering visually at low altitude in the traffic pattern at night, acquiring inbound traffic, and being distracted by the reported high cabin temperature and multiple EGPWS alerts. 
The passenger was seated in the right front seat and in the immediate vicinity of the flight controls, but no evidence was found indicating that she was operating the flight controls during the flight. Although the pilot had a history of coronary artery disease, the autopsy found no evidence of a recent cardiac event, and an analysis of the CVR data revealed that the pilot was awake, speaking and not complaining of chest pain or shortness of breath; therefore, it is unlikely that the pilot’s cardiac condition contributed to the accident.
Toxicological testing detected several prescription medications in the pilot’s blood, lung and liver, including one to treat his heart disease; however, it is unlikely that any of these medications resulted in impairment.
Although the testing revealed that the pilot had used marijuana at some time before the accident, insufficient evidence existed to determine whether the pilot was impaired by its use at the time of the accident.
Toxicology testing also detected methylone in the pilot’s blood. Given the level of methylone (0.34 ug/ml), it is likely that the pilot was impaired at the time of the accident. The pilot’s drug impairment likely contributed to his failure to maintain control of the airplane.
In the end, the Safety Board determined the probable cause of this accident was, “the pilot’s failure to maintain airplane control while maneuvering the airplane in the traffic pattern at night. Contributing to the accident was the pilot’s impairment from the use of illicit drugs.
The lesson for us all arising from this investigation requires no further explanation.
This article appears in the January 2016 issue of Business & Commercial Aviation with the title "Deadly Combination."