NTSB Cites Pilot Error for 2011 Z Islander Apartments Plane Crash — (KBTX.com)

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KBTX.com

By: Clay Falls

May 28, 2011

BRYAN, Texas It’s been nearly three years since a fatal Memorial Day weekend plane crash at the Z Islander Apartments in Bryan and we are just now learning what caused it.

A North Texas couple died when they were attempting to make an Emergency Landing at Easterwood Airport and crashed just two miles from the runway into a parking lot.

The National Transportation Safety Board’s Final Report was released earlier this month.

It details why the plane crashed and that in the agency’s opinion, the pilot should not have been flying.

Pilot error is being blamed for a horrific site back on Memorial Day weekend 2011 when a Rockwell 112 single engine plane came crashing to the ground at the Z Islander Apartments on Wellborn Road in Bryan.

“They went down trying to make Easterwood,” said Matt Puckett, who heard the distress call then on May 28th, 2011.

The pilot 57-year-old John Holmstrom of Cedar Hill near Dallas and his wife Katherine Ruth died in the crash.

The National Transportation Safety Board says the pilot ran out of gas during the flight from Fort Worth Spinks Airport to Galveston and he didn’t refuel the plane after two recent flights.

Matt Puckett was a member of the Texas A&M Flying Club at the time of the crash and spoke with us then about hearing the distress call while in another plane.

“We were coming in to the tower and the tower asked us to hold off ’cause we heard the radio call some people had ran out of gas and the next thing we know there wasn’t anymore radio call,” said Puckett on May 28th, 2011.

Besides not properly managing fuel for the flight the NTSB’s report also says the pilot had been battling depression and anxiety since 1989 and was on depression medication that would have restricted him from flying.

The report said, “Contributing to the accident was the pilot’s impaired judgment, which led to his failure to recognize the fuel shortage earlier and his improper decision to fly with disqualifying medical conditions.”

Prior to the crash Holmstrom had more than 460 hours of flying experience.

No one else on the ground was injured.

 

To view National Transportation Safety Board Accident Report click here

NTSB Identification: CEN11FA358
14 CFR Part 91: General Aviation
Accident occurred Saturday, May 28, 2011 in Bryan, TX
Probable Cause Approval Date: 03/07/2014
Aircraft: ROCKWELL 112, registration: N1041J
Injuries: 2 Fatal.

On May 28, 2011, at 2044 central daylight time, a Rockwell 112, single engine airplane, N1041J, impacted terrain during a forced landing at Bryan, Texas. The pilot and passenger were fatally injured. No persons on the ground were injured. The airplane sustained substantial damage. The airplane was registered to a private individual and was being operated by another private individual for the 14 Code of Federal Regulations Part 91 personal flight. Dusk visual meteorological conditions prevailed and a flight plan had not been filed. The flight had originated from Fort Worth Spinks Airport (FWS), Fort Worth, Texas, about 1922 and was en route to Scholes International Airport (GLS), Galveston, Texas.

A witness statement and fueling records show that the airplane was last refueled on May 25, 2011. Other records showed that the pilot made two flights of 1.4 hours each, totaling 2.8 hours, on May 26, 2011. Another witness reported the pilot may have made two other local flights on either May 26, or May 27, 2011, and records show the airplane was not refueled after any of those flights.

On the day of the accident the airplane was in cruise flight about 9,500 feet mean sea level (msl) when the pilot advised the controller that he wanted to make a fuel stop at Easterwood Field Airport (CLL), College Station, Texas. The airplane then made a right turn of about 90 degrees and began descending toward CLL.

Several minutes later the pilot reported that he was “running out of fuel”. When the airplane was at 600 feet msl the pilot reported that he would not make the airport.

A witness at an apartment complex reported seeing the airplane flying “extremely low” and parallel to the road when he saw it suddenly turn right and head toward the witness’s location.

The airplane struck terrain and an unoccupied automobile in the parking lot of the apartment complex and came to rest upright; 47 feet from the initial impact point.

autopsy was performed on the pilot by the Travis County Office of the Medical Examiner in Austin, Texas. The cause of death was listed as blunt force injuries.

Forensic toxicology was performed on specimens from the pilot by the FAA, Aeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma.

The toxicology report stated: NO CARBON MONOXIDE detected in Blood; NO CYANIDE detected in Blood; NO ETHANOL detected in Vitreous; Fluoxetine detected in Blood and Urine; Norfluoxetine detected in Urine and Blood; Quinine detected in Urine.

The NTSB Chief Medical Officer reviewed the IIC’s narrative, the autopsy report, the toxicology results, the pilot’s FAA airman medical certification file, and the pilot’s personal medical records.

The toxicology evaluation identified quinine, fluoxetine, and its primary metabolite, norfluoxetine, in urine, and fluoxetine (1.515 ug/ml), and norfluoxetine (1.036 ug/ml) in cavity blood. Therapeutic levels for fluoxetine are 0.09 to 0.40ug/ml but it can become concentrated in cavity blood post mortem. Quinine is an antimalarial drug which is also found in tonic water. At usual doses, it does not affect performance.

Fluoxetine, marketed under the trade name Prozac, is an atypical antidepressant in the class of selective serotonin reuptake inhibitors. Fluoxetine carries official FDA warnings: “Side effects of fluoxetine include insomnia, anxiety, and headache; manic behavior and suicidal ideation have also been reported. Warnings – may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery).”

Prescription bottles were found in the wreckage. There were bottles with the pilot’s name for fluoxetine, Abilify (aripiprazole), Tramadol (ultram), Lyrica (pregabalin), and simvastatin.

Aripiprazole is used to treat bipolar disease and as an adjunct in major depression which is non-responsive to first line treatments. It carries a specific FDA warning, “use caution when operating machinery.”

Ultram is a synthetic opioid pain reliever used to treat moderate to severe pain. Concomitant administration of ultram and selective serotonin reuptake inhibitors has been demonstrated to increase the risk of seizure and serotonin syndrome. In addition, ultram carries a specific FDA warning, “may impair the mental and physical abilities required for the performance of potentially hazardous tasks such as driving a car or operating machinery”.

Pregabalin is indicated as treatment for pain and to prevent partial complex seizures. It carries a specific FDA warning: “may cause dizziness and somnolence and impair patient’s ability to drive or operate machinery”. The FAA’s toxicology lab does not test for pregabalin.

 

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

The pilot’s inadequate fuel planning, which resulted in a loss of engine power due to fuel exhaustion, and his improper control inputs following the loss of engine power, which resulted in an aerodynamic stall and subsequent loss of control. Contributing to the accident was the pilot’s impaired judgment, which led to his failure to recognize the fuel shortage earlier and his improper decision to fly with disqualifying medical conditions.