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NTSB Identification: MIA01FA140
HISTORY 0F Flight
On May 13, 2001, about 1933 Atlantic daylight time, a Cessna 404, N404BA, registered to Air Cargo Systems International Inc., and operated by City Wings Inc., as a Title 14 CFR Part 91 positioning flight, impacted with rising terrain, at night, in the Caribbean National Forest, near Pena Pobre, Puerto Rico (PR). Visual meteorological conditions prevailed. No flight plan was filed. The airplane was destroyed. The commercial rated-pilot was fatally injured. The flight had departed from St. Croix, U.S. Virgin Islands at 1900.
The flight was en route to Aguadilla, PR (TJBQ), with a stopover at Luis Munoz Marin International Airport, San Juan, PR (SJU). According to the air traffic control tapes, the pilot was in radio contact with San Juan approach control and was being handled as a VFR aircraft. The pilot was given a discreet transponder code of 0411, and was in radar contact at about 1910, 12 miles west of St. Croix, at an altitude of 4,500 feet. The pilot requested a VFR descent from 4,500 feet. The controller coordinated with Roosevelt Roads Naval Station, the sector that the flight was in, and subsequently cleared the flight at 1923:59, to “…descend unrestricted west bound.” The flight appeared to follow the 160 degree radial, inbound to the San Juan VORTAC (Very High Frequency Omni-Directional Radio Range Tactical Air Navigation Aid). According to ATC controllers at SJU approach control, the minimum-vectoring altitude for all aircraft flying in the same area as N404BA, on instrument flight rule (IFR) flight plans was 6,000 feet.
At 1924:10, radar showed that the flight started to descend out of 4,500 feet, and at 1928:33, had stopped its descent at 2,700 feet. Radio and radar contact were lost at 1930:26, and the last radar hit on the flight showed it at an altitude of 2,700 feet. The controller tried to re-establish radio contact with the airplane’s pilot 10 times before initiating search and rescue efforts. About 2020, a U.S. Coast Guard helicopter located the wreckage, with the aid of the aircraft’s emergency locator transmitter, and rescue workers got within 2 to 3 nautical miles of the wreckage, but due to night darkness, and the steep-rugged terrain elected to wait until day light before continuing the search and rescue operations, postponing their efforts for several hours. The next day a ground search for the aircraft was halted because of hazardous terrain, and the air rescue continued. Search and rescue personnel were air lifted into the crash site to remove the victim.
The pilot, held an FAA commercial pilot certificate, with airplane single and multi-engine land, airplane instrument, last issued on June 6, 1998. The pilot held an FAA class 2 medical certificate issued on August 24, 2000, with no limitations. The pilot received a biennial flight review, as required by 14 CFR Part 61, on August 6, 1999. As per the entries in his company flight records, he had accumulated a total of 550 total flight hours, 166 total single engine flight hours, and 384 hours muti-engine aircraft when he was hired by City Wing Inc; on May 24, 2000. In addition, the records showed that he had a total of 80 night flight hours, 50 simulated instrument flight hours, and 20 actual instrument flight hours. In the last 90 days before the accident the pilot flew a total 90 hours all in this make and model aircraft. In the last 30 days before the accident the pilot flew a total of 67 hours all in this make and model aircraft. According to the company flight records the pilot had not logged any instrument flight hours in the three months before the accident. In addition, the company records showed that the pilot had logged 6.5 of night flight hours in the 90 days before the accident. As of the pilot’s last flight physical on August 24, 2000, at the time of the accident, the pilot had logged a total of about 1,000 flight hours in all aircraft.
MEDICAL AND PATHOLOGICAL INFORMATION
Dr. Janet J. Rivera performed an autopsy on the pilot, at the Medical Examiner’s Office, San Juan, Puerto Rico, on May 15, 2001. According to the autopsy report the cause of death was “…Severe trauma to the body…” No findings, which could be considered causal to the accident, were reported.
Toxicological tests were conducted at the Federal Aviation Administration, Research Laboratory, Oklahoma City, Oklahoma, and revealed, “No ethanol detected in Blood.” Drugs were found in the urine and blood, to include; Venlafaxine and Desmethylvenlafaxine (See the Federal Aviation Administration’s Toxicology Report, an attachment to this report).
The National Transportation Safety Board’s, Medical Officer reviewed the FAA-CAMI toxicology report and gave the following information about the drugs that were found in the study.
Venlafaxine is a prescription antidepressant also known by the trade name Effexor, used for a variety of additional purposes including the treatment of certain painful muscle conditions. Desmethylvenlafaxine is a metabolite of venlafaxine. The levels of venlafaxine and desmethylvenlafaxine that were found in the pilot’s blood were consistent with the recent ingestion of more than 10 times a normal dose of venlafaxine. Recent controlled studies of venlafaxine in healthy volunteers have shown no significant impairment of cognitive or psychomotor performance. However, the second of those studies indicated a reduction in vigilance, particularly in the first week of beginning the medication, prompting the authors to conclude that drugs in this class may reduce arousal in particularly monotonous tasks or environments. Overdose has been reported to cause dizziness, abnormal heart rhythms, and loss of consciousness, but deaths due to overdose of venlafaxine alone are rare. (NOTE: the two sources of the studies were; Nathan, P.J.; Sitaram, G.; Stough, C.; and others. 2000. “Serotonin, noradrenaline and cognitive function: a preliminary investigation of the acute pharmacodynamic effects of a serotonin versus a serotonin and noradrenaline reuptake inhibitor.” Behavioral Pharmacology 11(7-8):639-42; and O’Hanlon, J.F.; Robbe, H.W.; Vermeeren, A.; and others. 1998. “Venlafaxine’s effects on healthy volunteers’ driving, psychomotor, and vigilance performance during 15-day fixed and incremental dosing regimens.” Journal of Clinical Psychopharmacology 18(3):212-21.)
The NTSB Medical Officer, from the medical records maintained on the pilot by the Federal Aviation Administration (FAA) Aerospace Medical Certification Division, extracted the following medical information:
The pilot’s initial application (dated November 15, 1995) for an Airman Medical and Student Pilot Certificate noted the use of “…Wellbuton [sic] – chemical imbalance/ 3 daily.” A letter from the FAA dated December 7, 1995, indicated that consideration of the pilot’s application disclosed that he did not meet the medical standards due to a “medical condition requiring the use of disqualifying medication (Wellbutrin).” A letter from the pilot’s psychiatrist dated November 12, 1996, noted that the pilot had been seen on “… two occasions. The first time was over a year ago. He presented [me] with symptoms, which I thought warranted a trial of antidepressant medication. I gave him a prescription, which he never filled. I recently re-examined [the pilot]. There were no signs of depression. He told me he had never taken the antidepressants I had prescribed, and his emotional complaints had cleared by themselves. I do not believe [the pilot] is in need of further psychiatric treatment.” A second letter from the FAA dated November 12, 1996, indicated “Our review of your medical records has established that you are eligible for a third-class medical certificate. …” Further applications for airman medical certificate indicate “no” in response to the question “Do You Currently Use Any Medication?”