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NTSB Final Report: Piper J5A

No Record Of A Current Flight Review For The Pilot Was Found

Location: Iola, Wisconsin Accident Number: CEN23FA369
Date & Time: August 19, 2023, 12:54 Local Registration: N35417
Aircraft: Piper J5A Aircraft Damage: Substantial
Defining Event: Loss of control on ground Injuries: 1 Fatal
Flight Conducted Under: Part 91: General aviation - Personal

Analysis: The 78-year-old pilot had flown his airplane to the destination airport where an annual inspection was to be performed. The airplane did not have a current annual inspection and did not have a ferry permit for the accident flight. No record of a current flight review for the pilot was found. In addition, the pilot did not possess current FAA medical certification or BasicMed qualifications.

Recorded GPS device data showed the airplane made several turns around the airport and then proceeded in the direction of and onto a grass taxiway with a prevailing tailwind, where it was found nosed over. There were no witnesses to the accident. There were no indications of ground scars or rotational features on the propeller and spinner indicative of engine power production. Although the airplane’s right front brake master cylinder arm had a bungee cord tied around it that connected to the pilot seat frame, the brakes actuated and released without anomaly. Examination of the airplane revealed no useable fuel aboard; however, the airplane’s flight path indicated that it circled the airport multiple times before landing, indicating that the flight had adequate fuel to reach and land at the airport. No mechanical anomalies were found that would have precluded normal operation.

Although the pilot’s cardiovascular disease placed him at increased risk of an impairing or incapacitating medical event such as heart attack, arrhythmia, or stroke, there was no autopsy evidence that such an event occurred, and such an event does not reliably leave autopsy evidence if it occurs just before death. Toxicology results indicated that the pilot had used the opioid pain medication tramadol and likely was experiencing some effects of tramadol at the time of the accident. Although details of the pilot’s tramadol use are unknown, there is no specific evidence that this use was significantly different from the pilot’s baseline use of tramadol, which had begun years previously. Toxicology results also indicated that the pilot had used venlafaxine and a cannabis product. The measured postmortem levels of the substances in the pilot’s system at the time of the accident neither exclude nor specifically predict any impairing effects, especially in combination with one another and considering the pilot’s age and medical conditions.

Based on the evidence, the pilot likely did not maintain control of the airplane after landing on a grass taxiway with a tailwind. Whether the impairing effects of the pilot’s substance use and medical conditions contributed to the accident could not be determined.

Probable Cause and Findings: The National Transportation Safety Board determines the probable cause(s) of this accident to be -- The pilot’s failure to maintain control of the airplane after landing on a grass taxiway with a tailwind, which resulted in a nose over.

FMI: www.ntsb.gov

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