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Mon, Feb 13, 2006

Australian Crash: Dope In Pilot's Body

Could Have Been High, Or Just Regular User

Aero-News SAFETY by Senior Correspondent Kevin R.C. "Hognose" O'Brien

Exactly when Andrew Morris, 27, last used marijuana, medical science can't tell. But toxicologist Olaf Drummer said that the levels might indicate he had used the drug several hours before the crash, or he might just have been a regular user with high (no pun intended) quantities of THC, the drug's active ingredient, retained in his tissues.

His tissues became a matter of interest to the Australian authorities on September 26, 2002, when he tried to turn back to a runway after the engine began running rough and skipping. Morris's Piper Cherokee Six 300 stalled, and the four adults and two children aboard -- including Morris -- perished.

The passengers were the Bowles family from New Zealand: Kevin, 47, Joanne, 46, Sophie, 9, and Michael, 6; and American Christopher Le Gallo, 33. Le Gallo was on his honeymoon; newspapers at the time reported that his wife was afraid to fly, and let him go on the ten-minute interisland flight alone.

The ATSB, Australia's accident investigation authority, has already attributed the probable cause of the crash to Morris's error. Morris was an experienced pilot with 1300 hours total, although only 19.2 on type, all obtained in the last week of his life -- he had just started with that charter operator, Western Air Services, eight days prior.

Then-Chief Pilot for Western, Alan Gray, said that Morris was the best pilot with the service, despite being new to the Cherokee Six. Gray chose Morris over other applicants because he was "well above the average experience of other applicants," according to Australian media reports. "He had a very good attitude towards flying.... he was flying to a better standard than other staff there," Gray told the inquest.

The picture below is the actual mishap aircraft, VH-MAR. The flight was a charter from Hamilton Island to Lindeman Island. ATSB took interest in the training that Morris had, which didn't include emergency procedures after takeoff or stall recovery in the Cherokee Six. The issue may have been somewhat moot, as the stalled at too low an altitude to make a recovery (a laden Cherokee Six can lose 300-400 feet in a normal stall).

It is also interesting to note that two pilots who flew as passengers in VH-MAR the same day perceived the engine as running rough. The engine had only 300 hours since overhaul, and Gray said it had been running "so sweetly" in the days before the crash. The ATSB theorized that Morris may have mismanaged the elderly Six's complicated fuel selector, a part of the plane that Gray agreed was not optimal; but the destruction of the plane and its systems was so absolute that they couldn't find a definitive reason for the loss of power.

Along with the cannabis, Morris's samples also contained a variety of other substances, including codeine, morphine and paracetamol, as well as an alcohol level of .08. But Professor Drummer said there could be an innocent explanation for these items. The alcohol was, in his opinion, produced postmortem; and the other drugs were ingredients or metabolites of two common Australian cold and headache -- or hangover? -- remedies that were found in Morris's home, codral and panadol.

"There was insufficient evidence to definitively link the pilot's prior intake of alcohol and/or cannabis with the occurrence." the ATSB wrote in its final report, in March, 2004. "However, the adverse effects on pilot performance of post-alcohol impairment, recent cannabis use and fatigue could not be discounted as contributory factors to the occurrence. In particular, the possibility that the pilot experienced some degree of spatial disorientation during the turn as a combined result of the manoeuvre, associated head movements and alcohol-induced balance dysfunction could not be discounted."

At the inquest, Gray, the former chief pilot, told Coroner Michael Barnes that he could not believe that Morris had had any alcohol the morning of the flight. Morris had flown a leg with Western Air Pilot Andrew Zantis, and Gray said that Zantis "doesn't drink at all.... he would have easily smelt it on him."

Australia, like most nations, does not conduct random drug tests of pilots and other transportation workers -- the USA is in the minority, by requiring such tests.

The turn back to the runway on engine failure is a well-known, and far too frequent, killer. Morris had attended a pilots' meeting at which loss of power on takeoff from Hamilton Island was one scenario discussed -- and a ditching offshore was the consensus solution. But he had an ambiguous situation with partial power, and although the decision turned out poorly, ATSB is reluctant to fault him overly: "His decision to commence a turn was in response to an ill-defined, unenviable, over water emergency situation to which it was likely that varying responses could be expected from individual pilots."

To complicate the matter, the Cherokee Six, a 1970 model, had the early idiot-light stall warning indicator, and not the more usual -- and, says ATSB, less easily overlooked -- aural warning.

The aircraft crashed on a hillside near the departure end of Runway 14 at Hamilton Island. The aircraft struck in an approximately 70-degree nose down attitude. The impact forces were not survivable, and fire destroyed most of the wreckage before the island's volunteer firefighters could extinguish the blaze.

While the ATSB could not determine whether Morris's dope-smoking and social drinking had any influence on the grim events of September 26, 2002, the Board did commission two in-depth reports, which take the form of a survey of the scientific literature on the effects of cannabis and alcohol on human performance, particularly with respect to aviation. (The reports, which were filed with the ATSB's 2004 report, are .pdf files that you can download at the linked pages).

The purpose of the coroner's inquest now underway is to examine the death of the six crash victims. An Australian Department of Justice website explains that "[a]n inquest is a public court inquiry presided over by a Coroner in which the circumstances surrounding a death are examined. A Coroner is an independent judicial officer who must inquire into every death from unknown or apparent non-natural causes."

The Australian government stresses that this is a fact-finding hearing, and will not answer directly any questions of civil responsibility or criminal culpability: "An inquest does not decide questions of civil liability and the Coroner is not allowed to include in a comment or finding a statement that any person is or may be guilty of an offense."

In the end, it's like so many other accidents: a human tragedy, with no upside at all -- unless we can learn from it.

FMI: www.atsb.gov.au

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