Friday, February 19, 2021

Visual Flight Rules encounter with Instrument Meteorological Conditions: Cirrus SR22, N917SR; fatal accident occurred February 15, 2019 in Ely, White Pine County, Nevada

National Oceanic and Atmospheric Administration (NOAA) calls for revisions for automated weather observing systems

(WASHINGTON) — The National Transportation Safety Board (NTSB) is providing the following information to urge the National Weather Service (NWS) and the Federal Aviation Administration (FAA) to take action on the safety recommendations in this report. In the interest of transportation safety, the recommendations address various concerns with malfunctioning automated surface observing systems (ASOS) and automated weather observing systems (AWOS), as well as their respective reporting capabilities, which can result in erroneous weather information being provided to the transportation community.

These recommendations derive from the NTSB’s investigation of a fatal accident involving a privately operated Cirrus SR22 that crashed while maneuvering at low altitude near Ely, Nevada, on February 15, 2019, as well as the investigation of the sinking of the amphibious passenger vessel Stretch Duck 7 on July 19, 2018, near Branson, Missouri. The NTSB is issuing two new safety recommendations to the NWS and two new recommendations to the FAA to address identified safety issues.

Recommendations for the National Weather Service

Revise National Weather Service Instruction 30-2111 to clearly define “outage,” “failure,” and similar terms regarding individual automated surface observing system (ASOS) sensor and component performance and to include explicit maintenance actions intended to mitigate presumed erroneous ASOS sensor reporting that does not generate failure flags in maintenance monitoring data. (A-21-1)

Revise National Weather Service Instruction 30-2112 to provide operational (forecasting) staff at weather forecast offices the authority to determine whether report processing for an automated surface observing system sensor at an unattended site (or other site not currently being appropriately augmented) should be turned off immediately if the sensor is believed to be reporting erroneously but does not yield flags in its maintenance monitoring data and to include clear instructions for performing this task. (A-21-2)

Recommendations for the Federal Aviation Administration

Revise Federal Aviation Administration Order 7930.2S to make the standards for issuing notices to airmen (NOTAM) as they relate to automated surface observing systems (ASOS) consistent with the NOTAM issuance standards for automated weather observing systems, including criteria addressing inaccurate or unreliable ASOS sensor information and VHF outages. (A-21-3)

Establish maintenance standards to eliminate erroneous timestamping and related delayed longline dissemination of weather observations due to excessive internal clock drift and system events from affected automated weather observing system models. (A-21-4)

— National Transportation Safety Board

Phillip and Linda Bethell

Aviation Accident Final Report - National Transportation Safety Board 

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Reno, Nevada
Continental Motors; Mobile, Alabama 
National Weather Service; Silver Springs, Maryland 
National Weather Service; Sterling, Virginia 
Cirrus Aircraft; Duluth, Minnesota

Location: Ely, Nevada 
Accident Number: WPR19FA084
Date & Time: February 14, 2019, 17:30 Local 
Registration: N917SR
Aircraft: Cirrus SR22
Aircraft Damage: Destroyed
Defining Event: VFR encounter with IMC
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General aviation - Personal


The noninstrument-rated pilot departed on a visual flight rules (VFR) 336 nautical mile (nm) cross-country flight to the northwest in a direct path toward the destination airport. Shortly after departure, the pilot advised air traffic control that he would be diverting to the south for weather; a cold front was passing over the route of flight, in which both VFR and instrument meteorological conditions (IFR) prevailed.

About 1 hour and 27 minutes into the flight, the controller suggested to the pilot that in order to circumvent the weather, he fly from his present position southwest to an alternate airport, where he could then turn north to his destination; at this time the alternate airport was about 154 nm southwest of his position. The pilot subsequently advised the controller that he was “…going north to go under [the] deck in about 50 miles. Over the next several minutes, the airplane descended, followed by the controller advising the pilot that he was going in and out of radar contact. The controller provided the pilot a heading to the previously advised alternate airport which was reported as VFR.

The pilot arrived at the alternate airport terminal area about 25 minutes after his decision to divert. Witnesses reported that the weather was below VFR minimums, with a solid ceiling of 200 ft above ground level, and visibility between 1/4 and 1/2 mile with snow. They also reported hearing the pilot click his microphone several times to activate the pilot-controlled runway lights. The pilot stated that if he could see the runway he could land, to which one of the witnesses informed the pilot that the runway lights were on.

There were no further communications with the pilot. 

Onboard recorded data revealed that for about the last 10 minutes of flight, the pilot entered the airport terminal area south of the airport on a westerly heading at an altitude of 9,000 ft msl. He subsequently made a 90° right turn toward the north, followed by multiple right and left turns over the airport area at altitudes of between 7,100 ft msl to 7,800 ft msl; the airport elevation was 6,259 ft msl. The pilot then proceeded toward the northeast in a climbing right turn, most likely to proceed eastbound toward a more favorable airport. At this time, it was estimated that the pilot had about 2 hours of fuel remaining, an adequate fuel supply to divert back to the east about 80 nm where a myriad of airports were located that were operating under VFR conditions. However, in an attempt to ascend over a ridgeline to the east of more than 10,750 ft msl, upon reaching an altitude of about 9,400 ft msl, the airplane entered a descending right turn at a rate of descent of about 6,400 ft per minute and an indicated airspeed of about 210 kts, which is consistent with a high rate of descent. As icing was present in the area at the time of the accident, airframe icing most likely precipitated the stall, followed by entering the right spin and subsequent impact with terrain about 3.4 nm northeast of the airport at an altitude of about 6,929 ft msl. The airplane was not authorized for flight into known icing conditions.

Postaccident examination of the airframe and engine revealed no mechanical anomalies that would have precluded normal operation.

The diversion airport’s ASOS visibility sensor was reporting visibilities which were inaccurate for weeks leading up to the accident, as well as on the day of the accident. The ASOS was scheduled to be repaired that day; however, the technician who was to perform the maintenance was unable to do so due to the weather conditions. Because snowfall intensity reporting was dependent on the visibility observation, inaccurate visibility reporting likely resulted in an unrepresentatively low reported snowfall intensity on the day of the accident. Although the erroneous visibility information provided by the ASOS may have contributed to the pilot’s decision to divert to the airport, as a noninstrument-rated pilot, it remained incumbent upon the pilot to maintain VFR conditions while maneuvering in an attempt to land.

Had the pilot been aware of the impending instrument meteorological conditions that he was about to encounter he might have diverted to an airport with better conditions. According to Flight Services, neither they nor any third-party vendors had any contact with the accident pilot.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot’s decision to continue the visual flight rules flight into instrument meteorological conditions and icing conditions which resulted in a high rate of descent and impact with terrain. Contributing to the accident was the inaccurate weather reporting from the airport weather reporting facility.


Personnel issues Decision making/judgment - Pilot
Personnel issues Aircraft control - Pilot
Environmental issues Below VFR minima - Decision related to condition
Environmental issues Mountainous/hilly terrain - Contributed to outcome
Environmental issues Low visibility - Accuracy of related info

Factual Information

History of Flight

Enroute-descent VFR encounter with IMC (Defining event)
Maneuvering Loss of visual reference

On February 15, 2019, about 1730 Pacific standard time, a Cirrus SR22 airplane, N917SR, was destroyed when it was involved in an accident near Ely, Nevada. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight.

The pilot and passenger departed on the cross-country flight from Craig-Moffat Airport (CAG), Craig, Colorado, about 1425, with a planned destination of Joslin Field-Magic Valley Regional Airport (TWF), Twin Falls, Idaho, about 336 nautical miles (nm) to the northwest. Visual and instrument meteorological conditions (VFR & IFR) prevailed over the route at this time, as a cold front was moving over the area. Air traffic control radar and communications information provided by the Federal Aviation Administration (FAA) revealed that the pilot contacted air traffic control shortly after departure and requested visual flight rules (VFR) flight-following services to TWF. He also stated that he would "have to go quite a ways south of direct because of convection." As the airplane proceeded west, then southwest, at an altitude of about 17,500 ft mean sea level (msl), the pilot reported to the air traffic controller that he planned to turn north upon reaching Salt Lake City, Utah. About 1552, or 1 hour and 22 minutes into the flight, and after discussing with the pilot his intent to deviate around the weather by continuing southwest, the controller suggested that the pilot proceed direct to Ely, Nevada (ELY) before continuing to TWF. At this time the airplane was about 154 nm east-northeast of ELY and about 217 nm south-southeast of TWF; TWF was about 192 nm north of ELY. The pilot replied, “I hadn't planned to go as far west as Ely but if that's what I have to do I can." About 1616, while still at an altitude of 17,700 ft msl, the pilot advised the controller that he was going north “to go under [the] deck in about 50 miles; 5 minutes later the pilot began his descent from 17,700 ft msl. This was followed about 7 minutes later when the pilot was observed having turned left to a southwest heading and descending through 12,300 ft msl. About 1632 while now descending through 10,400 ft msl and continuing on a southwest heading, the controller advised the pilot that he was going in and out of radar coverage; at 1634 radar contact was lost with the airplane while it was descending through 10,000 ft msl over mountainous terrain, with peaks over 11,000 ft msl. The controller subsequently advised the pilot that ELY was 75 miles southwest of his location and provided him with the current weather, which was wind 170° at 14 knots (kts) gusting to 22 kts, visibility 10 miles, broken ceiling at 5,000 ft and an overcast ceiling of 6,500 ft. About 1637, the pilot advised the controller that he was diverting to ELY with the intention of landing there. The controller stated that he would keep looking for the airplane on radar and provided the ELY altimeter setting, which the pilot acknowledged. Although radio communication between the controller and pilot was lost after this transmission, another airplane operating in the area established contact with the accident airplane and relayed to the pilot that radar service was terminated and to remain in VFR conditions. The relay aircraft reported to the controller that the accident pilot acknowledged the instructions. Subsequently, there were no further communications between the accident pilot and the controller, and radar contact was not reestablished.

A witness just east of ELY reported that about 1700, he heard an airplane flying low in the clouds over his residence. He stated that the weather was very bad at that time, that he could not see the house next door to him, and that the clouds were at tree-top level.

A second witness, who was about 2.6 miles north of the departure end of ELY runway 30, reported that he monitored the ELY UNICOM frequency and made unofficial visual estimates of the ceiling and visibility. He stated that, about 1719, he heard a series of 5 or 6 clicks on the frequency, which indicated that someone was attempting to activate the airport's pilot-controlled lighting. He stated that the snow was very heavy at the time and he estimated that the visibility was about 1/4 mile in snow. He then heard the following transmission, "Are the runway lights on? I can see the runway." About a minute later, he heard a second transmission of, "I'd like (or 'I'm trying') to land, but I cannot see the runway." He added that when he looked at a clock, it was 1721 or 1722. Neither transmission contained an aircraft identification number or any other identifying information; he did not hear any further communications.

The manager of a fixed-base operator at ELY reported that he was preparing to depart for the day between 1645 and 1700. Due to a fast-moving storm, the visibility had been reduced from 4 to 5 miles visibility to under 1/2 mile in just a few minutes. The witness stated that, about this time, he heard someone keying the microphone to turn on the runway lights. He added, "I was surprised that anyone was out there in the weather we were experiencing." The witness stated that he transmitted on the UNICOM frequency, and a pilot answered that he was trying to turn the runway lights on. The manager replied that the lights were on, but the visibility was "that bad." The pilot responded that if he could just see the runway, he could land. There were no further transmissions from the pilot. The witness added that the ELY Automated Surface Observing System (ASOS) had not been accurately reporting the visibility for at least 2 weeks before the accident; the problem had been reported by the ELY airport manager as well as by pilots.

Onboard non-volatile recorded data for the last 10 minutes of the flight (See Figure 1) revealed that the pilot entered the airport terminal area south of the airport on a westerly heading at an altitude of 9,000 ft msl. The pilot subsequently made a 90° right turn toward the north, followed by multiple right and left turns over the airport area at altitudes of between 7,100 ft msl to 7,800 ft msl; the ELY airport elevation is 6,259 ft msl. The pilot then proceeded toward the northeast.

Figure 1 – Overhead view of last 10 minutes of flight

Pilot Information

Certificate: Private 
Age: 72, Male
Airplane Rating(s): None 
Seat Occupied: Left
Other Aircraft Rating(s): None 
Restraint Used: 4-point
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 Without waivers/limitations
Last FAA Medical Exam: November 16, 2017
Occupational Pilot: No
Last Flight Review or Equivalent: February 16, 2018
Flight Time: (Estimated) 1619 hours (Total, all aircraft), 1118 hours (Total, this make and model), 23 hours (Last 90 days, all aircraft), 7 hours (Last 30 days, all aircraft), 3 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Cirrus
Registration: N917SR
Model/Series: SR22 Undesignated
Aircraft Category: Airplane
Year of Manufacture: 2005
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 1467
Landing Gear Type: Tricycle 
Seats: 4
Date/Type of Last Inspection: March 13, 2018 Annual
Certified Max Gross Wt.: 3400 lbs
Time Since Last Inspection: 
Engines: 1 Reciprocating
Airframe Total Time: 
Engine Manufacturer: Continental Motors
ELT: Installed, not activated 
Engine Model/Series: IO-550-N (27)
Registered Owner: 
Rated Power: 310 Horsepower
Operator: On file
Operating Certificate(s) Held: None

According to the manufacturer, the airplane was originally equipped with an Avidyne Multi-Functional Display (MFD), an Avidyne Primary Functional Display (PFD), an STEC 55X autopilot, and two Garmin GNS430 units. The airplane had also been retrofitted with an Avidyne DFC90 autopilot.

The airplane's MFD was capable of providing the pilot with a visual weather display, should the pilot elect to use it; however, the MFD was not located within the main wreckage or in the debris field. As such, it could not be determined whether the pilot was using the MFD as he approached ELY, nor was it able to be determined the level of proficiency the pilot possessed in the use the weather display.

The annual inspection entry stated that the pitot-static and transponder tests were due April 30, 2019.

The Cirrus Design SR22 Pilot Operating Handbook for the accident airplane make and model, Section 2, Limitations states, “Flight into known icing conditions is prohibited.

According to the airplane manufacturer, the accident airplane make and model cannot maintain flight at an airspeed of less than 50 knots.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC) 
Condition of Light: Day
Observation Facility, Elevation: ELY,6259 ft msl
Distance from Accident Site: 3 Nautical Miles
Observation Time: 17:04 Local
Direction from Accident Site: 205°
Lowest Cloud Condition: 
Visibility 9 miles
Lowest Ceiling: Broken / 1600 ft
AGL Visibility (RVR):
Wind Speed/Gusts: 17 knots / 28 knots
Turbulence Type Forecast/Actual: None / None
Wind Direction: 310° 
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 29.7 inches Hg 
Temperature/Dew Point: -4°C / -4°C
Precipitation and Obscuration: Light - Showers - Snow
Departure Point: Craig, CO (CAG)
Type of Flight Plan Filed: None
Destination: Twin Falls, ID (TWF) 
Type of Clearance: VFR flight following
Departure Time: 15:25 Local 
Type of Airspace: Unknown

At 1453, the ELY Automated Surface Observing System (ASOS), located about 3.4 nm southwest of the accident site, reported wind 160° at 19 kts, gusts at 25 kts, visibility 9 statute miles (sm), scattered clouds at 4,800 ft above ground level (agl), broken clouds at 7,000 ft agl, temperature 2° Celsius (C), dew point -3°C, and an altimeter setting of 29.68 inches of mercury. Remarks: snow began at 26 minutes after the hour and ended at 52 minutes after the hour.

At 1553, the ELY ASOS reported wind 170° at 14 kts, gusts 22 kts, visibility 10 sm, broken clouds at 5,000 ft agl, overcast clouds at 6,500 ft agl, temperature 2°C, dew point -4°C, and an altimeter setting 29.67 inches of mercury. Remarks: unknown precipitation began at 31 minutes after the hour and ended at 39 minutes after the hour.

At 1653, the ELY automated weather reporting system, reported wind 180° at 15 kts, gust 20 kts, visibility 10 sm, broken clouds at 4,200 ft agl, broken clouds at 5,500 ft agl, overcast clouds at 7,000 ft agl, temperature 2°C, dew point -4°C, and an altimeter setting of 29.67 inches of mercury.

At 1724, the ELY ASOS special observation reported wind 310° at 17 kts, gusts 28 kts, visibility 9 sm, light snow, broken clouds at 1,600 ft agl, light snow, broken clouds a 2,800 ft agl, overcast clouds at 3,800 ft agl, temperature -4°C, dew point -4°C, and an altimeter setting of 29.71 inches of mercury. Remarks: peak wind of 28 kts from 300° occurred at 1712, wind shift at 1710, snow began at 1702, pressure rising rapidly, trace amount of liquid equivalent precipitation since 1656.

At 1732, the ELY ASOS special observation reported wind 320 at 12 kts, visibility 9 sm, light snow, broken clouds at 1,200 ft agl, broken clouds at 2,800 ft agl, overcast clouds at 3,800 ft agl, temperature -4°C, dew point -4°C, and an altimeter setting of 29.73 inches of mercury. Remarks: peak wind of 28 kts from 300° occurred at 1712, wind shift at 1710, snow began at 1702, pressure rising rapidly, 0.08 inches of liquid equivalent precipitation since 1656, temperature of -3.9°C and dew point temperature of -4.4°.

At 1744, the ELY ASOS special observation reported wind 310° at 6 kts, visibility 9 sm, light snow, overcast clouds at 600 ft agl, temperature -4°C, dew point -4°C, and an altimeter setting of 29.74 inches of mercury. Remarks: peak wind of 28 kts from 300° occurred at 1712, wind shift at 1710, snow began at 1702, pressure rising rapidly, 0.03 inches of liquid equivalent precipitation since 1656, temperature of -3.9°C and dew point temperature of -4.4°C.

At 1520, a Terminal Area Forecast (TAF) was issued for ELY that forecasted for the time of the accident, wind 180° at 12 kts with gusts to 22 kts, visibility 5 miles, light snow, scattered clouds at 1,500 ft agl, ceiling overcast at 2,500 ft agl, with temporary conditions between 1700 and 2100, visibility of one mile, light snow, and vertical visibility of 1,200 ft agl.

The National Weather Service (NWS) Surface Analysis Charts for 1600 and 1900 showed a cold front northwest of the accident location advancing southeast. At 1600 the chart depicted a section of the front immediately northwest of the accident location as a warm front, and a low pressure center was located immediately southwest of the accident location. By 1900 the front was southeast of the accident location, with the entire front depicted as a cold front. Continuous light snow was identified near the accident location at 1900. Overcast skies were depicted near the accident site at both times.

Calculations made by the Rawinsonde Observation Program (RAOB) for 1700 indicated the potential for clouds above 8,400 ft agl, with light and moderate icing between about 7,800 ft agl and 15,200 ft and, moderate low-level wind shear (LLWS) near the surface.

RAOB calculations for 1800 indicated the potential for clouds above about 7,200 ft with moderate icing from the surface to about 11,300 ft and light low-level wind shear (LLWS) near the surface.

Geostationary Operational Environmental Satellite (GOES)-17 infrared imagery depicted an area of relatively high clouds, which were oriented in a southwest-to-northwest fashion and advancing to the southeast and through the accident region around the accident time. 

Infrared cloud-top temperatures corresponded to cloud top heights of about 22,200 ft msl. Brightness temperatures in the area immediately ahead of these advancing clouds in the accident region at 1632 corresponded to cloud top heights of about 9,500 ft msl.

The Area Forecast issued at 1534 predicted light to moderate snowfall in the area of the accident site and stated that cloud ceilings and visibility at ELY would deteriorate to instrument flight rules (IFR) or low IFR conditions.

The Area Forecast issued at 1735 stated that a band of snow showers would be moving through the area of ELY with deteriorating conditions through the evening hours.

AIRMET advisories for IFR conditions, mountain obscuration, moderate turbulence below 18,000 ft msl and moderate icing between the freezing level and 18,000 ft msl were active for the accident site at the time of the accident.

According to Leidos Flight Service (LFS), neither they nor any third-party vendors using the LFS system had any contact with the accident pilot.

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 1 Fatal 
Aircraft Fire: None
Ground Injuries:
Aircraft Explosion: None
Total Injuries: 2 Fatal 
Latitude, Longitude: 39.334167,-114.78055

The airplane wreckage was consistent with the airplane impacting shallow, upsloping, snow-covered terrain in an upright and right wing low attitude at an elevation of 6,929 ft msl about 3.4 nm northeast of ELY. All major components of the airplane necessary for flight were accounted for at the accident site. The initial point of impact comprised a roughly 5-ft-wide by 12-ft-long by 6-inch-deep crater; a debris path extended about 473 ft from the crater on a magnetic heading about 065°.

The firewall and instrument panel had separated from the fuselage and exhibited impact damage. Two composite propeller blades were observed in the debris field; both blades exhibited impact damage. The propeller hub was not observed or recovered. The engine was separated from the firewall, with most of the accessories observed separated from the engine. Examination of the induction system, ignition system, fuel and oil systems, and borescope examination of the cylinders revealed no anomalies that would have precluded normal operation.

The carry-through wing spar was separated from the fuselage. The left side of the spar, torque box structure, and wing skins were present. The right side of the spar, the torque box structure, and wing skins were fragmented. Both fuel tanks were breached.

The ailerons and flaps had separated from their respective wing and exhibited impact damage. Flight control continuity was established from the cockpit through overload separations or cuts made to facilitate recovery.

The Cirrus Airframe Parachute System (CAPS) enclosure panel was located in the debris field. A fragment of the aircraft roof, which contained the CAPS activation handle and handle holder was observed in the debris field. The rocket motor remained in the launch tube with its frangible link intact. The parachute enclosure was separated from the bulkhead and the parachute was observed on the ground in the immediate vicinity and remained in a packed state.

No anomalies were noted with the CAPS system.

Additional Information

Ely Automated Surface Observing System (ASOS)The ELY ASOS was owned and maintained by the NWS Weather Forecast Office in Elko, Nevada (LKN). Review of NWS records revealed that a "trouble ticket" for the ASOS at ELY was opened on February 5, 2019. The priority 1 ticket advised of unreliable wind and visibility reporting. 

On February 6, 2019, an entry in the maintenance shift log indicated that LKN technicians would have to visit the ASOS to determine visibility sensor accuracy.

On February 11, 2019, a maintenance shift log stated LKN technicians would be visiting Ely the following week to investigate the visibility reporting issue. A part was also ordered, which subsequently arrived at LKN on February 14.

On February 15, 2019, the day of the accident, a technician attempted to transport the part to Ely, but encountered adverse weather and returned to LKN.

On March 14, 2019, repairs to the visibility sensor were made.

An NWS Electronics System Analyst indicated that he believed the ELY ASOS visibility sensor was reporting erroneously on the day of the accident. According to the analyst, this would affect the snowfall intensity reporting. According to the NWS, erroneous observational elements can and do affect the issuance of automated Aviation Selected Special Weather Reports.

Non-Volatile Memory

Flight path data for the airplane revealed that from approximately 17:20:36 to 17:24:48, (see Figures 2 and 3) the indicated airspeed range was from 33 knots to 53 knots. According to the manufacturer, flight in an SR22 cannot be sustained at 50 knots, yet based on the data, the flight did continue. The airplane’s ground speed range during this time frame was from 55 kts to about 170 kts. After 17:24:48 the recorded airspeed returned to values that are in the range where flight can occur. Areas “C” and “D” represent the two areas where the airplane was maneuvering in the ELY terminal area at or below 50 kts indicated airspeed.

Figure 2 – Flight maneuvering (C & D) = 50 kts

Figure 3 – Flight parameters of last 10 minutes of flight

Medical and Pathological Information

The Clark County Coroner, Las Vegas Nevada, performed an autopsy on the pilot. The cause of death was attributed to multiple blunt force injuries. 

An NTSB Medical Officer reviewed the toxicological report for the pilot and reported the following: toxicology testing performed for the Clark County Coroner’s office and the FAA Forensic Sciences Laboratory detected the anti-depressant amitriptyline and its metabolite nortriptyline in liver tissue; nortriptyline was also detected in muscle tissue by the FAA laboratory. The FAA laboratory detected the psychoactive compound mitragynine, its psychoactive metabolite 7-hydroxymitragynine, and the sedating antihistamine cetirizine in the pilot’s liver and muscle tissue. Two over-the counter, nonimpairing pain medications, acetaminophen (commonly marketed as Tylenol) and naproxen (commonly marketed as Aleve) were detected in liver and/or muscle tissue by the coroner’s laboratory and FAA laboratory, respectively. Toxicology performed for the Clark County Coroner’s office on the pilot’s liver tissue was positive for ethanol at 1.4 grams per hectogram (gm/hg); testing performed by the FAA laboratory was negative for ethanol in the pilot’s brain and muscle tissue.

Amitriptyline is a prescription medication used to treat depression, attention-deficit hyperactivity disorder, headaches, and panic, phobia, and eating disorders. It carries the warning that its use may impair mental and physical abilities required to perform hazardous tasks. Its metabolite is nortriptyline, which also has anti-depressant properties and carries the same warning.

Mitragynine and 7-hydroxymitraginine are the primary psychoactive compounds found in the leaves of the southeast Asian kratom tree. It has stimulant effects at low doses, such as increased alertness, physical energy, and talkativeness, and sedative effects at high doses. It is considered a drug of concern by the U.S. Drug Enforcement Administration (DEA) and the U.S. Food and Drug Administration (FDA) has asked the DEA to attempt to place the drug into Schedule I drugs with high potential for abuse and no medical value similar to heroin. The FDA has not approved mitragynine for any medical use.

Cetirizine is a second-generation antihistamine used to relieve hay fever and allergy symptoms. It is available over the counter, commonly marketed as Zyrtec. Although designed to be less sedating, cetirizine does have some sedating properties. FAA provides guidance on wait times before flying after using this medication.

Ethanol is a social drug commonly consumed by drinking beer, wine, or liquor. It acts as a central nervous system depressant: it impairs judgment, psychomotor functioning, and vigilance. Ethanol is water soluble, and after absorption it quickly and uniformly distributes throughout the body’s tissues and fluids. The distribution pattern parallels water content and blood supply of the tissue. Ethanol can be produced after death by microbial activity.


  1. Good sense has no relationship to age.

  2. My question is what was this guy thinking flying a high performance aircraft and having 1700 hours with no IFR rating? Did he try getting one and failed the exam(s)? I've never heard of anyone with that many hours not having an IFR rating.

    1. Lots of pilots don't want to bother with the currency and proficiency requirements of an instrument rating. They like seeing where they're going and enjoy flying looking out the window.