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One pilot's "hazardous anti-authority attitude" contributed to a deadly 2022 crash in Harlan, Kentucky. The pilot, a doctor, was flying to attend to his patients for scheduled appointments near the airport when on his third and final approach to find the runway to land, his Beechcraft Bonanza A36 (N84R) impacted a ravine and steep rock wall, killing him and destroying the plane.
On Nov. 3, 2022 the pilot departed the Knoxville Downtown Island Airport (DKX) to see patients in Harlan, Kentucky. The NTSB Final Report noted that there was no record of a flight plan or weather briefing for the flight, nor was there any recorded communication with air traffic control. The report said the flight track was consistent with a route of flight the pilot entered into Foreflight before takeoff, containing multiple user-defined waypoints toward the Tucker-Guthrie Memorial Airport (I35). The reported ADS-B altitude data for the entire flight was in error and the report said it did not correspond to a reliable value. When the plane entered into the traffic pattern, archived audio recordings of the I35 common traffic advisory frequency found he had stated: "Harlan Tucker Guthrie bonanza 84 Romeo is two and a half to the west will circle for landing Harlan Tucker Guthrie."
According to the flight track data, the pilot completed multiple approaches and maneuvers over the airport. The Bonanza flew over runway 8 and made a slight right turn followed by a left 180-degree teardrop turn for the first pass over the runway. Minutes later the plane flew over runway 26 on an extended centerline before making another left teardrop 180-degree turn back toward runway 8. Two minutes later the plane made a second pass over runway 8 before entering a slight right turn and another left 180-degree teardrop turn. A few minutes later, the plane flew over runway 26 on a longer extended centerline before entering another left 180-degree teardrop turn to intercept the extended centerline course for runway 8 on the third and final approach made.
The Bonanza followed an extended centerline course toward the runway and the final recorded position was just 0.1 nautical mile from the runway 8 threshold. The plane impacted a ravine and steep rock wall roughly 50 feet below the runway elevation and 375 feet from the runway 8 threshold. A pilot who witnessed told investigators that he heard the Bonanza complete two approaches to runway 8. He did not visually observe the plane due to the fog and low clouds. He said the first approach seemed high and the second sounded "really low." The witness said that the engine noise was a steady piston engine sound for both passes, with no noticeable increases or decreases in power. He told the NTSB that after the second pass he assumed the plane performed a missed approach. The engine sound had become more distant from the airport and he did not hear it again, nor did he hear the Bonanza's impact with terrain. The witness told investigators that about two weeks before the crash, he observed the Bonanza land at I35 covered in airframe icing one morning. He said he noticed the plane on final approach and that it dived toward the runway on a short final. He observed the forward windscreen covered in airframe icing and took particular note of the event since he was concerned about the icing and clouds the morning before.
The airport manager's son told the NTSB that the surveillance footage showed foggy conditions at the time of the crash. He told investigators that the FAA had issued a Notice to Air Missions prior to the crash, telling the airport manager to shut off all airport lights on Oct. 19, 2022. At the time of the crash, the NOTAM was in effect, declaring that all airport lights were unusable. Roughly 10-12 years before, the airport received grant money from the FAA to install airport lighting but a Kentucky State agency did not match grant funding. The airport lights were "day only" and a "photocell" was not installed, which would have enabled night operation. When the Bonanza crashed, the airport beacon was off and could not have been turned on by the pilot with pilot-controlled lighting. The runway end identifier lights were also off and could not have been activated by a pilot. The visual approach slope indicator was also turned off due to recent damage by a lawn mower. The airport manager told investigators that in his opinion, the REIL runway lights and strobes could have made a difference in the pilot's approaches.
All of the major components of the plane were found and a post-impact fire consumed most of the cockpit, fuselage and portions of the left wing. Flight control cable continuity was established but due to the impact and fire damage, the position of the flaps, landing gear and fuel selector could not be determined. The cockpit, switches, levers and flight instruments were all damaged or entirely consumed by the fire and it was not possible to obtain any instrument reading from the recovered instrumentation. There was impact- or fire-related damage to many components of the Bonanza. The post-accident examination did not reveal any preimpact mechanical malfunctions or failures.
The pilot's most recent flight review and instrument proficiency check was completed on March 30, 2021. In the previous six months, the pilot had logged three instrument approaches. The last flight logged was on Oct. 28, 2022. The pilot did not meet the FAA's instrument currency requirements, which require the completion of six instrument approaches. A review of his logbook from Aug. 1, 2022 to Nov. 1, 2022 showed that the pilot had completed over 35 flights from either McGhee Tyson Airport (TYS) or DKX to I35 or the Middlesboro Bell County Airport (1A6). Logs revealed that the pilot frequently landed at I35 when the airport reported IFR conditions or low IFR conditions. His flight track approaches were varied, but multiple flights showed a similar circling maneuver and approach to runway 8, like in the Nov. 3 flight. Multiple flights in September 2022 were conducted with approaches and landings that were not consistent with the GPS-A instrument approach procedure.
At the time of the crash, I35 was experiencing low IFR conditions. Right after the crash, a METAR observed that the visibility was less than ¼ statute miles and the ceiling was overcast 200 ft above the ground, which was observed hours before and shortly after the crash. One hour after the crash the I35 METAR reported VFR conditions, with visibility improving to 10 statute miles and scattered clouds at 200 ft agl. The estimated visibility, based on aerial imagery, was limited to about 175 ft due to the fog and low clouds. The witness reported that conditions were very foggy at the time of the crash. He said he could not see farther than the south runway edge area and the red 8-26 runway sign from the terminal fueling area, which was measured with aerial imagery at about 250-300 ft. The weather conditions at the departure airport were VFR when the pilot took off.Engine as found at crash site
The toxicology report was positive for methamphetamine in the pilot's brain tissue at 40 nanograms per gram and results in his lung and liver tissue, but the results were inconclusive in the liver tissue and the kidney tissue was not suitable for analysis. The stimulant phentermine was found in the pilot's liver, brain, kidney, muscle and lung tissue. The sedating antihistamine chlorpheniramine and the non-sedating cough suppressant dextromethorphan and its metabolite dextrorphan were detected in the pilot's liver and muscle tissue.
Methamphetamine is a Schedule II controlled substance and medical indicated to treat ADHD, narcolepsy and obesity. The use of methamphetamine may impair the user's ability to engage in hazardous activities like driving a motor vehicle. The FAA does not allow a medical certificate to be issued if the pilot is using the substance. Phentermine is a stimulant with similar activity to amphetamine. Adverse reactions include overstimulation, dizziness, insomnia, tremor and headaches. Phentermine may impair the ability to operate machinery or drive a motor vehicle and is another substance that would prevent the FAA from issuing a medical certificate. The NTSB said methamphetamine was detected at low levels and due to his extensive injuries, no blood specimens were available for testing, so whether the medications were at therapeutic levels was not determined.
Chlorpheniramine is a sedating antihistamine available over the counter. The pilot's wife told investigators that he took reflux medication and something for cholesterol and before the crash the family had a cold and were all taking over-the-counter cold medicine. The FAA provides guidance on wait times before flying after taking this medicine and post-dose observation time is 60 hours. The medication is not for daily use. Due to the lack of specimens available for testing, it is unknown whether the pilot experienced side effects or if the substance was at therapeutic levels.
The NTSB found the probable cause to be the pilot's visual flight rules flight into instrument meteorological conditions during an approach to land at the airport with mountainous terrain, resulting in controlled flight into terrain. The report also noted that contributing to the crash was the pilot's "hazardous anti-authority attitude." The report noted that being fit to fly depends on more than a pilot's physical condition and experience. According to the FAA Pilot's Handbook of Aeronautical Knowledge, hazardous attitudes contribute to poor pilot judgment.
"Attitude affects the quality of decisions," the report said.
"Attitude is a motivational predisposition to respond to people, situations, or events in a given manner," the NTSB report said. "Studies have identified five hazardous attitudes that can interfere with the ability to make sound decisions and exercise authority properly: anti-authority, impulsivity, invulnerability, macho, and resignation."
"The antidote provided for anti-authority was ‘Follow the rules. They are usually right," the report said of the FAA Pilot's Handbook of Aeronautical Knowledge.Read the FAA Pilot's Handbook of Aeronautical Knowledge, Chapter 2 Aeronautical Decision Making here
The report said that the pilot's use of prohibited substances, as well as his decision to routinely fly to the airport under VFR and into IMC shows poor judgment and an anti-authority hazardous attitude.
"The detection of these medications was more emblematic of his disregard of safety and rules than of impairment," the report noted. "Thus, while stimulants were detected in the pilot's tissues, it is unlikely that the effects of the pilot's use of phentermine and methamphetamine contributed to this accident."
The pilot was 55-year-old Dr. David G. Sanford. He was survived by his wife Amy and two children, George and Mira.