Misfortune with Medications
By Dr. Susan Northrup, FAA Federal Air Surgeon
Given the IFR theme of this issue, I thought it would be useful to review several fatal accidents in which spatial disorientation and/or medication possibly contributed to the outcome (special thanks to Dr. Loren Groff at the NTSB for his assistance) and explain why we place restrictions on some of these conditions/medications. Here are a few examples listed by the NTSB’s Case Analysis and Reporting Online (CAROL) number (carol.ntsb.gov).
🛩️ CEN21LA089: A student pilot with a passenger on board, took off into night, instrument conditions despite having been advised that he could not carry passengers and was specifically told not to fly that day due to weather. At his Class III medical six months earlier, he had not disclosed his history of ADHD (attention deficit hyperactivity disorder) nor the use of Vyvanse, an amphetamine. The latter’s concentration greatly exceeded the therapeutic level and both it and the ADHD would have made him prone to impulsivity and poor decision-making. Following 20 minutes of erratic flight after take-off, he entered a spiral descent that led to a fatal crash.
🛩️ CEN14GA135: The commercial instrument pilot impacted the terrain on a fire-spotting mission in marginal VFR conditions. The Cessna 210 was instrument equipped but not maintained for instrument flight. There was no evidence that the pilot obtained a weather briefing prior to flight. Three weeks prior to the accident, the pilot had started nortriptyline, an anti-depressant also used for chronic pain, and tramadol, a synthetic opioid used for pain control. Neither is authorized for use when flying. While the pilot had disclosed the chronic knee pain, he began both medications after his last FAA medical examination.
🛩️ ERA17FA180: The non-instrument rated private pilot and his passenger were in a fatal crash following continued flight into IMC conditions and probable spatial disorientation. While the pilot did have over 80 hours of instrument experience, he had no instrument time logged in the past year and was not instrument rated. The pilot had not disclosed the use of imipramine, an anti-depressant not authorized for use by the FAA due to cognitive impairment and sedation, as well as doxylamine, a sedating antihistamine with a 60-hour no-fly period following use.
What is clear is that some medical conditions and many medications can impair both judgement and the ability to control an aircraft.
🛩️ CEN14FA042: A flight instructor and private pilot impacted rising terrain while on an instrument approach during a combined business trip and instrument training flight. The mishap was at night in instrument conditions at the end of a long day which began approximately 13 hours earlier and after almost 6 hours of flying over three legs. Toxicological testing showed the presence of dextromethorphan in the blood of the flight instructor and diphenhydramine at therapeutic levels in the blood of the private pilot receiving instruction. Both medications cause cognitive impairment and drowsiness. The FAA period for the residual concentration to be clinically insignificant is 48 and 60 hours, respectively. It could not be determined who was the pilot flying at the time of impact.
Looking at these accidents, it is clear that experience does not prevent spatial disorientation or controlled flight into terrain accidents. Pilots ranging from students to instructors, sport pilots to commercial pilots are represented. What is clear is that some medical conditions and many medications can impair both judgement and the ability to control an aircraft. There are reasons that these are considered incompatible with flying and disqualifying for an FAA medical. Flying either as a sport pilot or under BasicMed offers no protection from the impairment from these different conditions and medications. Of the total accidents between fiscal years 2019 and 2023, the percent positive for psychotropic medications (affecting the mind) rose from approximately 8.5% to approximately 13%. These medications include antidepressants, antipsychotics, anxiolytics, and stimulants with antidepressants the most common. Please note that this does not reflect accidents related to other conditions or medications. Remember, sometimes the best decision is not to go; you may save your life.
Dr. Susan Northrup received a bachelor’s degree in chemistry, a medical degree from The Ohio State University, and a master’s degree in public health from the University of Texas. She is double board-certified by the American Board of Preventive Medicine in Aerospace Medicine and Occupational Medicine. She is a retired U.S. Air Force colonel and a former regional medical director for Delta Air Lines. She is also an active private pilot.
