Epidemiology of 

Toxicological Factors in 

Civil Aviation Accident 

Pilot Fatalities, 1999-2003 

Arvind K. Chaturvedi 

Kristi J. Craft

Dennis V. Canfi eld

James E. Whinnery

Civil Aerospace Medical Institute

Federal Aviation Administration

Oklahoma City, OK 73125

November 2005

Final Report

DOT/FAA/AM-05/20 

Offi ce of Aerospace Medicine

Washington, DC 20591
NOTICE

This document is disseminated under the sponsorship of

the U.S. Department of Transportation in the interest of

information exchange. The United States Government

assumes no liability for the contents thereof.
i

Technical Report Documentation Page 

1. Report No. 2. Government Accession No. 3. Recipient's Catalog No. 

DOT/FAA/AM-05/20 

4. Title and Subtitle 5. Report Date 

Epidemiology of Toxicological Factors in Civil Aviation Accident Pilot November 2005 

Fatalities, 1999-2003 6. Performing Organization Code 

 7. Author(s) 8. Performing Organization Report No. 

Chaturvedi AK, Craft KJ, Canfield DV, and Whinnery, JE 

9. Performing Organization Name and Address 10. Work Unit No. (TRAIS) 

 11. Contract or Grant No. 

FAA Civil Aerospace Medical Institute 

P.O. Box 25082 

Oklahoma City, OK 73125 12. Sponsoring Agency name and Address 13. Type of Report and Period Covered 

 

 

 

Office of Aerospace Medicine 

Federal Aviation Administration 

800 Independence Ave., S.W. 

Washington, DC 20591 14. Sponsoring Agency Code 15. Supplemental Notes 

This work was accomplished under the approved task AM-B-05-TOX-202. 

 16. Abstract 

Prevalence of drug and ethanol use in aviation is monitored by the Federal Aviation Administration (FAA). 

Under such monitoring, epidemiological studies for the 19891993 and 19941998 periods indicated lower 

percentages of the presence of illegal (abused) drugs than that of prescription and nonprescription drugs in 

aviation accident pilot fatalities. In continuation of these studies, an epidemiological assessment was made for an 

additional period of 5 years. Postmortem samples from aviation accident pilot fatalities submitted to the FAA 

Civil Aerospace Medical Institute (CAMI) are toxicologically analyzed, and those analytical findings are stored 

in a database. This CAMI database was examined for the period of 19992003 for the presence of controlled 

substances of Schedules IV, prescription and nonprescription drugs, and ethanol in the pilot fatalities. Out of 

1629 fatal aviation accidents from which CAMI received biosamples, there were 1587 accidents wherein pilots 

were fatally injured. Drugs and/or ethanol were found in 830 of the 1587 fatalities. Controlled substances of 

Schedules I and II and Schedules IIIV were detected in 113 and 42 pilots, respectively. Prescription drugs were 

present in 315 pilots, nonprescription drugs in 259 pilots, and ethanol in 101 pilots. Controlled substances of 

Schedules I and II were detected in only 5 of the 122 First-Class medical certificate-holding airline transport 

pilots. In addition to the controlled substances, many of the prescription and nonprescription drugs found in 

the fatalities have the potential for impairing performance, thereby adversely affecting the ability of an 

individual to optimally pilot an aircraft. Findings from this study were consistent with those of the 2 previous 

epidemiological studies and support the FAA's programs, including the FAA's drug-testing program, aimed at 

identifying potentially incapacitating medical conditions and reducing the usage of performance-impairing 

drugs or ethanol. 

 

17. Key Words 18. Distribution Statement 

 

 

Epidemiology, Toxicological Factors, Pilot Fatalities, 

Civil Aviation Accident Investigation 

Document is available to the public through the 

Defense Technical Information Center, Ft. Belvior, 

VA 22060; and the National Technical Information 

Service, Springfield, VA 22161 19. Security Classif. (of this report) 20. Security Classif. (of this page) 21. No. of Pages 22. Price 

Unclassified Unclassified 17 

Form DOT F 1700.7 (8-72) Reproduction of completed page authorized

1

EPIDEMIOLOGY OF TOXICOLOGICAL FACTORS IN CIVIL

AVIATION ACCIDENT PILOT FATALITIES, 1999-2003 

INTRODUCTION

The Federal Aviation Administration’s (FAA’s) Offi ce of Aerospace Medicine is tasked with determining 

the fi tness of pilots to fl y aircraft and enforcing related 

drug and alcohol use regulations (1,2). Under this task, 

specifi c medical conditions and the use of certain drugs 

and ethanol are strictly controlled to ensure the safety 

of the pilots and the general public. The 1988 Aviation 

Safety Research Act (1) and the U.S. Department of 

Transportation Order 8020.11B (3) require that the Offi ce of Aerospace Medicine’s Civil Aeromedical Institute 

(CAMI)1

 assist in assessing the role of potential medical 

condition- or drug/ethanol-related performance impairment of pilots in aviation accidents. In this regard, CAMI 

is also required to conduct special pathological studies 

and perform toxicological analyses on specimens from 

aircraft accident fatalities. 

Such toxicological analyses of postmortem samples 

from aviation accident pilot fatalities are useful in determining whether performance impairment from medical 

condition(s) and/or drug and ethanol usage was a contributory factor in a particular accident. This analytical 

process includes identifi cation of controlled substances of 

Schedules I and II, such as amphetamines, cocaine, and 

marihuana; controlled substances of Schedules III, IV, 

and V, such as benzodiazepines, phentermine, and propoxyphene; prescription drugs, such as antidepressants, 

antihypertensives, and anticonvulsants; nonprescription 

drugs, such as antihistaminics, antipyretics, and decongestants; and ethanol in the postmortem samples (4,5). 

Including controlled substances and ethanol, several 

prescription and nonprescription medications are known 

to affect the central nervous system (5−7). For example, 

fi rst-generation antihistaminics—brompheniramine, 

chlorpheniramine, diphenhydramine, and doxylamine—

cause drowsiness and sedation (8), leading to performance 

impairment. Negative infl uences of chlorpheniramine and 

diphenhydramine have been evaluated on a wide range 

of task performance and mood measures (9,10). Studies 

such as the presence of methamphetamine in toxic concentration in a civil aviation accident pilot fatality (11) 

and the prevalence of fi rst-generation antihistaminics 

(12,13) and of selective serotonin reuptake inhibitors 

(SSRIs; 14) have been reported. Antihistamines were 

found in approximately 5% of pilot fatalities (12,13), 

while SSRIs in only 1.5% of the fatalities (14). Previous 

epidemiological studies have indicated relatively low 

percentages of pilot fatalities wherein abused drugs were 

found, in comparison to prescription and nonprescription 

drugs during the time periods of 1989−1993 (15) and 

1994−1998 (16). In the present study, the epidemiological assessment of the presence of drugs and ethanol was 

evaluated in the civil aviation accident pilot fatalities for 

an additional 5-year period of 1999−2003.

MATERIALS AND METHODS

Postmortem Biological Specimens

During the investigation of aircraft accidents occurring 

within the jurisdiction of the United States, autopsied 

biological samples (blood, urine, liver, kidney, vitreous 

fl uid, and other body specimens) collected from pilot 

fatalities of civil aircraft accidents are submitted to 

CAMI for toxicological analyses (1). These aviation accidents encompass accidents involving registered as well 

as unregistered aircraft. Not all of the pilots involved in 

these accidents may necessarily have been certifi ed pilots 

or may necessarily have been medically certifi ed to fl y an 

aircraft. Biological sample submissions are coordinated 

through the FAA’s Offi ce of Accident Investigation by 

the National Transportation Safety Board (NTSB), which 

is responsible for investigating all U.S. civilian aircraft 

accidents. The collected samples are submitted to CAMI 

in the FAA’s TOX-BOX evidence containers described 

elsewhere (17). 

Analytical Toxicology

The biological specimens from pilot fatalities are 

routinely analyzed for the presence of combustion gases 

(carbon monoxide and hydrogen cyanide), a wide range 

of illicit, prescription, and nonprescription drugs, and 

alcohol/volatiles (17). This process entails screening 

(preliminary) and confi rmatory/quantitative analyses. All 

of these exogenous substances (analytes) in the specimens 

are analyzed according to established standard procedures 

1

In 2001, the Civil Aeromedical Institute’s name was changed to Civil Aerospace Medical Institute (CAMI). The Institute is located in Oklahoma 

City, Oklahoma, and is an organizational element of the Offi ce of Aerospace Medicine.
2

of the CAMI Laboratory, utilizing ultraviolet/visible 

spectrophotometry, fl uorescence polarization immunoassay, radioimmunoassay, gas chromatography/mass 

spectrometry (GC/MS), high- performance liquid chromatography (HPLC), and HPLC/MS. Alcohol/volatile 

analysis is performed by headspace gas chromatography 

and radiative energy attenuation method. The analyses 

are dependent upon the nature of analytes, the sensitivity and specifi city of analytical methods used, and the 

availability of sample types and amounts. Analytes found 

in a fatality might not have necessarily been detected, 

or even analyzed, in each of the sample types submitted 

from that particular accident pilot fatality. 

Database

The toxicological fi ndings of civil aircraft accident fatalities are electronically stored in a database maintained at 

CAMI. This CAMI Toxicology Database was examined for 

the presence of controlled substances (scheduled drugs), 

prescription and nonprescription drugs, and ethanol in 

the pilot fatalities from whom postmortem samples were 

submitted to CAMI during a 5-year period, 1999−2003. 

For this period, the database search also entailed the 

numbers of all aviation accidents and pilot fatalities, 

including the airman fl ying and medical certifi cates of 

those pilots and the fl ight categories of the associated 

accidents. Pilots that did not have airman fl ying and/or 

medical certifi cates were also part of the study. In the 

present study, fatalities consist of only pilots—copilots 

are not included. 

Since caffeine and nicotine are not considered drugs, 

these compounds are not incorporated in the list of drugs 

found in the pilot fatalities. Ethanol is reported in only 

those cases wherein ethanol concentrations were ≥ 0.04% 

(w/v), as the FAA regulations (2) forbid the operation 

of an aircraft by a pilot with a blood ethanol reading ≥

0.04% (40 mg·dL−1

).

Drug Classifi cation (or Grouping) and Pilot Fatality Numbers

Although efforts were made to group controlled 

substances (scheduled drugs) as classifi ed by the U.S. 

Drug Enforcement Administration (4), it was sometimes 

necessary to combine the same types of several substances 

into 1 group to minimize the cumbersomeness of tables 

incorporated in this study. For example, the group 

barbiturates consisted of butalbital, pentobarbital, and 

phenobarbital; the group synthetic opiates included 

hydrocodone, hydromorphone, meperidine, oxycodone, 

and their metabolites; and the group benzodiazepines 

entailed α−hydroxyalprazolam, alprazolam, diazepam, 

midazolam, nordiazepam, oxazepam, and temazepam. 

Some of the barbiturates included in Schedule II could 

also be classifi ed in Schedule III or IV. Pharmaceutical 

preparations containing opiates, up to certain concentrations, are classifi ed under Schedule III, but they fall in 

the category of Schedule II at higher concentrations, or if 

they are seized during a drug law enforcement action in 

any solid or other dosage form. Drugs could be classifi ed 

as prescription drugs instead of nonprescription drugs, 

depending upon the amounts and formulations of those 

drugs. It is common in the pharmaceutical industry to 

categorize a drug in prescription or in nonprescription 

category based upon the nature of pharmaceutical formulation and preparation wherein the drug is present. 

Therefore, in the present study, drugs found in the 

fatalities were classifi ed based upon their mere presence, 

even though some of the drugs could be classifi ed differently. In fatalities wherein multiple drugs and ethanol 

were found, such fatalities were counted more than 

once—that is, for each drug under its respective category 

and for ethanol. 

RESULTS

Pilot Fatalities, Flight Categories, and Airman Flying and Medical Certifi cates

During 1999−2003 with respect to airman fl ying 

certifi cates, 1367 (90%) of the total 1524 pilot fatalities 

were associated with general aviation [Title 14 Code of 

Federal Regulations (CFR), Part 91] accidents (Fig. 1). In 

these accidents, the highest number of pilots (693) were 

rated as private pilots and the second highest number of 

pilots (413) were rated as commercial pilots. Also, there 

were 201 pilots rated as airline transport pilots. 

In relation to airman medical certifi cate categories (Fig. 

2), the highest number of pilot fatalities (1350; 90%) of 

the total 1508 pilot fatalities were associated with general 

aviation accidents. Of these 1350 fatal accidents, 183 

pilots held First-Class medical certifi cates, 437 SecondClass medical certifi cates, and 730 Third-Class medical 

certifi cates. The total of 1508 pilot fatalities does not 

include medically uncertifi ed pilots.

As exhibited in Figure 3, there were 122 airline transport pilots of the 222 pilots holding First-Class medical 

certifi cates. In this medical certifi cate category, there were 

78 commercial pilots, 18 private pilots (1 private pilot 

with the fl ying certifi cate of a foreign country), and 4 

student pilots. Of the 548 Second-Class medical certifi cate 

holders, 108 pilots were rated as airline transport pilots, 

348 commercial pilots, 86 private pilots, and 6 student 

pilots. In the category of the Third-Class medical certifi cate holders, 15 pilots were rated as airline transport 

pilots, 82 commercial pilots, 590 private pilots (5 private 

pilots with the certifi cate of a foreign country), and 48 

student pilots, totaling 735 pilots.
3

Part 91

Part 135

Part 121

Part 137

Part 133

Part 103

Public Use

Part 129

Other

Student

Airline Transport

Commercial

Private

693

6 3

413

41 44

7 1 10

201

26

7 2 1 1 7 1

59

1 0

75

150

225

300

375

450

525

600

675

750

Pilot Fatalities

Flight Categories (Title 14 CFR Parts)

Fig. 1. Number of total pilot fatalities (1999–2003) with respect to airman fl ying 

certifi cate categories and fl ight categories (Title 14 CFR Parts) of the aircraft 

involved in the fatal accidents. For the description of fl ight categories under Title 14 

CFR Parts, refer to the fi rst column of Table IV.

Part 91

Part 135

Part 121

Part 137

Part 133

Part 103

Public Use

Part 129

First-Class

Second-Class

Third-Class

730

7 2

437

38

2

45

8 2 16

183

29

5 1

2 1

0

100

200

300

400

500

600

700

800

Pilot Fatalities

Flight Categories (Title 14 CFR Parts)

Fig. 2. Number of total pilot fatalities (1999–2003) with respect to airman medical 

certifi cate categories and fl ight categories (Title 14 CFR Parts) of the aircraft involved 

in the fatal accidents. For the description of fl ight categories under Title 14 CFR Parts, 

refer to the fi rst column of Table IV.
4

Pilot Fatalities With Drugs and Ethanol, by Year

Out of 1629 fatal aviation accidents from which CAMI 

received biosamples, there were 1587 accidents wherein 

pilots were fatally injured. Postmortem biosamples were 

received from these 1587 pilot fatalities, ranging from 

305 to 334 fatalities each year during the 5-year period 

of 1999−2003 (Table I). The number of fatalities wherein 

drugs and/or ethanol were detected was 830, which was 

52% of the 1587 fatalities. Of the 830 fatalities, prescription and nonprescription drugs were detected in 574 

(69%) fatalities, whereas controlled substances (Schedules 

I–V drugs) were found in 155 (19%) fatalities and ethanol 

in 101 (12%) fatalities. The percentages of fatalities in 

which Schedules I and II drugs, Schedules III−V drugs, 

and ethanol were detected ranged from 6–9, 2–3, and 

5–9%, respectively. The fatality percentage, based upon 

the presence of drug(s) and/or drug metabolite(s), was 

approximately 38% of all pilot fatalities.

Pilot Fatalities With Drugs and Ethanol by Medical 

Certifi cate Classes

Based on the category of pilot medical certifi cate held, 

there were 1519 fatalities, of which 222 pilots had FirstClass certifi cates, 551 Second-Class certifi cates, and 746 

Third-Class certifi cates (Table II). Of the 1519 fatalities, 

there were 783 fatalities in which drugs and/or ethanol 

were found. In the 783 pilots, the First-Class certifi cate 

was held by 79 (10%), the Second-Class certifi cate 

by 270 (34%), and the Third-Class certifi cate by 434 

(55%). Scheduled drugs and/or ethanol were detected 

in 241 and prescription and nonprescription drugs in 

542. Schedules I−V drugs were found in 15, 53, and 78 

pilots holding First-Class, Second-Class, and Third-Class 

medical certifi cates, respectively.

Pilot Fatalities With Drugs and Ethanol by Medical 

Certifi cates and Flying Ratings 

Drugs and/or ethanol were found in 79 of the 221 

pilots with First-Class medical certifi cates, in 270 of the 

548 pilots with Second-Class medical certifi cates, and in 

424 of the 730 pilots with Third-Class medical certifi cates 

(Table III). Schedules I−V drugs were detected in 7 of 

the 122 First-Class, in 10 of the 108 Second-Class, and 

in 1 of the 15 Third-Class medical certifi cate-holding 

airline transport pilots. Of the 585 private pilots with the 

Third-Class medical certifi cates, there were 346 (59%) 

pilots wherein drugs and/or ethanol were detected, and 

Schedules I−V drugs were present in 62 (11%) of the 

pilots. None of the Schedules I−V drugs were found in the 

4 student pilots holding First-Class medical certifi cates. 

Among Second-Class medical certifi cate-holding pilots, 

there were 2 of the 6 student pilots wherein Schedules 

I−V drugs were detected. Of the 48 Third-Class medical 

certifi cate-holding student pilots, Schedules I−V drugs 

were present in 8. 

122

78

18 4

108

348

86

6 15

82

590

48

0

100

200

300

400

500

600

Airline

Commercial

Private

Student

Airman Flying Certificate Categories

Pilot Fatalities

First-Class

Second-Class

Third-Class

Fig. 3. Airman fl ying certifi cate and airman medical certifi cate categories 

of pilots (1999–2003) who were involved in fatal aviation accidents. One of 

the 18 First-Class private pilots held a foreign fl ying certifi cate, and 5 of the 

590 Third-Class private pilots held a foreign fl ying certifi cate.
5

Table II. Medical Certificate Categories With Drugs and Alcohol Found in Aviation Accident Pilot Fatalities, 1999–2003 

Pilot Fatalities
 Medical

Certificate 

Category 

Schedules I and 

II Drugs†

Schedules III, 

IV, and V 

Drugs†

Prescription

Drugs

Nonprescription

Drugs

Ethanol Total with 

Drugs and 

Ethanol

All Pilot 

Fatalities by 

Medical

Certificate 

Category 

First-Class 12 (5) 3 (1) 25 (11) 30 (14) 9 (4) 79 (36) 222 Second-Class 41 (7) 12 (2) 95 (17) 84 (15) 38 (7) 270 (49) 551 Third-Class 55 (7) 23 (3) 170 (23) 138 (18) 48 (6) 434 (58) 746 Total 108 (7) 38 (3) 290 (19) 252 (17) 95 (6) 783 (52) 1519 


Numbers in parenthesis indicate percent fatality based on the corresponding numbers in the last column (All Pilot Fatalities by Medical Certificate Category). More than 1 drug 

and ethanol were present in some fatalities. Therefore, those fatalities were counted more than once—that is, for each drug under its respective category and for ethanol. For the 

names of drugs found under the airman medical certificate categories, refer to Tables V, VI, and VII. Pilots flying unregistered aircraft were also included. 

†

Table I. 

Controlled substances (Schedules I–V drugs) as classified by the U.S. Drug Enforcement Administration (4). 

Drugs and Ethanol Found in Aviation Accident Pilot Fatalities, 1999–2003 

Pilot Fatalities
 Year

Schedules I and 

II Drugs†

Schedules III, 

IV, and V 

Drugs†

Prescription

Drugs

Nonprescription

Drugs

Ethanol Total with 

Drugs and 

Ethanol

All Pilot 

Fatalities by 

Year

1999 19 (6) 8 (3) 55 (18) 47 (15) 26 (9) 155 (51) 305 2000 22 (7) 9 (3) 47 (14) 57 (17) 22 (7) 157 (47) 334 2001 26 (9) 8 (3) 61 (20) 47 (15) 22 (7) 164 (54) 305 2002 20 (6) 9 (3) 74 (24) 52 (17) 16 (5) 171 (55) 312 2003 26 (8) 8 (2) 78 (24) 56 (17) 15 (5) 183 (55) 331 Total 113 (7) 42 (3) 315 (20) 259 (16) 101 (6) 830 (52) 1587 


Numbers in parenthesis indicate percent fatality based on the corresponding numbers in the last column (All Pilot Fatalities by Year). More than 1 drug and ethanol were present 

in some fatalities. Therefore, those fatalities were counted more than once—that is, for each drug under its respective category and for ethanol. Pilots flying unregistered aircraft were also included. 

†Controlled substances (Schedules I–V drugs) as classified by the U.S. Drug Enforcement Administration (4). 
6

Table III. Flying Ratings and Medical Certificates With Drugs and Ethanol Found in Aviation Accident Pilot Fatalities (1999–2003) 

Pilot Fatalities
 Airman Flying 

Rating Schedules I and 

II Drugs†

Schedules III, 

IV, and V 

Drugs†

Prescription

Drugs

Nonprescription

Drugs

Ethanol Total with 

Drugs and 

Ethanol

All Pilot 

Fatalities by 

Flying Rating 

First-Class Medical Certificate-Holding Pilots

Airline Transport 5 (4) 2 (2) 17 (14) 23 (19) 4 (3) 51 (42) 122 Commercial 3 (4) 0 (0) 5 (6) 7 (9) 2 (3) 17 (22) 78 Private 4 (24) 1 (6) 2 (12) 0 (0) 3 (18) 10 (59) 17 Student 0 (0) 0 (0) 1 (25) 0 (0) 0 (0) 1 (25) 4 Total 12 (5) 3 (1) 25 (11) 30 (14) 9 (4) 79 (36) 221 

Second-Class Medical Certificate-Holding Pilots

Airline Transport 8 (7) 2 (2) 24 (22) 10 (9) 5 (5) 49 (45) 108 Commercial 23 (7) 9 (3) 60 (17) 56 (16) 28 (8) 176 (51) 348 Private 8 (9) 1 (1) 9 (10) 16 (19) 5 (6) 39 (45) 86 Student 2 (33) 0 (0) 2 (33) 2 (33) 0 (0) 6 (100) 6 Total 41 (7) 12 (2) 95 (17) 84 (15) 38 (7) 270 (49) 548 

Third-Class Medical Certificate-Holding Pilots

Airline Transport 1 (7) 0 (0) 8 (53) 2 (13) 0 (0) 11 (73) 15 Commercial 4 (5) 1 (1) 20 (24) 16 (20) 4 (5) 45 (55) 82 Private 44 (8) 18 (3) 130 (22) 114 (19) 40 (7) 346 (59) 585 Student 4 (8) 4 (8) 9 (19) 4 (8) 1 (2) 22 (46) 48 Total 53 (7) 23 (3) 167 (23) 136 (19) 45 (6) 424 (58) 730 


Numbers in parenthesis indicate percent fatality based on the corresponding numbers in the last column (All Pilot Fatalities by Flying Rating). More than 1 drug and ethanol were 

present in some fatalities. Therefore, those fatalities were counted more than once—that is, for each drug under its respective category and for ethanol. For the names of drugs found under the airman medical certificate categories, refer to Tables V, VI, and VII. Pilots flying unregistered aircraft were also included. 

†Controlled substances (Schedules I–V drugs) as classified by the U.S. Drug Enforcement Administration (4). 
7

Flight Categories and Pilot Fatalities With Drugs 

and Ethanol

With respect to the fl ight categories of aviation accidents, there were a total of 1570 pilot fatalities (Table 

IV). Of these fatalities, there were 821 (52%) fatalities 

in which drugs and/or ethanol were present. There were 

152, 568, and 101 fatalities wherein Schedules I−V drugs 

(controlled substances), prescription and nonprescription 

drugs, and ethanol were, respectively, found. Associated 

with general aviation (Title 14 CFR, Part 91) accidents, 

there were a total of 1409 pilot fatalities, of which 757 

(54%) fatalities were found to contain drugs and/or 

ethanol. Schedules I−V drugs were detected in 140 of the 

757 fatalities. There were no fatalities in which Schedules 

I−V drugs were found in the fl ight category of air carrier 

(Title 14 CFR, Part 121), rotorcraft external load (Title 

14 CFR, Part 133), or public use (fl ights used for the 

governmental agencies). Of these 3 categories, ethanol 

was detected in only 1 of the total 7 pilots of the CFR 

Part 121 related accidents and in 2 of the total 20 pilots 

of the public use related accidents. The percentage of the 

fatalities with scheduled drugs (controlled substances) was 

high in the accidents associated with ultralight aircraft 

(Title 14 CFR, Part 103). There was only 1 foreign air 

carrier (Title 14 CFR, Part 129) involving pilot fatality. 

In this fatality, no drug or ethanol was detected. 

Medical Certifi cate Categories With Scheduled 

Drugs Found in Pilot Fatalities

In general, the number of First-Class medical certifi -

cate-holding pilots wherein Schedules I−V drugs and/or 

their metabolites were found was lower than the number 

of Second-Class and Third-Class medical certifi cateholding pilots (Table V). The number of pilots wherein 

scheduled drugs were present and who were holding 

Second-Class medical certifi cates was relatively higher 

than the number of First-Class medical certifi cate-holding pilots, but was less than the number of Third-Class 

medical certifi cate-holding pilots. Marihuana (tetrahydrocannabinol and/or tetrahydrocannabinol carboxylic 

acid) was detected in the highest number of 21 pilots 

with Third-Class medical certifi cates. Codeine and/or 

morphine were present in 31 pilots. Of these pilots, 4 

held First-Class, 13 Second-Class, and 13 Third-Class 

medical certifi cates, while 1 pilot was medically uncertifi ed. Benzodiazepines were also found in 13 pilots holding Third-Class medical certifi cates. Synthetic opiates 

were detected in the fatalities—the fatality number was 

2 in the First-Class medical certifi cate category, and the 

numbers were 9 and 8 in the Second-Class and ThirdClass medical certifi cate categories, respectively. Including 

marihuana and benzodiazepines, other drugs were also 

detected in medically uncertifi ed pilots. Phencyclidine 

was not detected in any pilot fatality.

Medical Certifi cate Categories With Prescription 

Drugs Found in Pilot Fatalities

The presence of prescription drugs and/or their metabolites was relatively more prevalent in the pilots holding 

Third-Class medical certifi cates than in pilots holding 

First-Class or Second-Class medical certifi cates (Table VI). 

Diphenhydramine was found in the maximum number 

of 83 pilot fatalities. The number of fatalities wherein 

lidocaine and atropine were detected ranked numbers 

2 and 3, respectively. The presence of antihypertensives 

and SSRIs also dominated in the fatalities. 

Medical Certifi cate Categories With Nonprescription Drugs Found in Pilot Fatalities

Nonprescription drugs and/or their metabolites were 

most prevalent in the pilots who held Third-Class medical certifi cates (Table VII). Pseudoephedrine ranked as 

the number-1 drug, as this was present in 91 fatalities, 

followed by acetaminophen in 84, phenylpropanolamine 

in 76, and ephedrine in 74. Salicylate was found in 41 

pilots, whereas chlorpheniramine was present in 31. 

DISCUSSION 

Biological samples from pilot fatalities of circa 80% of 

the total U.S. civil aviation accidents investigated by the 

NTSB are submitted to CAMI for toxicological evaluation (17). During 1999–2003, samples from a total of 

1587 pilot fatalities were received, translating into the 

equivalent number of fatal aircraft accidents. This number 

entails registered as well as unregistered aircraft, such as 

ultralight vehicles. The pilots of such aircraft could also 

be noncertifi ed to fl y aircraft and may or may not hold 

medical certifi cates. The highest number of all pilot 

fatalities observed with the general aviation (Title 14 

CFR, Part 91) accidents in comparison to the other fl ight 

categories of Title 14 CFR Parts—Part 135, Part 121, 

Part 137, Part 133, and Part 103—is consistent with the 

previous observations made during the fi rst-generation 

H1

 antihistaminics (13) and SSRIs (14) studies.

Comparison of the epidemiological toxicology fi ndings 

of the 1999–2003 period with those of the 1994–1998 

period (16) suggested that the incidents of drug and 

ethanol use in pilots did not increase considerably during the 1999–2003 period. The total pilot fatalities 

with drugs and/or ethanol were 830 (52%) of the 1587 

pilot fatalities during this period, while such fatalities 

were 803 (48%) of the 1683 pilot fatalities for the 

1994–1998 period (16). However, both 52% and 48% 
8

Table IV. Aviation Accident Flight Categories With Drugs and Ethanol Found in Pilot Fatalities (1999–2003) 

Pilot Fatalities† Flight Category


Schedules I and 

II Drugs‡

Schedules III, 

IV, and V 

Drugs‡

Prescription

Drugs

Nonprescription

Drugs

Ethanol Total with 

Drugs and 

Ethanol

All Pilot 

Fatalities by 

Flight Category 

General Aviation (14 CFR, Part 91) 

101 (7) 39 (3) 291 (21) 234 (17) 92 (7) 757 (54) 1409 

Air Taxi and Commuter (14 CFR, Part 135) 

5 (7) 1 (1) 7 (10) 5 (7) 2 (3) 20 (30) 67 

Air Carrier(14 CFR, Part 121) 

0 (0) 0 (0) 0 (0) 0 (0) 1 (14) 1 (14) 7 

Agricultural(14 CFR, Part 137) 

2 (4) 1 (2) 6 (13) 12 (26) 3 (7) 24 (52) 46 

Rotorcraft External Load(14 CFR, Part 133) 

0 (0) 0 (0) 1 (13) 3 (38) 0 (0) 4 (50) 8 

Ultralight(14 CFR, Part 103) 

2 (17) 1 (8) 4 (33) 1 (8) 1 (8) 9 (75) 12 

Public Use§ 0 (0) 0 (0) 1 (5) 3 (15) 2 (10) 6 (30) 20 

Foreign Air Carriers (14 CFR, Part 129) 

0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 

Total 110 (7) 42 (3) 310 (20) 258 (16) 101 (6) 821 (52) 1570 

*Code of Federal Regulations (CFR), Title 14—Aeronautics and space, Chapter I (1-1-04 Edition)—Federal Aviation Administration, Department of Transportation, U.S. 

Government Printing Office (2004), Washington, DC. 

†Numbers in parenthesis indicate percent fatality based on the corresponding numbers in the last column (All Pilot Fatalities by Flight Category). More than 1 drug and ethanol 

were present in some fatalities. Therefore, those fatalities were counted more than once—that is, for each drug under its respective category and for ethanol. Pilots flying unregistered aircraft were also included. 

‡Controlled substances (Schedules I–V drugs) as classified by the U.S. Drug Enforcement Administration (4). §Flights used for the federal, state, and local government agencies. 
9

Table V. Airman Medical Certificate Categories With Controlled Substances (Scheduled Drugs) 

Found in Pilot Fatalities*

 (1999–2003) 

Drugs/Drug Groups First-Class 

Medical

CertificateHolding Pilots 

Second-Class

Medical

CertificateHolding Pilots 

Third-Class

Medical

CertificateHolding Pilots 

All Pilot 

Fatalities†

Schedules I and II Drugs‡

Amphetamine/ 

Methamphetamine 

1 5 5 11 

Barbiturates§ 0 2 8 10 

Cocaine/Metabolite(s) 3 4 8 16 

Codeine/Morphine 4 13 13 31 

Marihuana¶ 3 11 21 39 

MDMA** 0 1 0 1 

Synthetic Opiates†† 2 9 8 20 

Schedules III, IV, and V Drugs‡

Benzodiazepines‡‡ 2 6 13 24 

Phentermine 1 1 2 5 

Propoxyphene/ 

Norpropoxyphene 

0 5 6 12 

Zolpidem 0 0 2 2 

*

More than 1 drug was present in some fatalities. Therefore, those fatalities were counted more than once—that is, for each drug.

Pilots flying unregistered aircraft were also included. 

†

Also includes medically uncertified pilots. 

‡

Controlled substances (Schedules I–V drugs) as classified by the U.S. Drug Enforcement Administration (4). 

§

Butalbital, pentobarbital, and/or phenobarbital, though some of these barbiturates could also be classified in other schedules.

¶

Tetrahydrocannabinol and/or tetrahydrocannabinol carboxylic acid. 

**3,4-Methylenedixoymethamphetamine. 

††Hydrocodone, hydromorphone, meperidine, oxycodone, and/or their metabolites. 

‡‡DHydroxyalprazolam, alprazolam, diazepam, midazolam, nordiazepam, oxazepam, and/or temazepam. 
10

Table VI. Airman Medical Certificate Categories With Prescription Drugs Found in Pilot Fatalities*

(1999–2003) 

Drug/Drug Metabolite(s) First-Class 

Medical

CertificateHolding Pilots 

Second-Class

Medical

CertificateHolding Pilots 

Third-Class

Medical

CertificateHolding Pilots 

All Pilot 

Fatalities†

 Amitriptyline/Nortriptyline 0 1 5 7 

 Amlodipine 0 1 5 6 

 Atenolol 1 2 10 14 

Atropine 1 6 15 24 

Azacyclonol 3 0 2 5 

Benzocaine 0 1 0 1 

Bisoprolol 1 0 1 2 

Brompheniramine 0 2 0 2 

Bupropion/Metabolite 1 4 3 9 

Carbamazepine 0 1 0 1 

Cetirizine 0 0 3 3 

Chloroquine 0 3 0 3 

Cimetidine 0 5 4 9 

Citalopram/Metabolite(s) 2 1 8 11 

Cyclobenzaprine 0 0 1 1 

Diltiazem 0 3 6 10 

Diphenhydramine 7 24 46 83 

Doxazosin 0 1 0 1 

Doxepin/Nordoxepin 0 1 0 1 

Etomidate 1 0 0 1 

Fluconazole 1 0 2 3 

Fluoxetine/Norfluoxetine 1 5 9 21 

Hydrochlorothiazide 0 1 2 3 

Hydroxyzine 0 0 1 1 

Imipramine/Desipramine 0 2 1 4 

Labetalol 0 0 1 1 

Lidocaine 3 8 17 30 

Metoclopramide 1 0 0 1 

Metoprolol 0 4 10 17 

Mirtazapine 0 0 1 2 

Moricizine 0 0 0 1 

Nadolol 1 0 0 1 

Naproxen 0 1 2 3 

Nizatidine 0 0 1 1 

Pantoprazole 0 1 0 1 

Paroxetine 1 2 12 16 

Phenyltoloxamine 0 1 0 1 

Procainamide/NAcetylprocainamide 

(continued)

0 2 0 2 
11

Table VI. Airman Medical Certificate Categories With Prescription Drugs Found in Pilot Fatalities*

(1999–2003) (Continued) 

Drug/Drug Metabolite(s) First-Class 

Medical

CertificateHolding Pilots 

Second-Class

Medical

CertificateHolding Pilots 

Third-Class

Medical

CertificateHolding Pilots 

All Pilot 

Fatalities†

Propranolol 0 1 3 5 

Quinidine 0 0 1 1 

Ranitidine 2 3 9 17 

Sertraline/Desmethylsertraline 0 6 11 19 

Sildenafil/Metabolite(s) 0 1 3 4 

Theophylline 1 3 2 6 

Tramadol 0 1 11 12 

Trazodone 0 1 2 4 

Triamterene 1 5 2 8 

Trimethoprim 1 0 4 5 

Venlafaxine/Desmethylvenlafaxine 1 3 2 6 

Verapamil/Norverapamil 0 3 6 11 

*

More than 1 drug was present in some fatalities. Therefore, those fatalities were counted more than once—that is, for each 

drug. Pilots flying unregistered aircraft were also included. 

†

Also includes medically uncertified pilots. 

Table VII. Airman Medical Certificate Categories With Nonprescription Drugs Found in Pilot Fatalities*

(1999 – 2003) 

Drug/Drug Metabolite(s) First-Class 

Medical

CertificateHolding Pilots 

Second-Class

Medical

CertificateHolding Pilots 

Third-Class

Medical

CertificateHolding Pilots 

All Pilot 

Fatalities†

Acetaminophen 11 34 36 84 

Chlorpheniramine 1 11 18 31 

Dextromethorphan/Metabolite(s) 1 7 9 20 

Doxylamine 0 8 11 19 

Ephedrine 9 24 41 74 

Meclizine 0 0 1 1 

(–)-Methamphetamine 1 4 3 8 

Oxymetazoline 0 1 0 1 

Phenylpropanolamine 10 27 38 76 

Pseudoephedrine 11 33 46 91 

Quinine 3 13 20 37 

Salicylate 8 13 18 41

Triprolidine 0 1 1 2

*

More than 1 drug was present in some fatalities. Therefore, those fatalities were counted more than once—that is, for each 

drug. Pilots flying unregistered aircraft were also included. 

†

Also includes medically uncertified pilots. 
12

values were higher than that of the 31% value (565 out 

of 1845 fatalities) for the 1989–1993 period (15). The 

presence of Schedules I and II drugs increased from 74 

fatalities during 1989–1993 and from 89 fatalities during 1994–1998 to 113 fatalities during 1999–2003; an 

increase was also noted with the prescription drugs in 

the 1999–2003 study. The presence of Schedules III–V 

drugs increased from 28 fatalities during 1989–1993 and 

decreased from 49 fatalities 1994–1998 to 42 fatalities 

during 1999–2003. An increase-and-decrease pattern 

in the number of fatalities was also observed with the 

nonprescription drugs. The number of fatalities with 

ethanol decreased from 146 (15) and 124 (16) to 101 

in the current study. The pilot fatality percentage, based 

upon the presence of drug(s) and/or drug metabolite(s), 

was higher (38%) during 1999–2003 than the percentages observed during the periods of 1989–1993 (27%) 

and 1994–1998 (32%). 

Airline transport-rated pilots holding First-Class 

medical certifi cates qualify to fl y aircraft for transporting 

passengers and for other purposes, but Second-Class and 

Third-Class medical certifi cate-holding airline transport 

pilots do not qualify to transport passengers. Since most of 

the airline transport and commercial pilots are subjected 

to random drug testing for the presence of amphetamines, 

cocaine, marihuana, opiates, phencyclidine, and/or their 

metabolites (18), the present study examined the positive drug rate based on the airman medical, as well as 

airman fl ying certifi cate classifi cations. It was found that 

the percentage of pilots with Schedules I and II drugs 

in a given medical class (First-Class, Second-Class, and 

Third-Class) was approximately within 1% of each other. 

With respect to airman medical certifi cate categories, the 

percentage of fatalities wherein Schedules I–V drugs and 

ethanol were detected was approximately the same (241 

out of 1519 fatalities; 16%) in the present study than 

that was observed (245 out of 1616 fatalities; 15%) in 

the 1994–1998 study (16). However, prescription and 

nonprescription drugs during 1999–2003 were found in 

a higher number of fatalities (542; 36%) relative to the 

fatalities (520; 32%) reported in the 1994–1998 study. 

With respect to fl ight categories, it is clearly evident that 

scheduled and prescription drug use dominated in fatalities 

associated with general aviation and ultralight fl ights. 

Although the prevalence of scheduled drugs in the 

fatalities was, in general, consistent with the fi ndings 

of the previous studies (15,16), the increase in their 

prevalence, if any, could be attributed to the possibilities 

of (i) scientifi c and technical advances in the sensitivity 

of analytical detectability, (ii) genuine authorized medical use of such drugs, and/or (iii) their real abuse. The 

analytical sensitivity enhanced the detection of not only 

the parent drugs but also their metabolite(s), even if they 

were present in low concentrations. Narcotic analgesics 

found in pilot fatalities could have been administered by 

emergency health care providers at accident scenes, or at 

hospitals for pain reduction and/or surgical procedures. 

However, the presence of abused drugs—for example, 

amphetamine, methamphetamine, 3,4-methylenedixoymethamphetamine, cocaine, and marihuana—could 

have been attributed to their unauthorized use. Prescription drugs, such as atropine and lidocaine, might have 

been administered by health care providers for resuscitation. The presence of prescription drugs found in the 

fatalities refl ected the current trends in the popularly 

dispensed groups of medications—antihypertensives 

and antidepressants—in the U.S. (19–24). The use of 

nonprescription drugs was primarily associated with drug 

preparations and formulations used to alleviate allergy 

and cold symptoms. 

The percentages of fatalities with ethanol during 

1999–2003 on yearly and medical certifi cate category 

bases ranged from 4–9%, which were similar to the 

numbers reported in the 2 previous studies (15,16). Since 

the method used for ethanol analysis does not differentiate ingested ethanol from postmortem ethanol (25), the 

presence of ethanol in those pilots may not necessarily 

suggest the consumption of ethanol. In reducing the use 

of ethanol in pilots, the Driving Under the Infl uence 

(DUI)/Driving While Intoxicated (DWI) rule (26) plays 

a crucial role under which the FAA monitors DUI/DWI 

convictions of pilots and takes action to suspend medical 

certifi cates where necessary. 

Although no pilot fatality in an air carrier (Title 14 

CFR, Part 121) related aviation accident was found to 

be positive for scheduled drugs, it is diffi cult to assign 

any signifi cance to this fi nding due to the small number 

of CFR Part 121 accidents that occurred between 1993 

and 2003. This observation agrees with the FAA drugtesting program’s conclusion that less than 1% of those 

pilots tested under the drug-testing program are positive 

for abused drugs (18,27). Overall, fi ndings from the present study were consistent with those of the 2 previous 

epidemiological studies (15,16) and support the FAA’s 

programs, including the FAA’s drug-testing program, 

aimed at identifying potentially incapacitating medical 

conditions and reducing the use of performance-impairing drugs or ethanol (18,27). In addition to scheduled 

drugs (controlled substances), many of the prescription 

and nonprescription drugs found in the fatalities have the 

potential for impairing performance, thereby adversely 

affecting a pilot’s ability to safely fl y an aircraft. 
13

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