Table 2. All drugs identified between 1989 and 1993

Class Drug Cases (%)
Cl and Cll Marihuana 46 3
Cocaine 16 1
Codeine/Morphine 11 <1
Amphetamine/Methamphetamine 6 <1
PCP 0 0
Barbiturates 18 1
Synthetic Opiates 7 <1
Methaqualone 1 <1
Citl-CV Benzodiazepines 24 1
Phentermine 2 <1
Phendimetrazine 1 <1
Rx Fluoxetine/Norfluoxetine 3 <1
Imipramine/Desipramine 2 <1
Amitriptyline/Nortriptyline 2 <1
Sertraline 1 <1
Maprotiline 1 <1
Doxepine/Nordoxepin 1 <1
Metoprolol 3 <1
Atenolot 2 <1
Propranolol 1 <1
Acetylprocainamide/Procainamide 2 <1
Quinidine 3 <1
Verapamil/Norverapamil 5 <1
Diltiazem 2 <1
Triamterene 1 <1
Cimetidine 2 <1
Gemfibrozil 5 <1
Phenytoin 6 <1
Carbamazepine 3 <1
Metoclopramide 2 <1
Nizatidine 1 <1
Diphenhydramine 32 2
Promethazine 2 <1
Brompheniramine 2 <1
Cyclizine 2 <1
Cyclobenzaprine 1 <1
Naproxen 5 <1



screened using a combination of HPLC, TLC, im-
munoassay, and Mass Spectroscopy, making it pos-
sible to identify more drugs at therapeutic and
subtherapeutic levels. It is not clear from these data
whether the increased number of positive drug cases
(Fig. 1) found during this period is due to improved
methods of analysis, or whether there is an actual
increase in the use of drugs. Specifically, new more
sensitive methods have been instituted for the analy-
ses of OTC and Rx medications. These changes may
explain the increased drug findings. Future mea-
surements will provide additional information on
this issue.

REFERENCES

1. Canfield, D., Kupiec, T., and Huffine, E., “Post-
mortem Alcohol Production in Fatal Aircraft
Accidents,” Journal of Forensic Sciences,
JFSCA, 38, No. 4, July 1993, pp. 914-917.

‘{YUS. GOVERNMENT PRINTING OFFICE: 1995 - 760-062/20037


polarization immunoassay (FPIA). Only cases with
ethanol at or above 0.04% are reported in this study
due to the FAA regulations forbidding the opera-
tion of an aircraft by a pilot with a blood ethanol
reading at or above 0.04% (40mg/dL). All data col-
lected by the laboratory are electronically entered
into a computer for future analysis.

RESULTS

The Toxicology and Accident Research Labora-
tory received specimens from 1845 fatally injured
pilots for postmortem toxicology analysis between
1989 to 1993 (Table 1.). During that time controlled
dangerous substances (schedules I and II) were

found in 74 (4%) of the pilots analyzed. Controlled
dangerous substances (schedules III - V) were found
in 28 (2%) of the pilots tested. Prescription drugs
were found in 110 (6%) of the pilots analyzed. Over-
the-counter drugs were found in 207 (11%) of the
pilots analyzed. Alcohol at or above the upper limit
of 0.04% for pilots was found in 146 (8%) cases.
The actual drugs identified in this study can be seen
in Table 2. Some drugs, such as antihistamines, in-
cluded in a given category may also be available in
an another category. Multiple drug positives were
found in several of the cases. It should be noted
that drugs in table 2 are classified based on the pure
drug, and that some of these drugs may be classified
differently, depending on the formulation of the drug.

Table 1. Fatal Aviation Accidents with Drugs and Alcohol

Rx% OT OT% Al Al% Fatal

2.0 24 6.9 28 8.0 349

65 32 8.7 29 7.9 367

62 42 108 30 7.7 389

6.0 52. 13.0 29 7.3 400

Year C1 C1% C3 C3% Rx
1989 8 2.3 7 20 7
1990 14 3.8 5 14 - 24
1991 22 5.7 3. 08 24
1992 17 4.3 3. 08 24
199313 38 10 29 31

91 57 168 30 8.8 340

Total 74 40 28 15 110

6.0 207 11.2 146 7.9 1845

C1 = Controlled Dangerous Substance Schedules | and II
Marihuana, Cocaine, etc.

C3 = Controlled Dangerous Substance Schedules III-V
Diazepam, Phentermine, etc.

Rx = Prescription Drugs
Amitriptyline, Imipramine, etc.

OT = Over-the Counter-Medications

Pseudoephedrine, Acetaminophen, etc.

Al = Alcohol levels equal to or greater than 0.04% (40.0mg/dL)
The values include in this tabulation incorporate cases in which the source of
the alcohol is both known and unknown.

Fatal= Fatal pilots only


Table 2. All drugs identified between 4989 and 1993 (Continued)

Class Drug Cases (%)

Rx Ibuprofen 3 <1
Fenoprofen 4 <1
Norpropoxyphene 1 <1
Theophylline 41 <1
Chloroquine 3 <1
Lidocaine 31 2
Thiopental 4 <1
Ketamine 2 <1
Aminophenazone 4 <1
Griseofulvin 1 <1
Orphenadrine 4 <1

oTc Salicylates 96 5
Acetaminophen 92 5
Pseudoephedrine 47 3
Phenylpropanolamine 26 4
Chiorpheniramine 36 2
Doxylamine 8 <1
Dextromethorphan 3 <1
Meclizine 4 <1
Ephedrine 1 <1
Dextrorphan 1 <1
Guaiphenesin 4 <1
Quinine 16 4

DISCUSSION AND CONCLUSION

Over-the-counter and prescription medications
are the most frequently found drugs in fatal avia-
tion accidents; many of these drugs, or the medical
conditions for which they are being used, could
impair a pilot’s ability to fly an aircraft. Chlorphen-
iramine and diphenhydramine, two antihistamines
found in 68 of the pilots analyzed, are sedative and
may cause impairment of a pilot’s ability to react
to an emergency. Drugs used for cardiovascular,
neurological, and psychiatric illness, where the drug
and/or medical condition may cause incapacitation
of the pilot, were found in 64 of the cases.

The low incidence of Controlled Dangerous Sub-
stances (CDS) III-V drugs found in fatal aviation
accidents (Fig. 1) may be a result of the difficulty
in finding and identifying the new benzodiazepines
commonly prescribed in this class. New procedures,
implemented in the latter half of 1993, resulted ina
significant increase in the number of benzodiaz-
epines found in 1993 (Fig. 1).

There appears to be a steady decrease in the per-
centage of positive schedules J and {I drugs (Fig.
1). The procedures for schedules I and II drugs have
not changed over the past 5 years, and the decrease


Merritt: Birky
National Transportat!
_ Washington, DC-20591

“November 1995 :

Final, Repart

r,



bad

observed may be a real decrease in the number of
pilots using controlled dangerous substances sched-
ules I and IJ, and not an anomaly caused by changes
in the method. The mean percentage of positive CDS
1 and II drugs is 4.0% over the past 5 years; the
1993 value of 3.8% is well within 1 standard de-
viation (s = 1.2%), which suggests there is no sig-
nificant change in the number of positive CDS I
and II drugs.

The percentage of alcohol positives has remained
relatively constant over the past 5 years. However,
there is a 0.9% increase in the number of positive
alcohol cases found in 1993, versus the mean per-
centage of alcohol cases of 7.9% found over the
past 5 years with a standard deviation of 0.6%. Some
of the alcohol cases reported in this study may be
the result of postmortem alcohol production. The
earlier research regarding postmortem alcohol (1)
led to a change in the CAMI procedure used for the
analysis of ethanol. Prior to 1993, blood was used
in the initial screening for alcohol; whereas in 1993,
only urine and/or vitreous fluid was submitted for
the initial screening. If the initial screening of urine
and/or vitreous was negative, the blood was not

tested and the case was reported as a negative for
ethanol. In. some cases, vitreous and urine were not
available. In these cases, other factors were used to
assist in determining the source of the ethanol.
These other factors include a visual examination of
the sample condition and the presence of other
volatiles, such as higher alcohols and aldehydes,
which might indicate putrefaction of the specimen.
More of the cases reported in 1993 would be from
the ingestion of ethanol, rather than from postmor-
tem alcohol production because postmortem alco-
hol production is rare in urine and vitreous. Using
urine and/or vitreous fluid routinely in the initial
screen may reduce the number of positive alcohol
cases reported in the future.

It would appear from the data in Table 1 that the
number of pilots using drugs has increased over the
past 5 years. However, new instruments and meth-
ods have made it possible to identify drugs that
would not have been identified using the technol-
ogy available in 1989, and this can explain the in-
crease. All specimens are now being extracted using
new methods that make it possible to recover a more
diverse group of drugs. All specimens are now

Figure 1. The increased number of drugs found in pilots.

18+

16+

144

12-

104



Technical Report Documentation Page

1. Report No. 2. Government Accession No. 3. Recipient's Catalog No.
DOT/FAA/AM-95/28

4. Title and Subtitle 5, Report Date

Drugs and Alcohol! Found in Fatal Civil Aviation Accidents Between November 1995

1989 and 1993

6. Performing Organization Code

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

Dennis Canfield, Jo Flemig, Jerry Hordinsky, and Merritt Birky

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

FAA Civil Aeromedical Institute
P. O. Box 25082
Oklahoma City, OK 73125-5066

17. Contract or Grant No.

12. Sponsoring Agency name and Address 13. Type of Report and Period Covered
Office of Aviation Medicine
Federal Aviation Administration
800 Independence Avenue, SW

Washington, DC 20591 T4. Sponsoring Agency Code

15. Supplemental Notes
Work was accomplished under approved task AM-B-94-TOX-66

16. Abstract
The FAA Office of Aviation Medicine's Civil Acromedical Institute (CAMI) is tasked under public law 100-591[H.R. 4686]; November 3,
1988, AVIATION SAFETY RESEARCH ACT OF 1988 to conduct toxicology tests on aviation accidents and determine the effects of drugs
on human performance. It.is important for the FAA to identify the extent to which drugs and alcohol are being used by pilots involved in
aviation accidents so that the FAA can take steps to prevent pilots from using drugs or alcohol, which could impair their ability to fly an
aircraft. The toxicology reports prepared by the CAMI Forensic Toxicology Research Section are used by the FAA and the National
Transportation Safety Board to determine the cause of aviation accidents and evaluate present FAA regulations.

METHODS: Specimens (blood, urine, liver, kidney, vitreous, and other bodily specimens) were collected by pathologists near the accident
and placed in evidence containers provided by CAMI. These samples were refrigerated and shipped by overnight air. Upon receipt, the
specimens were inventoried and accessioned for the analysis of drugs, alcohol, carbon monoxide, and cyanide. All data collected by the
laboratory were electronically entered into a computer for future analysis. The data base was searched using a program developed by the
Forensic Toxicology Research Section. The data base was sorted based on the class of drug, controlled dangerous substance schedules I and
Il, controlled dangerous substance schedules III-V, prescription drugs, over-the-counter drugs, and alcohol.

RESULTS: The Toxicology and Accident Research Laboratory received specimens from 1845 pilots for postmortem toxicology analysis
between 1989 to 1993. Controlled dangerous substances, CDSs (schedules I and II), were found in 74 of the pilots analyzed. Controlled
dangerous substances (schedules III - V) were found in 28 of the pilots tested. Prescription drugs were found in 110 of the pilots analyzed.
Over-the-counter drugs were found in 207 of the pilots analyzed. Alcohol at or above the legal limit of 0.04% was found in 146 pilots
analyzed. The reported number of positive drug cases has doubled over the past 5 years,

CONCLUSIONS: Over-the-counter medications are the most frequently found drugs in fatal aviation accidents and many of these drugs, or
the medical conditions for which they are being used, could impair a pilot's ability to safely fly an aircraft. The increased number of positive
cases found in this research is most likely the result of improved methods of analysis, rather than an increase in the use of drugs. The low
incidence of CDS III-V drugs found in fatal aviation accidents may be a result of the difficulty in finding and identifying the new
benzodiazepines commonly prescribed in this class.

17. Key Words 18. Distribution Statement.

Aviation, Drugs, Alcohol Document is available to the public through
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 9

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


DRUGS AND ALCOHOL FOUND IN FATAL CIVIL AVIATION
ACCIDENTS BETWEEN 1989 AND 1993

INTRODUCTION

The Federal Aviation Administration (FAA) has
the responsibility to ensure the safety of flight in
general and commercial aviation. Part of this re-
sponsibility includes enforcement of alcohol and
drug use regulations (14 CFR Part 91.17). The Civil
Aeromedical Institute (CAMI) is responsible un-
der the Department of Transportation (DOT) Order
8020.11A, Chap 4, Par 170, to “conduct toxicologi-
cal analyses on specimens from, and special
pathologic studies on, aircraft accident fatalities.”
In addition, DOT Order 1100.2C, Chap 53, Par 53-
15 requires that CAMI “investigates selected gen-
eral aviation and air carrier accidents and searches
for biomedical and clinical causes of the accidents,
including evidence of disease and chemical abuse.”
Post accident drug and alcohol testing after general
aviation accidents provides information for moni-
toring compliance with these regulations. The in-
vestigation of fatal aviation accidents is the
responsibility of the National Transportation Safety
Board (NTSB) with the assistance of the FAA, as
stated in the Independent Safety Board Act of 1974.
This Act under Section 304 (b) Powers of the Board,
subpart (5), authorizes the Board to obtain autop-
sies and seek other tests of persons who die as a
result of aviation accidents. This authority is also
stated in 49 CFR Part 831.10. The Act, Sec.
304(a)(1)(F) also states the Board shall provide for
the participation by other agencies, in this case the
Federal Aviation Administration. In fact, the Board
may ask the Secretary of Transportation to conduct
investigations of accidents. However, the Act re-
quires that the Safety Board make the determina-
tion of cause or probable cause.

To fully carryout its aviation accident investiga-
tive responsibilities, the NTSB issued Safety Rec-
ommendation A-84-93 requesting the FAA to
“establish at the Civil Aeromedical Institute the
capability to perform state-of-the-art toxicological
tests on the blood, urine, and tissue of pilots

involved in fatal accidents to determine the levels
of both licit and illicit drugs at both therapeutic and
abnormal levels.” On December 1990, Recommen-
dation A-83-93 was “Closed-Acceptable” after the
Civil Aeromedical Institute laboratory was up-
graded and fully staffed.

Under the cooperative efforts of the FAA and
NTSB, specimens from the pilots who were fatally
injured in aviation accidents were analyzed for
drugs and alcohol, as part of the investigation into
the cause of the accidents. Analysis for the pres-
ence of drugs in body fluids and tissues of pilots in
these fatal accidents was used to assist in the deter-
mination of accident causation, and whether impair-
ment from drug use and other medical conditions
caused or contributed to the accident.

METHOD

Specimens (blood, urine, liver, kidney, vitreous,
and other bodily specimens) were collected after
the accidents and placed in evidence containers pro-
vided by CAMI. These samples were refrigerated
and shipped by overnight air. Upon receipt, the
specimens were inventoried and accessioned for the
analysis of drugs, alcohol, carbon monoxide, and
cyanide. Specimens were screened for drugs of
abuse by immunoassay and any positives were con-
firmed by GC/MS. Specimens were screened for
prescription and over-the-counter medications us-
ing a variety of analytical procedures including:
immunoassay, HPLC, TLC, and GC/MS. Confir-
mation of positives in these classes was done by
GC/MS or by a different analytical procedure than
that used in the initial screening. The total number
of drugs reported in this research does not include
caffeine or nicotine. Alcohol is identified and quan-
titated in blood, vitreous fluid, and urine using head
space gas chromatography. All positive alcohols at
or above 20mg/dL are confirmed using fluorescence

we