Report: Sedatives found in pilot's blood
Stars and Stripes November 15, 2003
An Army aviator flying an MH-47 helicopter that crashed in the Philippines in February 2002, killing 10, had high levels of a sleep-inducing medication in his system, according to an Army aircraft accident report.
Capt. Bartt D. Owens, one of the 10 servicemembers who died in the crash, tested positive for the sedative temazepam, said the report obtained by Stars and Stripes through a Freedom of Information Act request.
Toxicology results included in the investigation report revealed that Owens’ body had 1.2 milligrams of the drug per liter of blood.
“That’s twice the therapeutic level normally needed for the drug to take effect,” said an official close to the investigation who asked not to be identified.
The Army Safety Center at Fort Rucker, Ala., which conducted the investigation, has not released a cause for the accident.
Temazepam, often sold under the brand name Restoril, is used to induce sleep and cause relaxation.
John Cooper, an independent medical examiner and forensic pathologist based in San Bernadino, Calif., who was not part of the investigation, said the investigators’ findings were “very significant.” Anybody with that much of the drug in his system “most definitely shouldn’t be flying,” said Cooper, a former Air Force flight surgeon. “The main factor is the drug is going to diminish reaction time and affect judgment.”
Cooper also said that it’s possible the drug could contribute to spatial disorientation, resulting from optical illusions or false depth-of-field perceptions, especially while flying in darkness with night-vision goggles.
Only when prescribed
Military flight surgeons routinely prescribe sedatives to aviators to help their bodies adjust to time zone changes and constant shift rotations, said Quay Snyder, a retired Air Force flight surgeon.
Snyder currently serves as a physician for Virtual Flight Surgeons, an organization that helps civilian pilots gain the medical certification that the Federal Aviation Administration requires for pilots to fly. He said pilots under the FAA charter would lose their medical certification if they were found to be using Restoril.
In some cases, Snyder said, military aviators use the sedatives, or “no-go pills,” to counteract the high from amphetamines, or “go pills,” the military dispenses to keep pilots awake and focused during long missions. He added that, in all cases, military regulations require that the use of the go and no-go pills be tightly controlled and prescribed only by flight surgeons.
Owens “was not taking medications prescribed by a flight surgeon at the time of the accident,” the accident investigation report said.
Use of Restoril or other sedatives must be under the direct supervision of the supporting flight surgeon, the report said, adding, “No aircrew member taking medication is fit to fly unless a flight surgeon has specifically cleared the crew member to fly.”
Lt. Col. Cynthia Gleisberg, the Army Safety Center’s legal adviser, confirmed the Army report’s findings that Owens tested positive for the drug.
But the center, which conducted the investigation, deleted from its releasable report all data pertaining to the cause of the accident.
Gleisberg said the center guarantees complete confidentiality, so witnesses can openly tell what caused an accident without fear of retribution.
“We want them to tell us the truth and not be afraid to say, ‘I did something wrong,’ so that nothing they say can be used against them or their friends in court,” said Gleisberg.
The Pacific Command, headquartered in Hawaii, conducted a separate investigation but would not immediately comment on what caused the crash or what corrective actions, if any, the command has taken to prevent recurrence.
The findings of such collateral reports are typically released; Stripes has filed a request to obtain a copy of this one.
The PACOM investigation could be used in any criminal proceeding, whereas the Fort Rucker investigation is used purely to track potential safety problems and to prevent recurrence.
Tireless mission tempo
The aircraft and eight crewmembers who perished were from the 160th Special Operations Aviation Regiment stationed at Taegu, South Korea, of which PACOM is the parent command.
Lt. Col. Deborah Bertrand, a U.S. Forces Korea spokeswoman, would not comment on the report, stating that “as a matter of policy, we do not comment on accident investigation reports.”
Two Air Force pararescuemen from the 353rd Special Operations Group at Kadena Air Base, Okinawa, also were aboard and died.
An “O-3,” identified as the onsite flight surgeon at Mactan Air Base on the Philippine island Cebu, the intended landing spot for the MH-47, said in testimony to Army Safety Center investigators that both Air Force and Army pilots had told him they were fatigued from the tempo of all the missions they were flying and from all the schedule changes. He said he had heard that the co-pilot of an aircraft that was in front of the MH-47 had almost fallen asleep the night of the accident, which occurred at 2:30 a.m. on Feb. 22.
Following the accident, he noted, a medic from the 160th asked if he could give the crew of the lead aircraft the sedative Ambien to help them sleep. In flight, those crewmembers made a radio request that the MH-47 climb when they saw the aircraft begin to descend on them.
The “pilot-in-command” of the MH-47, identified in the report as Chief Warrant Officer 2 Jody Egnor, then took controls and tried to make an “abrupt evasive maneuver” to avoid crashing into the lead aircraft. Egnor lost control of the aircraft, and it plunged nose down into the water at 180 mph, exploding into a “huge fireball” upon impact, the report said.
A chief warrant officer 3 in the lead aircraft whose name was blotted out of the report said the “right seat pilot” of the trail aircraft, whom the report identified as Owens, probably “got a visual illusion” — something that he and other crewmembers had experienced on several occasions during recent missions.
Drugs in the system
Robert Weien, a retired Army helicopter pilot and flight surgeon who now serves as a physician and toxicologist for Virtual Flight Surgeons, noted that anybody with the amount of temazepam Owens had in his blood at the time of his death “certainly had taken the medication within 12 hours.”
Military pilots typically are not allowed to fly within 12 hours of taking the drug, Weien said.
Owens had been airborne more than seven hours at the time of the accident and had attended preflight briefings several hours before the mission began.
From his time as a military flight surgeon, Weien said it was common knowledge that special operations personnel would often “make up their own rules or do whatever it took” to get the mission accomplished.
The regulations require flight surgeons to prescribe only the amount of medication required for near-term operations, thus requiring automatic follow-up for re-evaluation, but Weien said that wouldn’t keep some aviators in the special operations environment from “keeping a few pills for later on, if needed.”
“Aircrew are not authorized to carry additional doses of sedative,” according to a February 2003 policy letter from the U.S. Army Aeromedical Activity Web site, which provides guidance to military flight surgeons.
It added that sedatives “will not be carried in the aircraft to preclude inadvertent use during flight operations. A check to ensure aircrew are not carrying sedatives in flight must be part of safety, mission and preflight briefings during use of these agents.”
The Army report contained a discussion about tests in a flight simulator that revealed significant “performance degradation” after the use of Halcion, the “drug most like Restoril.”
And since the half-life — the time it takes the body to eliminate half of the drug from the body — of Restoril is longer than that of Halcion, “it is reasonable to expect that degradation of flight performance would last longer after taking Restoril,” the report stated.
Included in the investigation report was an aeromedical discussion paper that concluded use of temazepam “during combat or training situations by Army personnel needs further exploration before a specific policy can be drafted and accepted.” And it may “degrade cognitive performance and physiological resources, in some instances even 10 to 12 hours postadministration.
“Any drug which increases the time required to awaken or causes memory or psychomotor impairment postadministration will compromise safety,” the report said.
‘An accident of war’
The soldiers who died in the accident besides Owens and Egnor were Maj. Curtis D. Feistner, who was sitting in the center jump seat but not flying the night of the accident; Staff Sgt. James P. Dorrity; Staff Sgt. Kerry W. Frith; Staff Sgt. Bruce A. Rushforth Jr.; Sgt. Jeremy D. Foshee; and Spc. Thomas F. Allison. The Air Force personnel were Master Sgt. William L. McDaniel II and Staff Sgt. Juan M. Ridout.
The news of the drug use “does not change the way we feel, one iota,” said Pat Allison, Thomas Allison’s mother. Pat Allison said her son was to be promoted to sergeant in March 2002.
“I know our son would have flown with those same men on the same mission and would have been very proud doing it. … We feel it was an accident of war, and that’s all we want to say about it.”