Page:CAB Accident Report, Piedmont Airlines Flight 349.pdf/11

 To the Board there were numerous factors which were obviously inconsistent with Captain Lavrinc's record. Some were. The apparent navigational omission, a nonadherence to precise tracking procedures, and a descent below the authorized procedure turn altitude. Others were the failure to note that the time for station passage was in excess of that commensurate with a close-in position, and that ADF indications were not compatible With the normal procedure turn presentation. Still others were a failure to request the latest Charlottesville weather when the Communicator did not furnish it, and not using the altimeter setting given in response to the inrange report. The Board believes these factors were not only inconsistent with Captain Lavrinc's reputation as an exacting pilot but were indicative of a serious departure from the high standard and quality of performance expected during an instrument operation. Because of these factors a comprehensive investigation was made into the personal background of Captain Lavrinc. This was done to search for reasons which could seriously impair his normal piloting ability. During this work reasons were found which could result in his preoccupation.

Captain Lavrinc had, for several years, been under severe emotional strain. The Board considers that disclosure of detailed information relating thereto would adversely affect the interests of certain persons and is not required in the interest of the public. A resume of the Board's significant findings and certain recommendations, however, are in the public interest and are set forth below.

Captain Lavrinc received psychotherapy in 1953—1954; he obtained further psychiatric counseling in 1957; intensive psychotherapy was resumed in May 1959, which he underwent several times a week thereafter; his last appointment was the night before the accident. This latter treatment involved the services of two psychiatrists. In the course of this treatment the first psychiatrist prescribed certain psychotropic drugs. After trials on Compazine, Prozine, Sparine, and Thorazine, Prozine was prescribed in August 1959 in a dosage of three or four times daily and was reissued on September 18, 1959. This prescription specif- ied an amount which, if taken as directed, would have been sufficient to last until two days before the accident.

On September 23, 1959, however, Captain Lavrinc commenced psychotherapy under the second psychiatrist who prescribed no drugs. The Board has been arable to determine whether or not Captain Lavrinc continued to take the medicine in the prescribed manner during the latter treatments, although there is evidence that he took the earlier trial prescriptions.

The Board has evaluated the background and history of Captain Lavrinc, including data set forth above, In addition, it submitted all the available information covering Captain Lavrinc to particularly qualified medical experts for evaluation as to its Significance with respect to this acc1dent.

The consensus is that Captain Lavrinc was so heavily burdened with mental and emotional problems that he should have been relieved of the strain of flight duty while undergoing treatment for his condition. This condition was such that preoccupation with his problems could well have lowered his standard of per— formance during instrument flight. Furthermore, with respect to this accident the consensus is that the emotional and mental problems were of far greater importance in causing the preoccupation that could have the use of psychotropic medication.