Investigators blame pilot error, fatigue and impairment by a sleep medication for an airplane crash that killed four at Visalia Municipal Airport more than a year ago.
A report issued by the National Transportation Safety Board concludes that Bernard Sinor, a Visalia businessman and experienced pilot, flew too slowly in his Piper Twin Comanche during his landing approach on the evening of Jan. 13, causing the plane to stall and crash.
Sinor, 67, died along with his wife, Betty, 57, and grandchildren Jorjanna and Kyndall Plumlee, ages 6 and 3, of the San Francisco Bay Area town of Brentwood.
The safety board's "probable cause" report also states that "extremely high levels" of doxylamine -- an antihistamine found in some over-the-counter sleep aids -- were discovered in toxicology tests of Sinor's blood.
"Contributing factors ... were the pilot's impairment due to his prolonged use of a highly sedating over-the-counter sleep aid and fatigue due to lack of sleep," the report states.
Medical records showed Sinor complained of back pain that interfered with his sleep. The report suggests Sinor was using a sleep aid.
Doxylamine, the report said, "had likely accumulated [in Sinor's body] due to daily use and/or use in excess of the maximum recommended dose."
Investigators inspected the wreckage of Sinor's twin-engine airplane, built in 1964, for mechanical troubles. "Examination of the wreckage did not reveal any mechanical anomaly to preclude normal operation of the engine or the airplane control systems," the report states.
The Sinors were returning to Visalia after picking up the two grandchildren in Byron, near their hometown in Contra Costa County. The airplane crashed near the south end of the runway shortly before 6:30 p.m.
A witness, Geoff Ludlow of Visalia, was driving near the airport and saw the crash; he drove immediately to the Visalia Fire Department station at the airport to report the incident.
But when firefighters looked to the runway and saw nothing unusual, they opted not to investigate Ludlow's report.
Only later, after worried family members contacted city officials and the Federal Aviation Administration, did Airport Manager Mario Cifuentez search the airport grounds and discover the wreckage four hours after Ludlow's report.
NTSB investigator Kristi Dunks said the airplane's emergency radio beacon -- intended to alarm officials in case of trouble -- was armed but did not activate when the plane crashed.
Ted Lopatkiewicz, a safety board spokesman in Washington, D.C., said the issuance of the March 26 probable-cause report marks "the final step in the process" for the federal investigation of the accident. Within weeks of the accident, the agency released its preliminary report -- an early examination of the crash circumstances including weather reports, witness statements and radar tracking.
That was followed early this year by a fact report that revealed what investigators discovered in their analysis of the aircraft wreckage, maintenance records, the pilot's medical history and other information.
Don Ernst, an attorney representing the Sinor and Plumlee families, expressed reservations about the NTSB's findings.
"Our medical analysis is ongoing, but the fact-finding report indicates mechanical issues were present in the left motor that were not mentioned in the probable cause report," Ernst said Wednesday. "Our analysis is ongoing on that as well."
While the official investigation may be over, the same cannot be said of the aftermath.
The city took several steps in the weeks following the crash, including revamping how police and fire staff take reports of aircraft emergencies and respond to callers reporting an overdue aircraft.
And after the fire crew's inaction to the witness report, one firefighter was suspended, a fire engineer was demoted and suspended, and a battalion chief was reprimanded. A fire captain abruptly retired.
Ernst said the NTSB findings don't affect a claim by Sinor and Plumlee relatives against the city alleging negligence in the deaths of the victims.
"The claim ... is based on the delay of emergency services and the consequential death of the occupants based on that delay," Ernst said Wednesday.
The claim was filed on behalf of Bernard Sinor's children, Mike Sinor of Arroyo Grande, John Sinor of Oregon and Teri LaFleur of Woodlake; Beverly Adair of Visalia, Betty Sinor's mother; Betty's daughters Krista Plumlee of Brentwood and Ann Hover of Fresno; and Krista and Matt Plumlee as the parents of the children.
The claim seeks compensation for emotional distress, loss of companionship and more than $3 million in economic losses and future earnings.
Ernst and City Attorney Alex Peltzer said talks continue between the city and the family for a possible settlement.
Less than a week after the crash, the Tulare County Coroner's Office concluded that all four victims died on impact.
The reporter can be reached at or (559) 622-2410.
News stories provided by third parties are not edited by "Aircraft Maintenance Technology" staff. For suggestions and comments, please click the Contact link at the bottom of this page.