Pilot Debrief

Piper PA32 near Crisfield, MD — 2019-06-15

Final reportERA19LA197
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Date
2019-06-15
Location
Crisfield, MD, USA
Airport
W41
Aircraft
Piper PA32
Registration
N2750Q
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Approach

Probable cause

The pilot's sudden incapacitation from an undiagnosed cardiac arrhythmia while on final approach, which resulted in descent and collision with trees and terrain.

NTSB narrative

The pilot departed with the intention of remaining in the traffic pattern to perform one full-stop night landing before proceeding on a planned instrument flight rules cross-country flight. After takeoff, he remained in the traffic pattern and turned onto the final approach leg. He last recalled being about 1 mile from the runway threshold, then had a brief recollection of trees being in the cockpit. He awoke several hours later, exited the wreckage of the airplane, and walked to his house, where help was summoned. He reported that, to the best of his knowledge, there was no preimpact mechanical failure or malfunction. The pilot's description was consistent with unwitnessed temporary loss of consciousness during the landing approach. While there was no toxicology to support an alternative cause, a cardiac evaluation 2 months after the accident revealed that the pilot had intermittent complete heart block with prolonged pauses between heartbeats, which can lead to fainting. Additional cardiac tests showed normal coronary arteries but revealed that the pilot had cardiac sarcoidosis. The pilot denied having syncopal events prior to the accident and reported no symptoms before losing consciousness. His medical records contained no mention of any sarcoid disease. Given the natural course of cardiac sarcoidosis, the pilot's sudden incapacitation from complete heart block would not have been predicted. Thus, it is likely that the pilot experienced sudden incapacitation from an undiagnosed arrhythmia.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have opted to abort the landing when feeling unwell or dizzy.

NTSB coding

Evidence available

  • 6 docket documents
View NTSB final reportView NTSB docket

Docket documents6

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