Pilot Debrief

CESSNA 414 near Bowie, TX — 2014-08-15

Final reportCEN14FA438
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Date
2014-08-15
Location
Bowie, TX, USA
Airport
0F2
Aircraft
CESSNA 414
Registration
N127BC
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Approach

Probable cause

The pilot’s incapacitation in flight as the result of a an acute cardiac event, which resulted in a loss of control and collision with terrain.

NTSB narrative

The multi-engine airplane was about 500 ft above ground level (agl) and on a left base landing approach when a witness saw the airplane suddenly point straight down, begin spinning, and make three complete rotations before impacting terrain in a partially nose-down attitude. The airplane came to rest upright, and was mostly consumed by an immediate postimpact fire. A postaccident examination of the wreckage revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. A pilot operating another pipeline patrol airplane in the vicinity reported frequent severe-to-extreme turbulence about 1,000-2,000 ft above ground level. Data from an on-board GPS unit indicated that, while on the base leg of the airport traffic pattern for landing, the accident airplane's airspeed decayed 10 knots below the manufacturer's recommended approach speed for turbulent conditions. An autopsy performed on the pilot found significant existing atherosclerotic disease (60 to 80 percent) and described evidence of an acute, premortem, nonocclusive thrombosis of the left anterior descending coronary artery. The medical examiner's conclusion stated it "appears the decedent likely suffered an acute cardiac event while piloting his aircraft" and "died primarily due to hypertensive and atherosclerotic cardiovascular disease and that his multiple blunt force injuries likely contributed to his death." It is likely that the pilot was incapacitated due to the acute cardiac event and lost control of the airplane during the approach to land.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Pilot could have aborted the landing approach due to turbulence and wind conditions.

NTSB coding

Evidence available

  • Video
  • ADS-B / radar
  • Photos
  • 17 docket documents
View NTSB final reportView NTSB docket

Docket documents17

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