Pilot Debrief

CESSNA T206H near Borrego Springs, CA — 2010-05-07

Final reportWPR10GA231
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Date
2010-05-07
Location
Borrego Springs, CA, USA
Airport
KTRM
Aircraft
CESSNA T206H
Registration
N663HP
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Cruise

Probable cause

The pilot suffered a sudden incapacitating event as a result of his severe cardiovascular disease.

NTSB narrative

Representatives of the California Highway Patrol (CHP) stated that the CHP pilot was performing traffic surveillance activities with numerous ground units. The officers decided to transfer their activities to another location, and they reported that about 40 minutes after the mission was to be finished, the pilot had not checked in. About 6 hours later, the wreckage of the airplane was located at approximately 1,100 feet mean sea level (msl) on the east face of a 1,500-foot desert mountain. Recorded radar data showed that the autopilot-equipped airplane initially flew along a highway at 1,600 feet msl to the north and then changed direction to the southwest about 20 minutes after the mission was to be finished. The airplane then proceeded on a steady course of 225 degrees magnetic at 1,200 feet msl directly toward rising mountainous terrain. The final radar return occurred 3 minutes later, 1.7 miles northeast of the accident location. The accident location was directly on the extended course line of 225 degrees from the last radar return, at the 1,070-foot elevation level. The pilot’s autopsy report noted severe atherosclerotic coronary artery disease and evidence of a scarring from a prior heart attack. Toxicology testing did not detect any drugs or medications in the tissue evaluated. The pilot had autopsy evidence of severe heart disease, and radar track information was consistent with the autopilot controlling the airplane with an absence of pilot control inputs. There was no indication in the pilot’s medical records that he was aware of any heart disease. The pilot had spinal surgery approximately 1 year prior to the accident, and did have continual intermittent mild to moderate spinal pain, with a recent exacerbation of that pain, but it is unlikely that the pain was sufficiently distracting or impairing to have resulted in the complete absence of control .

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot did not maintain altitude or avoid mountainous terrain during cruise flight.

NTSB coding

Evidence available

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

Docket documents10

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