Pilot Debrief

CESSNA 172M near Poughkeepsie, NY — 2011-06-28

Final reportERA11FA369
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Date
2011-06-28
Location
Poughkeepsie, NY, USA
Airport
POU
Aircraft
CESSNA 172M
Registration
N61579
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Approach

Probable cause

The pilot’s loss of airplane control due to impairment or incapacitation as a result of coronary artery disease in combination with atrial fibrillation. Contributing to the accident was the pilot's failure to report his paroxysmal atrial fibrillation to the Federal Aviation Administration, which would have required follow-up testing that would likely have detected his undiagnosed coronary artery disease.

Contributing factors

Contributing to the accident was the pilot's failure to report his paroxysmal atrial fibrillation to the Federal Aviation Administration, which would have required follow-up testing that would likely have detected his undiagnosed coronary artery disease.

NTSB narrative

The airplane was flying in the airport traffic pattern in good weather and was in radio and radar contact with air traffic control. While on short final approach, without warning or distress, the airplane descended nose-down and impacted a field about 1/4 mile before the runway threshold. Examination of the airframe and engine did not reveal evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Although the pilot’s autopsy report listed the cause of death as multiple blunt impact injuries, it also noted significant coronary artery disease with stenosis of 85 to 90 percent in one of the arteries. Review of the pilot's personal medical records revealed that about 3 years before the accident, he was found to have paroxysmal atrial fibrillation and hypertension. Subsequent treatment with medications was unsuccessful, and 1 year before the accident, he underwent a procedure to ablate a foci initiating the abnormal heart rhythm. The procedure was initially successful with a return to normal sinus rhythm, but by 1 month before the accident, the atrial fibrillation recurred and medications were restarted. Toxicological testing confirmed the presence of medications used to treat high blood pressure, control the rate of atrial fibrillation, and thin the blood. None of the cardiology or prescription medication information was reported to a Federal Aviation Administration aviation medical examiner during any of the pilot's applications for medical certificates. Had the pilot reported the atrial fibrillation, he would have been initially disqualified for a medical certificate. However, pilots with well controlled rates, who are mostly asymptomatic and without concomitant coronary artery disease, could be issued a special issuance medical certificate with appropriate follow-up. In the pilot’s case, such follow-up would have likely detected the undiagnosed coronary artery disease, which, in combination with the atrial fibrillation, put him at increased risk for sudden cardiac death. It was very likely that the pilot became impaired or incapacitated by his underlying cardiac disease during the accident flight.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot's medical condition should have been reported to FAA for proper certification.

NTSB coding

Evidence available

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

Docket documents17

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