Pilot Debrief

HENDERSON W A/JOHNSON W L RV 6A near Bon Aqua, TN — 2015-09-02

Final reportERA15FA336
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Date
2015-09-02
Location
Bon Aqua, TN, USA
Aircraft
HENDERSON W A/JOHNSON W L RV 6A
Registration
N216LA
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Climb

Probable cause

The pilot's incapacitation from complications of a recent heart attack, which resulted in a loss of control during cruise flight.

NTSB narrative

During the cruise portion of a cross-country flight, about 20 minutes after takeoff, the commercial pilot stopped responding to air traffic controllers as the airplane reversed course. It then climbed from 6,500 ft to 9,000 ft mean sea level and completed two left circuits before descending rapidly into the ground. Examination of the wreckage did not reveal any preimpact mechanical malfunctions. The pilot's autopsy revealed that he had severe coronary artery disease, scarring from previous heart attacks, and evidence of ongoing or recent damage to two new areas of heart muscle, indicating recent heart attacks. All of these conditions put him at risk of experiencing acute heart failure or a disturbance of heart rhythm (arrhythmia). Both acute heart failure and arrhythmia can rapidly lead to decreased consciousness due to low blood pressure. It is likely that acute symptoms from complications of the pilot's ongoing heart attacks resulted in impairment /incapacitation of the pilot and led to his loss of airplane control.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have recognized and addressed potential cardiac issues before flight.

NTSB coding

Evidence available

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

Docket documents10

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