PIPER PA-28-140 near Saint Joseph, MO — 2022-11-20

Probable cause

The pilot lost control of the airplane while on the ground due to temporary incapacitation.

NTSB narrative

The pilot recalled communicating with air traffic control (ATC) for his taxi clearance and did not recall any events after acknowledging the taxi clearance. An ATC controller issued taxi instructions and observed the airplane taxi to the run-up area. After completing the run-up, the pilot was instructed to contact the ATC tower. After no communications were received from the pilot, the controller attempted to initiate contact but there was no reply. Several attempts to contact the pilot via radio were unsuccessful, and the tower controller noticed the airplane had turned around in the run-up area. Based on the airplane’s repositioning, the controller assumed the pilot was looking for a light signal and issued a green light. When the airplane did not move, the controller made several more attempts to contact the pilot but there was no response. The controller then noticed that the airplane appeared to be taxiing back to the general aviation ramp; however, the airplane accelerated, departed the movement area into the grass, and impacted a perimeter fence. Postaccident examination of the airplane revealed no evidence of any preimpact mechanical malfunction or failures that would have precluded normal operation. The airplane sustained substantial damage to the fuselage and both wings. Based on the witnessed circumstances of the accident, it is likely the accident was the result of the pilot’s temporary incapacitation. Postaccident medical care of the pilot revealed the pilot had an undiagnosed brain tumor. The incapacitation was possible due to a seizure trigged by the tumor, and it was also possible that the brain tumor was an incidental finding unrelated to incapacitation. The cause of the pilot’s incapacitation could not be definitively determined from available medical evidence.

Analysis

Primary failure mode

Human factors

First missed decision gate

Pilot could have recognized symptoms and not attempted to fly.

NTSB coding

• Medical event · Taxi
• Impairment / Incapacitation

Evidence available

• Photos
• 6 docket documents

Docket documents6

• PILOT/OPERATOR AIRCRAFT ACCIDENT REPORT, NTSB FORM 6120.1form
• FAA ACCIDENT NOTIFICATIONother
• FAA RECORD OF CONVERSATION - PILOTother
• INVESTIGATION PHOTOGRAPHSphotos
• MEDICAL FACTUAL REPORTreport
• TOXICOLOGICAL REPORTreport

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