Piper PA28 near Salem, SD — 2019-01-13
- Date
- 2019-01-13
- Location
- Salem, SD, USA
- Aircraft
- Piper PA28
- Registration
- N75191
- Category
- Airplane
- Highest injury
- Fatal
- Fatalities
- 1
- Phase of flight
- Climb
Probable cause
The incapacitating effects of an acute myocardial infarction (heart attack), which resulted in the pilot's loss of airplane control and impact with terrain.
NTSB narrative
About 15 minutes after departing on a cross-country flight in day visual meteorological conditions, the pilot contacted air traffic control to report that he was having chest pain and blacking out, and was having difficulty controlling the airplane. The controller continued to communicate with the pilot for about 20 minutes before radio contact was lost. The wreckage was subsequently located in a field. Examination did not reveal any preimpact anomalies that would have precluded normal operation of the airplane. The pilot's Federal Aviation Administration medical certificate expired about 10 weeks before the accident. He had begun but not completed the requirements for operation under BasicMed. Autopsy of the pilot identified coronary artery disease including 80% stenosis of the left anterior descending coronary artery and 50% stenosis of the right coronary artery and diagnosed an acute myocardial infarction (heart attack). It is likely that the sudden, impairing effects of the heart attack and associated severe chest pain resulted in the pilot's loss of airplane control while attempting to land in a field, and its subsequent impact with terrain.
Analysis
- Primary failure mode
- Human factors
- First missed decision gate
- Pilot could have chosen to land immediately after experiencing chest pains.
NTSB coding
Evidence available
- ATC audio
- ADS-B / radar
- 18 docket documents
Docket documents18
- Air Traffic Control - FAA Report of Accidentatc
- Air Traffic Control - Plotted Radar Data -- B. Soperatc
- Air Traffic Control - Transcriptatc
- Miscellaneous Information - CAMI Toxicology Drug Information for Amlodipine Ranitidine Valsartanform
- Miscellaneous Information - Fuel Receipt RAPform
- Miscellaneous Information - Fuel Receipt Y14form
- Miscellaneous Information - Pilot Logbook Excerptsform
- Other Pertinent Forms and Reports - Medical Factual Reportform
- Release of Aircraft Wreckage, NTSB Form 6120.15form
- Statement of Party Representatives to NTSB Investigationinterview
- Correspondence - CFI on BFRother
- Maintenance Records - Annual Inspections 9/10/18other
- Memorandum for Record – Communication Summary -- RAP FBOother
- Memorandum for Record – Communication Summary L. Alexander -- No record of wx briefother
- Memorandum for Record – Communication Summary R. Gebel, MHE FBO Managerother
- Reports from Parties to the Investigation - Examination Summary -- Piperreport
- Toxicological Report - 201900010001report
- Weather Reports and Recordsreport