Pilot Debrief

Piper PA28 near Salem, SD — 2019-01-13

Final reportCEN19LA053
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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
View NTSB final reportView NTSB docket

Docket documents18