Pilot Debrief

Piper PA28 near Evansville, IN — 2019-12-21

Final reportCEN20FA038
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Date
2019-12-21
Location
Evansville, IN, USA
Airport
EVV
Aircraft
Piper PA28
Registration
N601FL
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot’s failure to maintain control of the airplane.

NTSB narrative

The pilot was flying to an airport about 60 miles north of the departure airport. About 18 miles short of the destination airport, the pilot informed air traffic control (ATC) that he was returning to his departure airport and performed a 180° turn to the south. The pilot did not report any problems or concerns to ATC during the flight and he was cleared to land on runway 18 at the departure airport. Witnesses observed the airplane enter a right descending turn and impact a field about 2 miles north of the airport. No anomalies were noted with the airframe or engine during postaccident examination that would have resulted in a loss of aircraft control. According to the autopsy of the pilot, the cause of death was multiple blunt force injuries; however, the autopsy was limited due to the injuries the pilot received. The pilot’s medical records demonstrated the pilot had severe coronary disease than was not fully identified by the limited autopsy. The disease had progressed over the previous 20 years and placed the pilot at risk of sudden symptoms such as shortness of breath, chest pain, disturbances in heart rhythm causing palpitations and fainting. Heart rhythm problems leave no evidence at autopsy and even large heart attacks do not leave autopsy evidence if death occurs within about 3 hours. The absence of findings during the autopsy were not indicative that an acute cardiac event did not occur. Based on available evidence from the pilot’s medical records, it was possible that the pilot had experienced a sudden incapacitation due to an acute cardiac event, which led to a loss of control of the airplane. However, this could not be definitively determined based on a lack of additional corroborating operational evidence. Based on available evidence from the pilot’s medical records, the most likely explanation for the accident is sudden incapacitation of the pilot due to an acute cardiac event, which led to a loss of control of the airplane.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have reported difficulties before returning to EVV.

NTSB coding

Evidence available

  • Photos
  • 9 docket documents
View NTSB final reportView NTSB docket

Docket documents9

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