Pilot Debrief

CZECH SPORT AIRCRAFT AS PIPER SPORT near Homestead, FL — 2022-03-17

Final reportERA22LA162
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Date
2022-03-17
Location
Homestead, FL, USA
Aircraft
CZECH SPORT AIRCRAFT AS PIPER SPORT
Registration
N811PS
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Cruise

Probable cause

The airplane’s collision with water for underdetermined reasons.

NTSB narrative

The pilot and two friends flew their individual airplanes from their home airport on the mainland to an airport on an island in the Florida Keys to meet for lunch. Upon arrival, the pilot landed opposite the direction of other landing traffic and subsequently taxied erratically for 6 minutes, unresponsive to radio calls. The pilot had to be directed by a lineman to park at the location where his friends waited. The lineman stated that the pilot had difficulty getting out of the airplane, appeared “befuddled,” and did not respond to questions. When confronted by another pilot about the opposite-direction landing, the pilot did not respond, and his friends defended him. The lineman reported that the pilot was “devastated” by what he had done, but the only unusual behavior cited by his friends was that the pilot did not eat his lunch. The accident occurred on the return flight, which was conducted during the day and in visual meteorological conditions, and during which the airplane was lost from radar over the Gulf of Mexico. Debris from the airplane was recovered from the surface of the ocean, and the airplane was presumed to be destroyed. Flight track data revealed multiple altitude, heading, and speed excursions on both the accident flight and the previous flight; however, the airplane’s flight track was not erratic at the time radar contact was lost. Pre-event medical records showed that the pilot had multiple medical conditions that significantly increased his risk for a sudden cardiovascular event, including coronary artery disease with stenting of several coronary arteries, previous myocardial infarct, hypertension, high lipid levels, diabetes, and obesity. The pilot’s remains were not recovered, and no autopsy was performed. Based on operational evidence, including interviews, flight track data, and medical risk factors, the pilot may have been medically impaired or incapacitated at the time of the accident; however, given the available medical evidence, the reason for the impairment could not be determined.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have chosen to communicate with ATC after departure.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 7 docket documents
View NTSB final reportView NTSB docket

Docket documents7

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