Pilot Debrief

PIPER PA-39 near Caldwell, NJ — 2022-09-09

Final reportERA22LA414
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Date
2022-09-09
Location
Caldwell, NJ, USA
Airport
CDW
Aircraft
PIPER PA-39
Registration
N8925Y
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Takeoff roll

Probable cause

The pilot’s acute cerebrovascular event, which caused symptoms that diminished his situational awareness and prompted him to abort the takeoff, resulting in a runway excursion.

NTSB narrative

The 84-year-old pilot and the passenger made two attempts to take off on a cross-country flight. According to the passenger, once she and the pilot boarded the airplane, the pilot said he forgot where they were going and had to ask the name of the airport. After informing the pilot of their destination, the pilot taxied to the runway and began to accelerate for takeoff. The pilot aborted the takeoff because he thought the passenger’s door was open. The door was secured, and the pilot taxied back to the runway. Just before taking off again, the pilot asked a second time where they were going. The passenger again had to tell the pilot their destination. The pilot initiated the takeoff roll, but aborted because he felt something was wrong with the airplane. The airplane went off the end of the runway, resulting in substantial damage to the left wing. When first responders arrived on scene, they noted the pilot was confused and had memory problems. The pilot was hospitalized for neurological evaluation and consultation. Magnetic resonance imaging of the pilot’s brain performed the day after the accident demonstrated an acute-to-subacute lacunar stroke in the right medial temporal lobe. The pilot was discharged from the hospital with a diagnosis of transient global amnesia. As such, the pilot most likely experienced an acute cerebrovascular event. Impairing symptoms of this event likely diminished his situational awareness and prompted him to intentionally abort the takeoff, resulting in the runway excursion.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have recognized his confusion before initiating takeoff.

NTSB coding

Evidence available

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

Docket documents5