Pilot Debrief

CESSNA 152 near Tucson, AZ — 2013-02-08

Final reportWPR13FA118
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Date
2013-02-08
Location
Tucson, AZ, USA
Airport
RYN
Aircraft
CESSNA 152
Registration
N89059
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot's incapacitation due to his preexisting cardiac disease, which resulted in his degraded or complete loss of ability to control the airplane.

NTSB narrative

The pilot rented the airplane from the fixed-base operator (FBO) to fly to an airport about 11 miles away to practice takeoff and landings. He spoke briefly with two people in the FBO office and then went out to the airplane to preflight it and have it fueled. Review of the departure airport air traffic control tower (ATCT) communications and air traffic control radar tracking data did not reveal any abnormalities with the departure or flight. About 7 minutes after departure, the pilot contacted the ATCT at his destination airport and advised the controller that he was planning to do three touch-and-go maneuvers. Per instructions from the controller, the pilot entered a right downwind for his assigned landing runway. When the airplane was near a location consistent with it being established on the base leg, several motorists observed it in a steep nose-down attitude and descending rapidly. The airplane impacted flat terrain about 1.5 miles from the airport. Neither of the two ATCT controllers observed the descent or impact. Examination of the airframe and engine did not reveal any preimpact anomalies that would have precluded continued engine operation or flight. The pilot had obtained his first Federal Aviation Administration (FAA) medical certificate about 10 years before the accident, received annual recertification, and his most recent medical certificate was issued about 13 months before the accident. Review of the pilot's FAA medical records indicated that, for the intervening 9 years, the pilot was being treated for multiple cardiac issues and was subject to repetitive specialized medical testing. Further review indicated that the pilot had slow, essentially asymptomatic, progression of at least two components of his cardiac disease that are both independently associated with a significantly increased risk of sudden cardiac death as a result of a sudden arrhythmia. Although autopsy results indicated that the cause of death was blunt trauma, it is likely that a complication of the pilot's cardiac disease caused him to become incapacitated, which resulted in his loss of control of the airplane and the subsequent crash. The 0707 code found on the transponder was likely an artifact of the pilot's attempt to switch to the 7700 emergency code to indicate a problem to the controllers, but neither the timing nor the underlying reason for that action could be determined.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have chosen to abort the approach when losing visual contact.

NTSB coding

Evidence available

  • ATC audio
  • ADS-B / radar
  • 24 docket documents
View NTSB final reportView NTSB docket

Docket documents24

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