PIPER PA-28-140 near Gatesville, TX — 2010-02-27

Probable cause

The pilot’s incapacitation as a result of one or more pre-existing medical conditions.

NTSB narrative

Witnesses saw the airplane make abrupt changes in directional flight, “first to the right at a bank angle of at least 60 degrees,” then it flew straight and level before entering a steep left climbing turn. The aircraft then started a descent with wings level at about a 45-60 degree nose-down angle. Other witnesses saw the airplane make several loops. The airport manager said this was “entirely out of the pilot’s character.” The pilot had a medical history that included a traumatic brain injury following an accident that put him in a coma in 1993. This was accompanied with persistent cognitive deficits and frequent intermittent episodes of amnesia, severe chronic lung disease that required him to use supplemental oxygen to avoid hypoxia during periods of activity, and depression for which he had been receiving therapy. He had specifically denied any history of unconsciousness, lung disease, neurological disorders, or depression on his most recent application for a Federal Aviation Administration (FAA) Airman Medical Certificate, and the FAA would have denied that application had they been aware of the full extent of the pilot’s medical conditions. The pilot also had a slowly expanding abdominal aortic aneurysm, and coronary artery disease with evidence of heart muscle abnormalities on echocardiogram performed two months prior to the accident. He was on a medication that would have reduced his tolerance to increased G-loading. Although an oxygen generator was found in the pilot’s parked automobile, no oxygen was found in the airplane wreckage.

Analysis

Primary failure mode

Human factors

First missed decision gate

Pilot could have refrained from performing aerobatic maneuvers.

NTSB coding

• Abrupt maneuver · Maneuvering
• Impairment / Incapacitation

Evidence available

• Photos
• 6 docket documents

Docket documents6

• Medical Records Informationform
• Witness Statementsinterview
• Photo. Wreckage panorama.photos
• Toxicology Reportreport
• Weather Reports and Recordsreport
• Transcript of Weather Briefingstranscript

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