Pilot Debrief

CESSNA T310R near Chadron, NE — 2021-11-22

Final reportCEN22FA042
Sign in to save
Date
2021-11-22
Location
Chadron, NE, USA
Airport
CDR
Aircraft
CESSNA T310R
Registration
N310JA
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Takeoff roll

Probable cause

The incapacitating effects of a myocardial infarction (heart attack), which resulted in the pilot's loss of airplane control and impact with terrain.

NTSB narrative

The pilot departed on a personal flight in dark night visual meteorological conditions. The airplane impacted terrain northwest of the airport about 30 seconds after departure. The distribution of the debris was consistent with a wings-level, slightly nose-down impact. The airplane was destroyed by impact forces and a postimpact fire. Postaccident examination of the airframe and engines revealed no mechanical anomalies that would have precluded normal operation. Although toxicology results revealed that the pilot was taking at least two medications (chlorpheniramine and dextromethorphan) that may have impaired his performance, the fact that the medication levels were unquantifiable indicated that their levels were too low for them to have had significantly impairing effects at the time of the accident. According to the autopsy findings, the pilot was actively having a heart attack in the hours before the accident. This placed him at severely increased risk for acute impairment/incapacitation from chest pain, shortness of breath, feeling faint, or becoming unconscious. Any of these symptoms would have likely led to the low altitude loss of control identified in this crash. Therefore, the pilot’s ongoing myocardial infarction (heart attack) is the most likely cause of this accident.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have delayed takeoff due to dark conditions and lack of visible horizon.

NTSB coding

Evidence available

  • Video
  • ADS-B / radar
  • 9 docket documents
View NTSB final reportView NTSB docket

Docket documents9

Related mishaps