Pilot Debrief

PIPER PA-30 near Merced, CA — 2010-04-27

Final reportWPR10FA217
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Date
2010-04-27
Location
Merced, CA, USA
Airport
MCE
Aircraft
PIPER PA-30
Registration
N847DE
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

Probable cause

Pilot incapacitation due to the combined effect of multiple unreported medical conditions.

NTSB narrative

The 88-year-old pilot, who was a property appraiser, departed for the short local flight in the multiengine airplane to perform aerial property observation. Although family members and associates reported normal behavior that morning, witnesses stated that at the airport, he appeared pale, listless, and slightly confused as he attempted to remove his airplane from the hangar. Unable to muster the strength to move the airplane, he enlisted the help of an employee at the fixed base operator. Airport security video captured the airplane’s ground roll and departure; the airplane took twice the normal distance to take off than was required; however, video and radar track data recorded a normal departure from the pattern. The airplane leveled off shortly after takeoff, and continued to fly at a constant airspeed and appropriate altitude for ground observation. Shortly thereafter, the airplane initiated a descent and made a left turn back toward the airport. The airplane continued to descend during the first portion of the return leg, and the pilot reported over the common traffic advisory frequency that he was experiencing “all kinds of trouble/problems in the cockpit” and that he was returning to the airport. The airplane leveled off about 50 feet above ground level as it approached the traffic pattern. It subsequently struck a wooden communications pole 3 miles short of the runway and then collided with a highway embankment. A postaccident examination did not reveal any anomalies with the airframe or engine that would have precluded normal operation. The airplane was not configured for landing, and the cockpit controls were not set to any positions that would have indicated that an emergency situation existed. The pilot had successfully completed a flight review the day before the accident. The flight instructor, who performed the review, stated that the pilot had lost a considerable amount of weight within the last 30 days since he had last seen him and that, although he met the minimum acceptable standards, there was an appreciable degradation in his performance since his flight review the previous year. In particular, the pilot experienced difficulty applying sufficient brake pedal pressure and exhibited symptoms of mild confusion during the taxi and run-up. The pilot had been diagnosed with prostate cancer 5 years before the accident and non-insulin-dependent diabetes 2 years later. In the few months before the accident flight, his cancer had grown and spread, and was unresponsive to treatment. He had not reported these diagnoses during his FAA medical examinations. Following the accident, the pilot was initially semi-conscious but in cardiac arrest by the time emergency medical personnel arrived. The autopsy concluded that he died from blunt force trauma but did not identify a traumatic injury which would have resulted in his cardiac arrest. The autopsy confirmed that his prostate cancer had in fact spread. Additionally, large quantities of fluid were removed from his chest cavity during the resuscitation attempt and the subsequent autopsy. The fluid buildup was most likely due to a preexisting condition related to his cancer, rather than from a traumatic injury. Laboratory analysis from the hospital also revealed that he had mild diabetic ketoacidosis. The cumulative effect of the pilot’s medical conditions would have left him with decreased motor strength, shortness of breath, and declining cognitive function, which would have impaired his ability to cope with any urgent or emergent situations. This, and his advanced age, likely also contributed to his death from injuries that might otherwise have been survivable.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot's declining health and performance should have led to reconsideration of flying.

NTSB coding

Evidence available

  • Video
  • FDR / data
  • ADS-B / radar
  • Photos
  • 28 docket documents
View NTSB final reportView NTSB docket

Docket documents28

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