Pilot Debrief

BEECH B200 near Fort Myers, FL — 2009-04-12

Final reportERA09IA240
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Date
2009-04-12
Location
Fort Myers, FL, USA
Airport
RSW
Aircraft
BEECH B200
Registration
N559DW
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Initial climb

Probable cause

The pilot’s abnormal heart rhythm resulting in incapacitation.

NTSB narrative

Shortly after takeoff during the incident flight, the pilot had an abnormal heart rhythm and was incapacitated. The passenger took control of the airplane and with assistance from several FAA air traffic control personnel, was provided information concerning operation of the airplane and was vectored to a nearby airport where he landed uneventfully. The pilot had a history, known to the FAA, of a previous heart attack and known coronary artery disease, treated with angioplasty and stent placement. He underwent comprehensive cardiovascular evaluation following this treatment, including a stress test with nuclear medicine imaging and a repeat cardiac catheterization. This testing revealed evidence of the previous heart attack, but no other areas of the heart with poor blood flow, and good heart function. On the basis of these studies, a Federal Aviation Administration (FAA) cardiology consultant indicated that the pilot was “qualified for Special Issuance Limited 2nd Class certification,” and the pilot subsequently received an Authorization for such certification. The pilot was noted to have an abnormal heart rhythm during resuscitation efforts and died. The autopsy report noted coronary artery disease essentially identical to the pilot’s cardiac catheterization findings, and there was no noted evidence of sudden clot formation. The autopsy report noted a thickening of the main heart chamber, which, in combination with the pilot’s coronary artery disease, would have increased the risk for sudden cardiac death in this pilot. The cardiovascular testing performed on the pilot prior to his most recent medical certification did not reveal any evidence of this thickening.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot's medical condition should have been assessed before flight.

NTSB coding

  • Miscellaneous/other · Enroute-climb to cruise
  • Impairment / Incapacitation

Evidence available

  • 4 docket documents
View NTSB final reportView NTSB docket

Docket documents4

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