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Were These Two Pilots Really Incapacitated?

Previous medical conditions suggest possible explanations but solid proof is hard to come by

The reports prepared by the NTSB on light sport and experimental category accidents usually don’t consume a significant amount of the agency’s resources. The airplanes are too light and carry too little fuel to cause mass destruction and, when there are fatalities, the number of deceased almost invariably is limited to one or two. It’s my observation that the Safety Board tends not to use too much manpower, paper or bytes on its computers when dealing with these accidents. Perhaps not too coincidentally, they tend to attract comparatively little attention both in the aviation community and news media. Recently, however, the reports on two of these accidents attracted a good deal of attention when their probable causes caused AOPA to do a double-take. Controversy flourished just as the aviation community was getting ready to move into the era of BasicMed, in which tens of thousands of pilots will no longer be handcuffed to the third-class medical certificate.

The first accident, which occurred on April 11, 2015, involved an Experimental Quad City Challenger II ultralight-style homebuilt, which crashed while on downwind at the Rosenbaum Field Airport near Chippewa Falls, Wisconsin. The pilot was killed and the airplane received substantial damage. He was the only one onboard. The second accident occurred on June 26, 2015, near Beloit, Ohio. The airplane was a homebuilt Europa XL two-seater. That solo pilot also was killed, and the airplane also received substantial damage.

The NTSB determined that both accidents were caused by “the pilot’s incapacitation due to a cardiovascular event.” In the case of the Challenger II, the agency added that the cardiovascular event “...resulted in a loss of control and subsequent impact with terrain.”

What caused AOPA to react was that, when it examined what the NTSB had compiled in the investigations, it could find no evidence demonstrating that there had been cardiovascular events. AOPA wondered whether someone at the agency had a hidden agenda having something to do with the fact that both pilots were flying under the sport pilot regulations and did not need to have an FAA medical certificate.

The Quad City Challenger II is a two-seat, high-wing, tricycle gear, light sport aircraft powered by a Rotax 503 engine in a pusher configuration. According to FAA records, the accident aircraft was manufactured by the pilot and received an FAA special airworthiness certificate in May of 2002. The aircraft was designed to cruise at 85 mph, stall at 28 mph, and had a maximum takeoff weight of 960 pounds. The aircraft was registered with the FAA and had an N-number assigned.

The airplane was at about the midfield position on downwind at Rosenbaum Field Airport near Chippewa Falls, Wisconsin, when it started to make a turn, according to several witnesses mentioned in the NTSB’s report. However, the NTSB did not send an investigator to the scene, and the backup material did not contain a record of the witness interviews. So, we cannot tell from what the Safety Board has made public who the witnesses were, what they said or to whom they said it. It’s possible that they were interviewed on-scene by an FAA inspector, but the report doesn’t tell us that. Nonetheless, the report says the airplane subsequently entered a steep dive that it maintained until ground impact. A fire then erupted. Impact was in an open field about one-half mile east of the runway. The crater created by impact was about 2 feet deep.

The weather reported at the time at an airport 9 miles away from the accident site showed that the wind was from 25 degrees at 11 knots, with gusts to 17 knots. Visibility was 10 miles, and it was clear.

The 77-year-old pilot held a recreational pilot certificate with a rating for single-engine land airplanes. He also held a repairman experimental aircraft builder certificate. The last time he applied for an FAA third-class medical certificate was on May 10, 2004. Nothing unusual turned up, and the examiner issued a certificate good for two years that required that the pilot “must wear lenses for distant—possess glasses for near vision.”   

A current logbook was not made available to investigators, but one they did examine showed that he had flown 416 total hours as of May 5, 2006. Nearly all of that time was in the accident airplane. His widow reported that he had flown a few times during the year leading up to the accident.

The NTSB’s file on this accident contained something I’m not used to seeing in its files on general aviation accidents: a four-page “Medical Factual Report.” Prepared by the NTSB’s medical officer, Nicholas Webster, M.D., the report looked at the pilot’s personal medical records, records of the autopsy performed after the accident, and the FAA’s toxicology study.

The FAA detected use of the drugs atorvastatin, fluoxetine and atenolol. Atorvastatin is a statin drug used to treat high cholesterol. Fluoxetine is used to treat depression or obsessive-compulsive disorder. Atenolol is used to treat high blood pressure.

According to the pilot’s personal medical records, his medications also included lisinopril for high blood pressure, the thyroid replacement drug levothyroxine, tamsulosin for prostate enlargement, naproxen to control pain and swelling, and aspirin.

Medical records from January 2012 until April 2015 revealed a history of coronary artery disease, multi-vessel bypass surgery, high blood pressure, elevated cholesterol and hypothyroidism. He also had type 2 diabetes, which was controlled by diet. But the diabetes resulted in nerve damage, causing difficulty with balance and walking.

The record of a cardiologist’s evaluation on October 6, 2014, showed that the pilot was stable and showed no symptoms of heart trouble. However, the cardiologist wrote that the pilot was not following a proper cardiac diet.

The pilot had an examination by his primary care physician just two days before the accident. His height was measured as being 70 inches and his weight was 251 pounds. The primary care physician wrote that the pilot had no chest pain or discomfort and no shortness of breath, and his high blood pressure was “well controlled.”

The post-accident autopsy was performed on the pilot by the Sacred Heart Hospital in Eau Claire, Wisconsin. The autopsy showed several abnormalities related to the heart. These included enlargement, severe coronary artery disease with greater than 80 percent blockage of the vessels, evidence of an old heart attack, and active inflammation of some muscle of the heart’s left ventricle with microscopic evidence of myocarditis. Myocarditis is an inflammatory disease that can result in irregular heartbeat, difficulty breathing and even sudden death. While the finding of the Chippewa County Coroner was that the cause of death was blunt force trauma in an accident, the examining pathologist reported that “the most likely scenario to explain [the pilot’s] death is that he suffered an arrhythmia [irregular heartbeat] secondary to myocarditis.” The autopsy report, however, did not show evidence of a fresh heart attack or irregular functioning before the crash. While a cardiac event that led to the crash may have been a most likely scenario, it was not established by the autopsy as being a fact.   

In the Beloit, Ohio, accident, the aircraft was a Europa XL. The aircraft was developed in England as a kit. It could be configured as a motorglider with extended wings or a traditional, aerobatics-capable airplane, like the one involved in the accident. It was built by the pilot and certified in the experimental amateur-built category on May 19, 2005. It used a Rotax 912S engine driving a full-feathering, constant-speed propeller.

A witness at the Tri-City Airport (3G6) in Sebring, Ohio, told a police officer that he saw the pilot taxiing the airplane toward the north, then back south with the canopy open. He saw that only the pilot was inside. He said that he had seen the pilot taxi the airplane around the airport many times but never saw it take off. He said the airplane had its annual inspection in the week before the accident.

Another witness told the same police officer that he was checking on soybean crops when he noticed the airplane wreckage about 300 feet from the edge of a field. He ran over to see if the pilot was inside and okay. When he found that the pilot was in the wreckage and deceased, he called 911, gave the location and directions on how to get there, and then felt the engine block to see if it was still warm to provide a clue as to when the crash had taken place. The witness reported that the engine’s temperature was about 120 degrees.

The NTSB sent an investigator to the scene. The wreckage and ground scars were consistent with an inverted, near-vertical impact. There was no post-impact fire, but the witness and first responders reported the smell of fuel. The wreckage was moved to a hangar for further examination. Some contaminants were found in the filters, which were installed in the fuel lines. No water was detected when the fuel was tested with water detection paste. The examination concluded that there were no preimpact problems with the engine or aircraft.

The pilot held a private pilot certificate with ratings for single-engine and multi-engine land airplane, and instrument and glider ratings. His third-class special issue medical certificate expired on June 30, 2013. It required that he “must have available glasses for near vision.” But by then, the pilot was flying under the light sport rules, and the FAA medical certificate was something for his scrapbook.

The pilot’s recent flight experience could not be determined. On his last medical certificate application in 2011, he reported 1,820 total flight hours. He was 72 years old and weighed 193 pounds at the time.

The NTSB medical officer, Dr. Webster, examined this pilot’s medical records and prepared a four-page report. The pilot had a history of coronary artery disease treated with bypass surgery, stents and medication. He also had elevated cholesterol and high blood pressure treated with medications. The Mahoning County Coroner prepared the autopsy report that determined the cause of death was blunt force injuries from an accident. It said a contributing factor to the cause of death was coronary artery disease and high blood pressure. It described enlarged heart muscle cells and some scarring, but did not determine that the pilot had a heart attack nor another type of cardiac event before the accident.

In a March 24, 2017, letter to Bella Dinh-Zarr, who was the acting chairman of the NTSB at that time, AOPA Senior Vice President James Coon expressed concern that “longstanding data driven, facts based standards continue to erode at the NTSB.” He alleged that the probable causes of these accidents were made without supporting evidence and “demonstrates to us a profound move away from the longstanding professional and detailed investigations that have been conducted and produced over the years.” He called for an internal review to “...help ensure that personal agendas in the medical office are not being incorporated into the Board’s reports.” Coon did not specify what he meant by “personal agendas,” but it’s easy to infer that he was concerned about undermining upcoming medical certification reforms.

On April 21, then Acting NTSB Chairman Robert L. Sumwalt, Member Earl F. Weener, Office of Aviation Safety Director John DeLisi and Senior Aviation Investigator Tim LeBaron visited with AOPA President Mark Baker and AOPA staffers at the organization’s headquarters in Frederick, Maryland. They discussed AOPA’s concerns about speculation in probable cause statements and the NTSB’s emphasis on data-driven investigations.

On April 25, 2017, Sumwalt wrote to Baker saying that the meeting was constructive and the dialogue beneficial. However, he went on the offensive about the disputed probable causes by telling Baker that the evidence in both cases “...supports the NTSB’s finding that the accident sequence was likely initiated by his [the pilot’s] incapacitation due to a cardiovascular event.” He said any interested party who disagrees or has new evidence can always petition the NTSB to reopen its investigation. Sumwalt also pointed out that the General Aviation Joint Steering Committee identified incapacitating medical conditions as a contributor to in-flight loss of control accidents.

During this back and forth, they didn’t address whether having an FAA medical certificate makes it safer for pilot, passengers and the public. I looked for more information and found three accidents reasonably close to the time of the accidents in question. Based on my layman’s reading of those reports, the backup medical material seemed to clearly support the NTSB’s conclusion that the pilot had suffered an incapacitating cardiac event, which was not the case for either of the reports AOPA brought to the Board’s attention.

First, on September 2, 2015, an RV-6A crashed near Bon Aqua, Tennessee, killing the commercial-rated pilot. Probable cause: “The pilot’s incapacitation from complications of a recent heart attack, which resulted in a loss of control during cruise flight.” This pilot held a current FAA second-class medical certificate.

Second, on August 15, 2014, at Bowie, Texas, a Cessna 414 was on left base for landing when it suddenly nosed down and crashed, killing both occupants. Probable cause: “The pilot’s incapacitation in flight as the result of an acute cardiac event, which resulted in a loss of control and collision with terrain.” This pilot held a current FAA third-class medical certificate.

Third, on August 27, 2015, at Llano, California, a Piper PA-25-260 crashed while approaching Crystal Airport for landing. The ATP-rated pilot was killed. Probable cause: “The pilot’s loss of airplane control during the landing approach due to an incapacitating medical event.” The pilot’s FAA second-class medical certificate had been renewed just six days before the accident.

It’s tempting, if a bit flip, to argue that these five accidents prove you’re more likely to suffer in-flight incapacitation from a cardiac event with an FAA medical certificate than without one. As for me, I’ll argue that there needs to be more attention paid to medical aspects in NTSB investigations so only the most accurate and complete data will be used when determining not only the probable cause of the accident but also the future of pilot medical certification regulations.


Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other news concerning the National Transportation Safety Board. To subscribe, visit www.ntsbreporter.us or write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.


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