This September 2007 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.
Aircraft: North American SNJ-2.
Location: Virginia Beach, Va.
Injuries: 1 Fatal.
Aircraft damage: Destroyed.
What reportedly happened: The airplane was one of five practicing for a formation aerial demonstration. In the final maneuver of the demonstration, each of the first four airplanes performed a “pop up break” to return for landing. The fifth airplane, however, continued straight ahead in a slight descent, and did not pull up or “break.” The airplane continued in a constant descent until it hit the ground and erupted in flames.
Examination of the wreckage did not reveal evidence of any pre-impact mechanical malfunctions or failures. During the investigation it was determined that the pilot became incapacitated by a previously known cardiac condition during the the flight.
A review of the pilot’s personal and FAA medical files revealed that the pilot had falsified information on at least three applications for medical certification regarding his evaluation and treatment for cardiac conditions. The FAA had once denied his application for a medical certificate when it became aware of the falsification, and the pilot submitted medical records to regain his medical certificate. Those medical records documented, in part, a long history of chest pain, an enlarged heart, intermittent atrial fibrillation treated with a blood thinner and a beta-blocker medication to reduce heart rate, and use of an alpha-blocker medication that also reduced blood pressure. After submission of those records, the pilot was granted an Authorization for Special Issuance of a medical with a requirement to not operate an aircraft if he had new symptoms or changed medication. No restrictions were placed on the pilot with regard to aerobatic flight, though records submitted to the FAA clearly noted the pilot’s participation in aggressive flying at air shows.
The AME who issued the pilot’s most recent medical certificate approximately eight months before the accident was also a pilot who had previously participated in formation flights with the accident pilot. There was additional information pertinent to the pilot’s condition available prior to his most recent medical certification that was not submitted to the FAA or the AME by the pilot or his cardiologist. Following his most recent medical certification, in the six months prior to the accident, the pilot had experienced increasing symptoms and had received at least one new diagnosis of pulmonary hypertension. Additionally, the pilot had visited his cardiologist three days before the accident, complaining of multiple episodes of atrial fibrillation over the previous three months with fatigue and shortness of breath lasting anywhere from several hours to up to 36 hours at a time.
At the time of the accident, the pilot had completed more than 15 minutes of high performance flight, including nearly two minutes of increased G-loading of up to 2.9 Gs and had just completed the longest sustained-G maneuver of the show, which was 30 seconds of 2G loading.
Probable cause: The pilot’s inability to maintain control of the airplane due to physical incapacitation. Contributing to the accident was the failure of the FAA to deny or restrict the pilot’s medical certification, and the pilot’s improper decision to perform the flight given his recent history of worsening symptoms.
Cindy Pickles says
Pulmonary hypertension (PH) is a rare disease with no cure. The pulmonary arteries that carry blood from the right side of the heart to the lungs to pick up oxygen become progressively narrowed (kind of like when you start pinch off a garden hose–the more you obstruct the flow, the greater increase in pressure for the water to get through). This increased resistance results in the heart having to work harder to pump blood through the lungs. Being overworked the heart enlarges and loses its ability to act as a pump. The average life span of someone with untreated PH is 2.8 years.
Because the symptoms of PH– shortness of breath, swelling of the ankles/legs, extreme fatigue, dizziness, fainting and bluish lips are common to other diseases such as asthma and congestive heart failure, often PH is misdiagnosed. On average it takes 2.5 years and 4 physicians before the correct diagnosis is made. Totally unacceptable in the USA in this day and time. PH can generally be identified on an echocardiogram but it takes a right heart catherization to confirm the diagnosis. PH education is desperately needed both in the public sector and the medical community.
Currently there are 8 FDA approved medications to treat PH. When the drugs are no longer effective the only other treatment option that might be considered is a lung transplant. For more information on pulmonary hypertension please visit http://www.phassociation.org
This scenario was a recipe for sure disaster. The only thing missing was when and where. Probably the only consolation from this incident is the pilot died doing what he loved to do. But just think of what would have happened if he had crashed into the crowd. It is not about age but diagnosis (the article does not list the pilot’s age–the outcome would most likely have been the same if he was 30). Shame on the FAA. Shame on the Doctor. Shame on the Pilot
How do I know this? I am a nurse with pulmonary hypertension.
Ivan Klugman says
This is not an isolated incident since the FAA has decided to allow airline pilots to fly till 65 there has been one death at the wheel on a transalantic flight at my carrier. The change in the age 60 rule may have satisfied a small group lobbying for it however the majority of ALPA pilots voted agianst it.
There is no way you can say that it enhanced the safety of the flying public.