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Health issues lead to loss of control

By NTSB · August 31, 2015 ·

The 58-year-old student pilot attempted a takeoff in light wind in Limington, Maine, but about 2,000 feet down the runway, he lost control of the Cessna 172. Only one witness saw the airplane after liftoff, and noted that it was “swerving all over the place before it crashed.”

While airborne, the plane veered off the left side of the runway, then hit the ground with the right wing tip, nosed down, bounced, and came to rest upright, facing opposite the direction of takeoff.

The pilot was obese, with a history of Type 2 diabetes and high cholesterol. Although he reported some medications on his FAA medical certificate applications, he routinely failed to report others.

Documentation from his most recent FAA medical examination included the use of two medications not recommended to be used together because of the risk of hypoglycemia.

Postmortem toxicology testing identified only salicylate, but would have been unable to identify many of the pilot’s other medications.

According to the medical examiner, the cause of death was multiple blunt impact trauma to the head and chest, indicating that the pilot was still alive when he lost control of the airplane.

Diabetics who become symptomatic from hypoglycemia may not notice warning signs until their psychomotor functioning is very impaired. It is unknown what precautions the pilot may have taken that day to prevent hypoglycemia or what the pilot’s eating schedule was.

In addition, because postmortem glucose levels are low and do not correlate with premortem levels, even if the pilot was severely hypoglycemic at the time of the accident, there would be no specific evidence to identify it.

The pilot also had severe coronary artery disease, with 85-95% occlusion of the left anterior descending artery, that put him at increased risk of a sudden, impairing cardiac event that would have left no observable evidence at autopsy.

There were no operational or mechanical factors to explain the student pilot’s loss of control at takeoff, but he did have multiple medical conditions that could have resulted in acute impairment without leaving evidence. Although the exact mechanism could not be determined, it is likely that the impairment resulted from one or more of the student pilot’s medical conditions, which then caused him to lose control of the airplane.

The NTSB determined the probable cause as an impairing medical event of undetermined origin that led to a loss of control during takeoff.

NTSB Identification: ERA13FA388

This August 2013 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.

About NTSB

The National Transportation Safety Board is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in the other modes of transportation, including railroad, transit, highway, marine, pipeline, and commercial space. It determines the probable causes of accidents and issues safety recommendations aimed at preventing future occurrences.

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Comments

  1. Marvin says

    September 1, 2015 at 8:45 pm

    Fooled himself. Just does not pays to lie,

  2. BJS says

    September 1, 2015 at 6:53 pm

    Just a comment or two. I have to agree, after reading it several times, that nothing in the report suggests conclusively that his medical condition did or did not contribute to the accident. I’m a veteran too but I pay for an annual physical so the fact that it isn’t free is no excuse. A majority of people who claim they can’t afford a physical can afford to smoke, drink beer or buy a new fishing boat.

  3. Brett Hawkins says

    September 1, 2015 at 10:49 am

    The entire tone of this report, including but not limited to its title, is bogus. Someone in the chain of investigation took a severe dislike to the fact the student pilot was obese and decided to use him for a poster boy.

    Where are the facts underlying the conclusions in this story? The poor shlub had some health problems and was taking some medications. Whether or not there was a cause and effect relationship between them and the accident is not proven but instead suggested through inuendo e.g. “well, we all know that fat people……”

    NTSB must have sent word to the front line troops that it needs cases to back up DOT’s opposition to medical certificate reform and here is a prime example of their attempt to do so.

    PS: as winter approaches it is wise to remember that every year a number of geezers, some fat some not, keel over while shoveling snow. Perhaps it is time to regulate such activity in the interests of public safety.

  4. Paul says

    September 1, 2015 at 9:47 am

    Never mind that we are facing and motoring alongside people on our highways everyday who are knowingly and intentionally physically impaired but require no medical exam, none, to determine if they are fit to operate a motor vehicle at closure speeds in excess of 100 mph. They can be and frequently are the cause of multiple fatalities when their impairment leads to an accident on a crowded highway. But if the means of transportation involves an airplane which can fall from the sky (oh dear oh my), the almighty fed will demand a medical exam by an FAA certified AME which in this case did nothing to prevent the accident. What the accident could do however is result in a more demanding medical exam for all before being allowed to take the controls as the sole operator of an airplane. Could we see in the future the requirement for a First Class Medical good only for 6 months for some GA pilots? Perhaps. You know the AMA and ALPA would lobby hard for that.

  5. Dan Vandermeer says

    September 1, 2015 at 9:05 am

    There is no doubt that this pilot did not report his complete medical history when he applied and was examined for a 3rd class medical cert. But a careful reading of the accident report suggests to me that the investigators’ probable cause is not supported by the evidence. Indeed there was not a single toxicological or postmortem finding that suggests that the pilot became incapacitated. These negative results present more questions and no answers.
    The NTSB data base if filled with reports of young, healthy, well trained student pilots who have loss of control accidents simply due to poor technique. Statistically it is more probable that this accident was just that. But we will never know for sure. Still this accident will fall into the “pilot incapacitation” category and be sadly be cited as evidence in supper of the current FAA medical certification rules.

  6. Mark says

    September 1, 2015 at 7:22 am

    Article sure spent a lot of verbiage on conjecture re medical issues, not so much re the ‘light winds’, general ability of the student pilot, other possibles.

  7. charlie says

    September 1, 2015 at 6:52 am

    Thank goodness for the third class medical ! his is a classic example why it needs to be eliminated !!
    charlie

    • John says

      September 1, 2015 at 7:28 am

      FWIW, I came to the opposite conclusion. The pilot obviously lied on his medical, knew he was unfit to fly, did it anyhow, and as a result killed himself. Charlie, I’d rephrase your comment to say: “Thank God this pilot didn’t have anyone with him in the plane. His lies, failure to behave responsibly by refraining from flying until AFTER he resolved his many obvious and known to him medical problems indicated he was grossly unfit to fly… from both a medical and ethical perspective. I feel sorry for the CFI who now has to deal with the mess this irresponsible ‘student’ created by his demonstrated self absorbed behavior. Overlooked in this entire debate over whether a pilot medical should be required is – who owns the liability for the bad decisions by pilots who fly with a known-to-them serious medical condition? Take away the AME and it puts the burden on the CFI who provides flight instruction or the CFI who does the BFR. I’d rather leave medical decisions to an AME than expose myself and my CFI friends to highly probable assertions in court of knowing about obvious, debilitating medical issues.

      • charlie says

        September 1, 2015 at 7:58 am

        The problem is that it is too easy to lie.
        If they really wanted us to pass a physical it should be a real one including Urine and/or Blood tests.
        As it is, it is only an easy money source for the physicians involved.
        I think all of us know people that are flying that in reality couldn’t pass the physical.
        The person in the example could have been driving a three ton RV down a crowded interstate.
        Doesn’t make it right, just the way it is !!
        charlie

    • jay says

      September 1, 2015 at 7:57 am

      This is sarcasm right?

      • charlie says

        September 1, 2015 at 8:00 am

        Yes !
        charlie

        • charlie says

          September 1, 2015 at 8:16 am

          A little about myself.
          O December 7,1998 I suffered a “mild cardiac event” which was corrected with a single stent.
          Being the “Idiot” that I am I notified the FAA of the event.
          Of course there went my medical.
          I have had no problems since.
          However the FAA refuses to issue me a medical certificate and I’m reduced to flying an ultra light.
          Had I kept my mouth shut I would still have a certificate.
          Some changes need to be made !!
          charlie

        • Greenie says

          September 1, 2015 at 9:32 am

          I’m a veteran, VA has yearly physicals ,blood urinan test ,clean health record. To bad everybody doesn’t have this benefit.

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