After a 90-minute instrument flight rules flight, the pilot descended toward his home airport in Seagoville, Texas, and attempted six unsuccessful instrument approaches in instrument meteorological conditions (IMC).
The controller terminated three GPS approaches and one instrument landing system approach because the pilot flew through the final approach course; one GPS approach was terminated because the pilot was performing S-turns on final.
Sunset occurred during the third approach attempt.
After the fourth approach attempt, the controller suggested that the pilot divert to an airport with visual meteorological conditions (VMC), which the pilot declined because of the Beech V35A’s low fuel status.
During the sixth approach attempt, he stated he was “getting tired of flying this airplane.”
The controller offered him vectors to a VMC airport, but he declined, stating he wanted to “keep working until we get it.”
Soon after he made this statement, the airplane turned right toward the final approach course and rapidly descended hitting terrain. The pilot died in the crash.
The pilot likely either attempted to descend below IMC and/or experienced spatial disorientation, but the investigation was unable to determine the precise reason for the loss of control.
The pilot’s six unsuccessful approach attempts and his decision not to divert to a VMC airport revealed poor instrument flight skills, poor fuel planning, lack of situational awareness, and poor judgment.
A review of medical records revealed that the pilot was using a sedating antihistamine and had several physiological issues, including vision deficits, diabetes, diabetic neuropathy. These conditions may have had an impairing effect on the pilot, but the medical investigation was limited by the degree of damage to the pilot’s body and the extent to which they may have affected the pilot at the time of the accident could not be determined.
The NTSB determined the probable cause as the pilot’s loss of control and subsequent impact with terrain in instrument meteorological conditions.
NTSB Identification: CEN15FA081
This December 2014 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.
Put on helmet goggles and bubble wrap and stay in bed.
So. many. experts.
Poor guy died. He’s got family. Show some respect.
All the complaints being made about medicals are worthless in this case. You take Benedryl or Dramamine and you get the same effects (based on same chemical). It makes no difference if you have a 3rd or 1st class medical or a “DL Medical”.
While I can fly without my glasses and I can land without them, I won’t be legal. So I don’t know what this guys vision issues were — wasn’t explained. So I can’t see how this was a cause of this crash. If he can read the approach plate and the panel, this has nothing to do with s-turns…
Next, all this blather about BFRs and DPEs means nothing. If you do the 6 with a hold and an intercept and that’s all you do, then you are not going to be proficient. And you could even go more than 6 months and file IFR knowing you can fly a GPS approach or ILS approach to 800 AGL and then go visual. After all, the only way you get caught on this is if someone ramp checks you and asks to see your log book (or similar). Come to think of it, a CFII caught a mistake in my log book where I wasn’t legal to fly PIC because at my BFR, the CFI failed to put in a certain endorsement!!
But looking at the pilot of the crash in question, when the weather is worse than forecast, and you aren’t proficient, and you took either of the drugs mentioned above, for any reason, that’s three strikes. If he had taken vectors to VMC and landed VFR, he wouldn’t have struck out. And that’s why some of us look at these things and try to figure out when we have the right stuff, and when we need to sit on the ground for a few hours. You have to break that chain somewhere or you will become an unfortunate statistic.
What everyone has to keep in mind: Ma Nature plays for keeps. There are no do-overs.
Yes guys this is exactly what you need to do is to talk about how a man crash because he didn’t have a medical. Yes maybe we can get the FAA to read this column and maybe we can get them to come up with a new standards even more strict than what they have been. Because you know they are in the process of rule making. You people are the dumbest goddamn people I have ever seen in my life. Just shut the F up. This proves you cannot fix stupid.
You can say that again.
I wouldn’t argue with any of the comments. The new medical requirements might seem to create a danger, but the new procedures coming in place of the third class will not be allowing one to go forever without seeing a doctor. Even with the highest level of FAA medical examinations, it hasn’t prevented airline captains from dropping dead on short final.
Quite a number of reports I’ve read, like this one, keep bringing back the theme of flight planning, not just cases where medications were involved. Many educational sources are urging better planning, but I keep seeing cases where it appears the pilot just runs out of energy and then is helpless. In this case it appears it may have been too much IMC. In another case I remember reading where a guy lost control after an IMC missed approach and the time was about 1am, apparently after a long day combined with a challenging flight. I don’t necessarily disagree with any of the comments about the medical exam issues, but no matter what those procedures are, we still need to be sure that we flight plan correctly and don’t put ourselves in a hole by over-estimating our personal endurance.
The ‘fix’ to seeing an anecdotal and rare case of an ATP heart attack or a guy slipping thru the cracks does not give justification to allowing ALL possible pilots with medical issues to fly. Remember, these medical exams take place every 2 to 5 years. Removing them entirely and presuming a non aviation doctor will screen out the hazards is incorrect logic.
I don’t know what an AME would recognize as a problem and a non-AME not recognize as a problem. My personal physicians have checked me for everything that have my AME’s. Actually more – no AME has ever done any blood work. The new procedures for class three will keep people in the loop with a physician.
The reform is an ‘honor’ system. It is not the same. It will lead to a LOT more of these incidences.
Hogwash. The existing system is an honor system too. It requires you to confess your medical issues to the AME on a third class medical. If you don’t he won’t detect them and has no way to access your medical history. If BP is ok and urine is ok when tested for sugar you’re ok to fly. No other tests are done. Changes in the third class medical requirements will have ZERO impact on pilot performance and will encourage pilots to have a legit medical exam instead of being afraid of one.
The new system is not like the current system at all.
Current: Pilots must be examined by an Aviation Medical Examiner who is trained and experienced in applying FAA medical standards. The AME ensures the pilot is fit to fly and make sure the information provided by the pilot on FAA Form 8500-8 is correct and current. Aside from getting an cardo, reflexes, lungs exam and reviewing current and drug history a vision exam is required.
New: Pilots have no obligation to be examined by an AME. None of the proscribed tests and information on Form 8500-8 apply. Pilots are basically flying as Sport Pilots on a DL but in far heavier and faster aircraft, higher and under potential instrument conditions.
Not true. NEW pilots must see an AME for the first, student pilot, medical. After that they are treated like current pilots who have a current medical at the time the regulation goes into effect.
Under the current system if you’re willing to jump thru the hoops you can get a special issuance to fly with no arm or legs, a heart condition, one eye or any number of conditions more serious than the ones the pilot in this case exhibited. Skill, training and judgement are what make a safe pilot not a piece of paper that says on a certain date this individual met some arbitrary requirements to be an airman.
The reform medical requires an initial AME medical for new PPL students. Those already licensed that have had one in the past 10 years are qualified also. That means older pilots who have not seen an AME in up to 10 years will be able to fly under the reform. And it means all PPL and PPL with an IR 3rd class medical will never again need to see an AME (the pilot decides when they are too ill to fly and/or quit flying).
The old system had a 2 and 5 year check where all pilots had to see an Aviation Medical pro, that is obliterated. That will mean thousands of pilots will be out there flying with all kinds of medical conditions many of which would have likely grounded them under the old system.
It’s all speculation that this guys medical condition had anything to do with this accident. What we do know is that he was an incompetent instrument pilot with a bad case of gethomeitis. Far more pilots wreck airplane’s because of poor skills and bad training than because of some perceived medical condition. Keep in mind also that the new medical standards are no different than the old in the sense that you still have to admit and confess your medical condition to someone. In the case of the old standards you had to confess to an AME if you didn’t the doc had no way of knowing or finding out your real medical condition. What’s changed is that now you confess to yourself and admit you’re not fit to fly. Same result. If the pilot hides his medical condition and continues to fly there’s really not much we can do.
This guy had medical issues. And if his skills were sub-par then the DPE and bi-annual review process also failed. One does not fix a situation like this by making it EASIER to fly while medically impaired.
The report mentioned three issues, but it didn’t say they were disqualifying. What do they mean by ‘vision deficits’, that you simply need glasses or something else?
A good rule of thumb is to not keep doing the same thing over and over again expecting it will work the next time.
This applies to many things other than flying.
But my rule is, if I fly an instrument approach well and miss because of the weather conditions, doing the same approach one time again is my limit. Looking straight down from minimums and seeing the runway isn’t the same as seeing the runway ahead of the airplane at straight in MDA. Going to an airport with an ILS or diverting to VMC makes sense.
But if a controller is terminating approaches because the pilot is unable to establish the final approach course, there may be little that can be done to save the plane and pilot. Was the airplane equipped with an autopilot and did the pilot know how to use it? No gyro-vectors might have worked if the pilot was willing to try.
But PIC assumes the pilot is still capable of rational thought.
The pilot is still the most common reason that accidents happen.
Good points. What’s frequently forgotten is what is usually told to new instrument pilots, particularly ones that finished their rating without ever seeing a cloud – for the first IFR flight go in visual conditions, and gradually work into more challenging weather conditions for subsequent flights. When a pilot does not fly frequently enough, he works himself back to the same status as the newly rated instrument pilot and then some. He will lose precision and physical endurance and considering that is critical for every go/no-go decision.
Appears as if his AME should have his practice checked.
There’s an interesting comment in the Medical Report contained in the NTSB Docket for this accident. “Compared to other antihistamines diphenhydramine causes marked sedation; it is also classed as a CNS depressant and this is the rationale for its use as a sleep aid. Altered mood and impaired cognitive and psychomotor performance may also be observed. In fact, in a driving simulator study, a single dose of diphenhydramine impaired driving ability more than a blood alcohol concentration of 0.100%.”
The drug shows up in quite a few fatal accidents where pilots made very poor decisions or ‘lost it’ resulting in a fatal crash. With all of the other serious medical issues he had, it’s sad that he decided to fly in challenging weather. “IMSAFE” did not seem to be part of his pre-flight self assessment.
Horrific. A. how did this guy get his instrument ticket and how did he keep passing his proficiency checks? B. how did this guy keep passing his AME exams? C. how many like this guy are an accident waiting to happen especially given the new 3rd class medical reform that will allow a guy like this to fly with no 2-year medical check.
Obviously this guy had no respect for his medical condition or medications he was taking.
You cannot cure stupid no matter how many rules there are to ignore.
Well Said !
Why do you single out third class medicals? I’ve heard, from a reliable source of an airline pilot with a cancerous brain tumor continuing to fly passengers. With the enormous financial pressures I can see why many with a First Class Medical may falsify the test. How about reports of widespread pilot depression? At least the Third Class doesn’t have monetary incentives.
You may not be aware that the 3rd class medical reform (PBORII) is allowing anyone who passed a 3rd class medical within the last 10 years to not have to take another one again. That will let in thousands of aging pilots to fly with all manner of medical issue and no one will know about it except them.
And what good did this guy’s present third class medical do in this situation? None!
Again, a few slipping thru should be a warning that when you remove the barrier entirely you could potentially have HUNDREDS slipping thru.
Ummm, doesn’t this case serve as an example of how pointless an airmen medical exam is?
Exactly the opposite. This proves there are guys with medical conditions flying that should not be and that will get worse if there is no filter at all…which will be the case with the removal of the 3rd class medical for an aging pilot population.