ERA12FA006

An aerodynamic stall at low altitude due to the pilot’s acute cardiac event.

Several witnesses reported that, shortly after takeoff, when the airplane was about 15 feet above ground level, it suddenly pitched up about 45 degrees, stalled, and then came to rest against a residence near the turf runway. GPS data were consistent with the witness reports. Examination of the airframe and engine revealed no mechanical malfunctions or abnormalities that would have precluded normal operation. The pilot's medical records revealed that he had hypertension and a pacemaker, and that, about 8 months before the accident, the pacemaker was upgraded to a combination pacemaker/Automatic Internal Cardiac Defibrillator (AICD). Medical records revealed that the pilot was using medications to treat hypertension, moderate-to-severe congestive heart failure, recurrent ventricular arrhythmias, and atrial fibrillation. Toxicology testing confirmed the presence of such medications in the pilot's body. Given the postmortem examination, reported medication use, and the upgrade to a pacemaker/AICD, it is likely that the pilot had experienced a serious arrhythmia and severe congestive heart failure some time before the accident. Although the exact degree of premortem cardiac dysfunction could not be determined, the presence of the AICD indicated that the pilot's doctors had identified a significantly elevated risk of sudden cardiac death. Although an AICD reduces the risk of sudden death from tachyarrhythmia, it does not reduce the risk of a sudden death from other cardiac-related causes. Federal regulations only require a valid driver's license to exercise the privileges of a sport pilot certificate in a light-sport aircraft as long as pilots are not aware of any medical condition that would make them unable to operate a light-sport aircraft safely. However, the pilot most likely did not have sufficient knowledge to accurately assess the aviation safety risks associated with his condition. It is likely that the pilot's underlying cardiac disease caused an acute medical event, which led to his loss of control of the airplane and the subsequent aerodynamic stall at low altitude and collision with terrain.

Green Landings Airport (WV22) was a privately owned airport and at the time of the accident it did not have an operating control tower. The airport was equipped with one turf runway designated as runway 3/21. The runway was 2600-foot-long by 100-foot-wide and was reported as "in good condition" at the time of the accident. The airport elevation was about 490 feet above mean sea level. An autopsy was performed on the pilot on October 6, 2011, by the Department of Health, Office of the Chief Medical Examiner, Manassas, Virginia. The cause of the death was reported as "blunt force trauma to thorax and extremities." Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology reported stated Amlodipine was detected in the liver and the blood, Etomidate was detected in the liver; 0.101 (ug/mL, ug/g) Midazolam was detected in the liver; however, neither Etomidate nor Midazolam were detected in the blood. Review of the pilot's personal medical records by an NTSB medical officer revealed a diagnosis of hypertension and Amlodipine (marketed under the trade name Norvasc) is a medication used to treat hypertension. Etomindate is an anesthesia induction agent and Midazolam is a benzodiazepine commonly used for sedation during medical procedures; both of which are only available in intravenous formulations and were documented as being administered during the hospital resuscitation. Trauma medical records also included documentation of the pilot's usual medication. Those listed medications were used to treat hypertension, decrease the heart's work in moderate to severe congestive heart failure, as well as other medications that treat and prevent life-threatening, recurrent ventricular arrhythmias and also used to treat atrial fibrillation. During the autopsy an indwelling medical device was removed and sent to the manufacturer for readout. There was no evidence of a tachyarrhythmia or defibrillation being recorded. The autopsy also revealed that the heart was enlarged overall and a "bulging left ventricle" with left ventricular hypertrophy. There was evidence of minimal coronary artery disease; however, the lateral aspect of the left ventricle has a 3.0 cm area of interstitial fibrosis was consistent with a remote heart attack. Review of the indwelling medical device manufacturer's records showed a previous pacemaker had been exchanged for a combination pacemaker/automated internal cardiac defibrillator about 8 months prior to the accident. For further information please refer to the "Medical Factual" report located in the docket associated with this accident. A Garmin 696 GPS was recovered from the accident airplane and was sent to the NTSB Records Laboratory for download. The GPS began recording data earlier in the day and also included data just prior to the accident. The last recorded data occurred at 1737:44 with a groundspeed of 55 knots and a GPS Altitude of 512 feet. Several data recordings that occurred prior to the last recording indicated a ground speed consistently under 10 knots and a GPS altitude of between 436 and 486 feet. According to CFR 61.23(c) states in part "a person must hold and possess either a medical certificate issued under part 67 of this chapter or a U.S. driver's license when… (ii) Exercising the privileges of a sport pilot certificate in a light-sport aircraft other than a glider or balloon." According to CFR 61.53(b) "Prohibition on operations during medical deficiency" states in part "… Operations that do not require a medical certificate…a person shall not act as pilot in command, or in any other capacity as a required pilot flight crewmember, while that person knows or has reason to know of any medical condition that would make the person unable to operate the aircraft in a safe manner." CFR Part 67 in reference to "Cardiovascular" states in part "…no established medical history or clinical diagnosis of any of the following: (e) permanent cardiac pacemaker implantation…" According to the FAA "Guide for Aviation Medical Examiners" which states in part "… the placement of a pacemaker is disqualifying for pilots, but special issuances may be considered…" The guide further notes that there was specific protocol regarding the information the FAA would request in order to grant a special issuance. The 1753 recorded weather observation at Martinsburg Eastern West Virginia Regional/Shepherd Airport (MRB), Martinsburg, West Virginia, located approximately 10 miles to the south of the accident location, included wind from 340 degrees at 7 knots, visibility 10 miles, clear skies, temperature 23 degrees C, dew point 10 degrees C; barometric altimeter 30.19 inches of mercury. The airplane impacted a concrete wall at a nearby residence in a nose down attitude and fractured into two pieces just aft of the aft baggage wall. Continuity was confirmed to all flight control surfaces from the control column and the rudder pedals. Continuity was confirmed to the elevator via the push/pull tube that was bent approximately mid span and was co-located with the impact damage of the airframe. The ailerons were operated by a push/pull tube system and continuity was confirmed from the control column to the right aileron bell crank. The left control column push/pull tube was found fracture separated at the base of the control column. Continuity was confirmed from the fracture point to the aileron bell crank. Right wing The right wing exhibited impact damage to the leading edge. The outboard section of the wing was impact separated beginning on the leading edge approximately 74.5 inches from the wing root and on the trailing edge, approximately 108 inches from the wing root, exposing the main wing spar. The main wing spar, comprised of fiberglass/composite material, was impact damaged and bent at the damaged point in the positive direction. The aileron was impact separated at the bell crank and located near the wreckage. The flap was impacted separated and co-located with the aileron. The right main landing gear remained attached at the fuselage attach point; however, was bent outward approximately 40 degrees beyond its normal position. Empennage The empennage was impact fractured approximately 65 inches forward of the elevator attach point and approximately 10 inches aft of the rear bulkhead. The elevator trim tab indicated approximately 8 degrees trailing edge down. The elevator and rudder remained attached to their respective attach points. Left Wing The left wing remained attached at the wing root; however, exhibited impact damage approximately 74 inches outboard of the fuselage attach point. The initial impact damage was consistent in dimension to the 6 inch by 6 inch anchor post, utilized to elevate the deck on the private residence, which the airplane impacted. The trailing edge impact separation point was slightly inboard of the aileron. The flap was impact separated at its respective attach points and was co-located with the wing and the anchor post. The aileron remained connected to its respective attach point; however, the associated push/pull tube was impact separated from the bell crank. Engine The engine remained attached to the firewall and the wood propeller blades were impact separated at the propeller hub. The engine mounts exhibited impact damage and numerous bends. The gascolator was of glass construction and was impact damaged. The propeller spinner exhibited torsional twisting. The fuel pump remained attached to the engine, was removed, and examined. It contained a blue fluid similar in color and smell as 100LL aviation fuel. The sparkplugs were removed and appeared to be relatively new with little wear and were tan in color. Thumb compression was achieved on all cylinders via hand rotation of the propeller hub. The right front cylinder indicated impact damage on the leadi