WPR10FA217

Pilot incapacitation due to the combined effect of multiple unreported medical conditions.

The 88-year-old pilot, who was a property appraiser, departed for the short local flight in the multiengine airplane to perform aerial property observation. Although family members and associates reported normal behavior that morning, witnesses stated that at the airport, he appeared pale, listless, and slightly confused as he attempted to remove his airplane from the hangar. Unable to muster the strength to move the airplane, he enlisted the help of an employee at the fixed base operator. Airport security video captured the airplane’s ground roll and departure; the airplane took twice the normal distance to take off than was required; however, video and radar track data recorded a normal departure from the pattern. The airplane leveled off shortly after takeoff, and continued to fly at a constant airspeed and appropriate altitude for ground observation. Shortly thereafter, the airplane initiated a descent and made a left turn back toward the airport. The airplane continued to descend during the first portion of the return leg, and the pilot reported over the common traffic advisory frequency that he was experiencing “all kinds of trouble/problems in the cockpit” and that he was returning to the airport. The airplane leveled off about 50 feet above ground level as it approached the traffic pattern. It subsequently struck a wooden communications pole 3 miles short of the runway and then collided with a highway embankment. A postaccident examination did not reveal any anomalies with the airframe or engine that would have precluded normal operation. The airplane was not configured for landing, and the cockpit controls were not set to any positions that would have indicated that an emergency situation existed. The pilot had successfully completed a flight review the day before the accident. The flight instructor, who performed the review, stated that the pilot had lost a considerable amount of weight within the last 30 days since he had last seen him and that, although he met the minimum acceptable standards, there was an appreciable degradation in his performance since his flight review the previous year. In particular, the pilot experienced difficulty applying sufficient brake pedal pressure and exhibited symptoms of mild confusion during the taxi and run-up. The pilot had been diagnosed with prostate cancer 5 years before the accident and non-insulin-dependent diabetes 2 years later. In the few months before the accident flight, his cancer had grown and spread, and was unresponsive to treatment. He had not reported these diagnoses during his FAA medical examinations. Following the accident, the pilot was initially semi-conscious but in cardiac arrest by the time emergency medical personnel arrived. The autopsy concluded that he died from blunt force trauma but did not identify a traumatic injury which would have resulted in his cardiac arrest. The autopsy confirmed that his prostate cancer had in fact spread. Additionally, large quantities of fluid were removed from his chest cavity during the resuscitation attempt and the subsequent autopsy. The fluid buildup was most likely due to a preexisting condition related to his cancer, rather than from a traumatic injury. Laboratory analysis from the hospital also revealed that he had mild diabetic ketoacidosis. The cumulative effect of the pilot’s medical conditions would have left him with decreased motor strength, shortness of breath, and declining cognitive function, which would have impaired his ability to cope with any urgent or emergent situations. This, and his advanced age, likely also contributed to his death from injuries that might otherwise have been survivable.

HISTORY OF FLIGHT On April 27, 2010, at 1135 Pacific daylight time, a Piper PA-30, N847DE, collided with a highway embankment in Merced, California. The pilot was operating the airplane under the provisions of Title 14 Code of Federal Regulations Part 91. The private pilot/owner sustained fatal injuries. The airplane sustained substantial damage to both wings and the forward fuselage. The local personal flight departed Merced Regional Airport/Macready Field at 1127. Visual meteorological conditions prevailed, and no flight plan had been filed. The pilot was a property appraiser, and the purpose of the flight was to overfly land east of Merced in order to perform an aerial property observation. On the morning of the accident, an employee from a local Fixed Base Operator (FBO) assisted the pilot with moving the airplane out of his hangar. The pilot asked for assistance starting the motor of the hand operated tug, because he was unable to muster the strength to pull the starter cord fast enough. The pilot then attempted to move the airplane utilizing the tug, but stated that he was experiencing problems with his hands, and again asked for assistance. According to the witness, once out of the hangar, the pilot appeared pale and listless, and lost his footing as he got into the airplane. On three occasions, he called the FBO employee by the wrong name, even though he had known him for many years. Video of the airplane's departure, captured by Merced Airport security cameras, revealed that it entered runway 30 at the threshold, and immediately began the takeoff roll. The airplane rotated about 2,200 feet further down the runway, initiated a climb utilizing the full runway length, and then turned left where it joined the downwind leg to the east. A few minutes later, an airport operations employee heard a weak and broken transmission over the airport's common traffic advisory frequency stating, "...try...make right base...all kinds of trouble/problems in the cockpit...I will try to make it back to Merced Airport...I am following Childs Ave..." A witness, located in a restaurant parking lot 3 miles east of the airport, observed an airplane fly directly over his position and to the west. The airplane was flying straight and level just below the top of an elevated restaurant sign. He described the airplane engine’s sound as, “full blown, similar to three Harley’s driving by." The airplane then clipped the top of a tree, and continued out of his view. He did not observe any smoke or vapors trailing the airplane at any time, and noted that the landing gear appeared to be retracted. Another witness, who was driving on the southbound lane of Highway 99, 3 miles east of the airport, noticed what he initially thought was a crop dusting airplane about 50 yards to his left, just above the highway. The airplane passed directly in front of his vehicle from left to right and collided with the highway embankment. Merced Airport was equipped with an airport surveillance radar system located on the eastern edge of the airport perimeter. Recorded radar track data provided by the FAA, revealed a target set to a 1200 beacon code beginning a ground roll at 1127 on runway 30. The target continued on a northwest heading, reaching an altitude of about 150 feet above ground level (agl), after travelling the full length of the 5,914-feet-long runway. The target initiated a climbing left turn, where it joined the downwind leg at an elevation of about 600 feet agl. The target continued the downwind climb, leveling off at 1,200 feet agl, about 0.5 miles south of the arrival end of runway 30. The target then turned towards the east, while maintaining altitude, and accelerating from a ground speed of 130 to 170 knots. About 6 miles east, the target initiated a 60-second-long descent to 800 feet agl. Over the course of the next 24 seconds, the target began a descending 180-degree left turn to 600 feet agl. The turn radius was about 1,250 feet, and the target reached a ground speed of about 210 knots, 12 seconds after rolling out of the turn. The target continued to descend, with an accompanying reduction in airspeed, before leveling off at 50 feet agl, about 1 mile east of the accident site. The last recorded target was at that same altitude, and just east of the accident site. At that time, the target was travelling at a groundspeed of 100 knots. PERSONNEL A review of Federal Aviation Administration (FAA) airman records revealed that the 88-year-old pilot held a private pilot certificate with ratings for airplane single-engine land, multiengine land, instrument airplane, and glider. He held a third-class medical certificate issued in June 2009, with the limitation that he must have glasses available for near vision. Complete pilot flight records were not recovered. A pilot flight logbook was located, indicating that his first entry occurred in 1943. His last logbook spanned the period from 1992 to April 26, 2010, contained 12 entries, and referenced a total flight time in 1992 of 8,200 hours. On the pilot's most recent application for a medical certificate, he indicated a total flight time of 9,805 hours, with 6 hours in the 6 months preceding the application. According to the certified flight instructor (CFI) who performed his most recent flight review, the pilot did not keep a record of all flight time, but rather a log of all flights required to meet regulatory requirements. The pilot completed a flight review in the airplane the day prior to the accident. The CFI who performed the review stated he generally flies with the pilot on a monthly basis, and this was their third consecutive flight review together. He reported that the pilot was required by his insurance company to take a flight review annually. The original review was scheduled to take place in the accident airplane 1 month prior, but was postponed due to mechanical problems with an engine magneto and tachometer. At that time, they elected to complete the ground portion of the review instead. The CFI noted on the day of the flight portion of the review, the pilot appeared to have lost weight. He further noted that there was a degradation in his performance since their flight review the year prior. He appeared to perform the preflight inspection at a much slower pace, and was unable to start the airplane tug using the starter pull cord. During the engine magneto check, he became confused, and audibly indicated that he was checking the right magnetos on the right engine, when in actuality he checked the left magneto on the left engine. During the initial engine run-up, the airplane crept forward, and the pilot was unable to maintain enough pressure on the brake pedals to stop the movement. He insisted that there was a deficiency with the brakes, so they swapped seats. The CFI subsequently applied brake pressure and was able to easily stop the airplane. Additionally, just prior to takeoff, the pilot audibly called to turn on the auxiliary fuel pumps, but inadvertently turned on the landing lights. For the remainder of the review, the pilot's performance appeared to improve, and was "adequate" according to the CFI. They performed multiple takeoff and landings at two other airports, and during the return flight, the CFI simulated an engine failure by setting an engine to zero thrust. He stated that the pilot handled the event in an adequate manner, although not entirely to his liking. He rated the pilot's overall flight skills as acceptable, and commented that he was often stubborn, and would have his own procedures, which while technically correct, did not meet the CFI's personal standards. He stated that the pilot would often resist the CFI's advice for altering his techniques and procedures. The CFI stated that the airplane performed in a smooth and flawless manner for the review flight, he specifically recalled that both he and the pilot agreed that the airplane was, "runni