WPR13FA118

The pilot's incapacitation due to his preexisting cardiac disease, which resulted in his degraded or complete loss of ability to control the airplane.

The pilot rented the airplane from the fixed-base operator (FBO) to fly to an airport about 11 miles away to practice takeoff and landings. He spoke briefly with two people in the FBO office and then went out to the airplane to preflight it and have it fueled. Review of the departure airport air traffic control tower (ATCT) communications and air traffic control radar tracking data did not reveal any abnormalities with the departure or flight. About 7 minutes after departure, the pilot contacted the ATCT at his destination airport and advised the controller that he was planning to do three touch-and-go maneuvers. Per instructions from the controller, the pilot entered a right downwind for his assigned landing runway. When the airplane was near a location consistent with it being established on the base leg, several motorists observed it in a steep nose-down attitude and descending rapidly. The airplane impacted flat terrain about 1.5 miles from the airport. Neither of the two ATCT controllers observed the descent or impact. Examination of the airframe and engine did not reveal any preimpact anomalies that would have precluded continued engine operation or flight. The pilot had obtained his first Federal Aviation Administration (FAA) medical certificate about 10 years before the accident, received annual recertification, and his most recent medical certificate was issued about 13 months before the accident. Review of the pilot's FAA medical records indicated that, for the intervening 9 years, the pilot was being treated for multiple cardiac issues and was subject to repetitive specialized medical testing. Further review indicated that the pilot had slow, essentially asymptomatic, progression of at least two components of his cardiac disease that are both independently associated with a significantly increased risk of sudden cardiac death as a result of a sudden arrhythmia. Although autopsy results indicated that the cause of death was blunt trauma, it is likely that a complication of the pilot's cardiac disease caused him to become incapacitated, which resulted in his loss of control of the airplane and the subsequent crash. The 0707 code found on the transponder was likely an artifact of the pilot's attempt to switch to the 7700 emergency code to indicate a problem to the controllers, but neither the timing nor the underlying reason for that action could be determined.

Review of audio recordings from TUS revealed that about 0917, the pilot contacted TUS clearance delivery for "departure to Ryan" and the airplane was assigned a transponder code of 0405. The pilot then contacted TUS ground control for taxi clearance for departure. He was assigned runway 11R as the departure runway. The flight was cleared for takeoff about 0923, and about 4 minutes later, the TUS ATCT controller instructed the pilot to contact departure control. The pilot remained on the departure control frequency for less than 2 minutes before requesting a frequency change in order to contact RYN ATCT, which the departure controller approved. There were two controllers working in the RYN ATCT at the time of the accident. Neither controller witnessed the airplane's descent or impact. The RYN ATCT audio information was not provided with any timing track/data. Therefore the times noted below represent the best estimates, but they could not be synchronized exactly with the communications or radar data provided by TUS. TUS data indicated that the pilot left the TUS TRACON frequency no earlier than 0929, but the RYN information indicated that the pilot checked on with RYN ATCT nearly 2 minutes prior. Review of the recorded RYN ATCT communications indicated that the pilot first contacted the facility about 0926:38, and requested "touch and goes." The controller instructed the pilot to enter a right downwind for runway 6R, verified that the pilot requested touch and goes, and asked if the pilot had the current automated terminal information service (ATIS) information. The pilot confirmed that he had the ATIS information, and that he was assigned to 6R. About 0927:37, the controller cleared the pilot for touch and goes, and announced "wind calm." The pilot then initiated an exchange clarifying his intent to conduct three landings, and then return to TUS, which the controller acknowledged by instructing the pilot to make "right closed traffic." About 0928:03, the pilot responded with "right closed traffic runway six right zero five niner." That was the last recorded communication from the airplane. The controller then began working with one departing and one arriving airplane. About 0929:20, the controller broadcast "Cessna zero five niner say position." There was no response, and the controller repeated the broadcast. Twice more, in rapid succession, the controller tried to again contact the airplane. About 10 seconds later, the two controllers noticed the dust cloud to the southwest. According to FAA information RYN was equipped three paved runways designated 06-24 L and R, and 15-33. The intended landing runway, 6R, measured 5,500 by 75 feet. Airport elevation was 2,417 feet above mean sea level (msl). Traffic pattern altitude was 800 feet above ground level, or about 3,200 feet msl. The airport was equipped with a non-federal ATCT operated by a private contractor Serco. The ATCT was located about 1,000 feet east of the threshold of runway 6R, and about 800 feet south of that runway. ATCT cab elevation was 2,484 feet msl. Radar Data Review of ATC radar tracking data revealed that the antenna sweep and data interval rate was 5 seconds. About 0934, the airplane entered a right downwind leg for runway 6R, at an indicated altitude of 3,200 feet. About 0935:28, the airplane passed abeam of the 6R threshold, at an indicated altitude of 3,000 feet. About 5 seconds later, the flight track deviated slightly south (away from the airport), before turning first northwest, and then almost south. The last secondary radar target in the continuous data was recorded at 0936:33, and was located 1.6 miles southwest of the 6R threshold, with an indicated altitude of 3,000 feet. The final, and only other, secondary target was recorded at 0936:56, and was located about 0.4 miles southeast of the previous point, with an indicated altitude of 2,700 feet. The reason for the flight path deviations and the 20-second (three radar sweep) gap could not be determined. No record of the 0707 code data which was found on the transponder was observed in the TUS radar target data. Eyewitness Observations A total of four eyewitnesses provided information for the investigation. A motorist who was driving eastbound on Ajo Highway first saw the airplane to the southeast of his location. He estimated that the airplane was about 500 yards away, at an altitude of about 1,000 feet above the ground, and headed approximately north. He described the attitude as unusually nose down, and stated that the airplane was descending very rapidly towards the ground. He saw the indications of ground impact, and stopped his car to render assistance. A passenger in a westbound car on the highway first saw the airplane to his south, when it was about 150 feet above the ground, and descending very rapidly. He initially thought the pilot was attempting to land on the road, but then he saw the airplane make a sharp turn to its left. The witness interpreted the turn as the pilot's maneuver to avoid the powerlines just south of the road. When the airplane was about half-way through the run, the left (lower) wingtip was approximately the same height as the top of the vegetation. The airplane continued the turn until it paralleled the road, and then disappeared behind the vegetation. The driver of his car pulled over to help after they saw the dust cloud from the impact. The witness reports did not yield any definitive information regarding whether the engine was running. All witnesses reported that the pilot was unresponsive, and that they cut his seatbelt to extract him from the right seat of the airplane. The witnesses reported that they could smell fuel, and that electrical power was continuing to operate mechanisms in the airplane. Refer to the accident docket for additional details. Information from the Fixed Base Operator The owner and president of AAT also owned Velocity Air, which provide maintenance, fuel, and logistical services, including tie-down spaces and hangars. Both AAT and Velocity Air were based at TUS. AAT shared an office with another FBO owned by the same president. AAT airplane rental procedures were typical of many FBOs, including provision of initial documentation plus oral, written, and practical training and evaluation of the pilots. Once checked out, pilots typically reserve airplanes by telephone; they normally speak to the office manager (OM). A 3-ring binder, specific to each airplane, contains airplane maintenance status and flight log information, as well as a variety of other relevant procedural and operational information. The binder resides in the AAT office, and is provided to the pilot when renting the airplane. The AAT airplanes cannot be seen from the office lobby According to the AAT office manager, the pilot arrived there about 0820, and left the office for the airplane about 10 minutes later. While he was still in the office, the pilot mentioned to the president that he was planning to fly in the right seat to RYN to conduct some touch and go landings and takeoffs. Although the president was unaware at that time, he was subsequently informed by one of his flight instructors that the pilot had recently flown in the right seat with that CFI, and that the pilot had "plenty of right seat experience." Records indicated that the pilot had flown about 13 hours each in AAT C-172 and C-152 airplanes, since starting with AAT in September 2012. The pilot's most recent previous flight with AAT took place on February 2, 2013. That flight was in a C-172, where he trained in the right seat with his CFI. The pilot was described as a "meticulous" individual, particularly with regard to his flying behaviors and practices. Information from Pilot's Flight Instructor The pilot's most recent certificated flight instructor (CFI) was employed by AAT. The CFI started flying with the pilot because the pilot wanted to practice his "radio work