Lakeside, CA, USA
N22CR
Beech 35-B33
The pilot took off at about 0935 pacific daylight time. At 0945, the pilot had advised the radar controller that he was returning to the departure airport, and he stated that he was not feeling well. A minute later, during a subsequent transmission, the controller asked the pilot if he was feeling any better. The pilot's answer was unintelligible. Thereafter, at 0950, the pilot stated "Tower, get an ambulance to the field." Several eyewitnesses observed the airplane approaching the airport at a low altitude. As the airplane descended it entered a steep left bank and collided into the side of a parked truck. The airplane came to rest about 3.3 nm from the airport. In 1999, the manager of the FAA Aeromedical Certification Division had reviewed the pilot's medical information, which revealed a history of congestive heart failure and other ailments. The FAA determined the pilot was ineligible for issuance of a third-class aviation medical certificate. However upon the pilot's submission of additional medical information, the FAA granted authorization for special issuance of the requested third-class medical certificate. The certificate was subsequently renewed, and at the time of the accident it bore an expiration date of August 31, 2001. In the autopsy report the deputy medical examiner indicated that the "history of severe cardiac dysfunction and the findings of severe arteriosclerosis and myocardial scarring and granulation tissue suggest that the [the pilot's] incapacitation was likely due to an acute cardiac event."
HISTORY OF FLIGHT On June 25, 2001, about 0954 Pacific daylight time, a Beech 35-B33, N22CR, impacted terrain during an uncontrolled descent in Lakeside, California. The accident site was about 3.3 nautical miles east-northeast of the Gillespie Field, El Cajon, California, where the pilot had been cleared to land. The airplane was co-owned and operated by the pilot, and it was destroyed. The private pilot was fatally injured. No one on the ground was injured. Visual meteorological conditions prevailed, and no flight plan was filed. The personal flight was performed under 14 CFR Part 91. The flight originated from Gillespie Field about 0935. The pilot's destination was Deer Valley, Arizona. The National Transportation Safety Board investigator's review of recorded radar data and the Federal Aviation Administration (FAA) radio communications to and from the pilot indicates that at 0938:58 the pilot contacted Southern California Terminal Radar Approach Control (SOCAL) and reported "with you off Gillespie eastbound three thousand climbing seven thousand five." About 0945, the eastbound airplane's altitude had reached 7,000 feet, as reported by the airplane's Mode C equipped transponder. At 0945:19, the airplane began a right turn southbound, and at 0945:22, the pilot advised SOCAL that he was "returning for Gillespie." When asked to identify, at 0945:36, the pilot said "I'm indenting twelve hundred [cough] I'm not feeling well." SOCAL acknowledged the pilot's transmission and inquired regarding his position. At 0945:50, the pilot responded and according to SOCAL his transmission was partially unintelligible and coughing was heard. Thereafter, at 0945:57, SOCAL asked the pilot "Do you require any assistance? I have you radar contact." The pilot's reply was unintelligible. At 0946:07, the SOCAL controller again asked the pilot, "Do you require any assistance sir?" At 0946:11, the pilot responded "I don't know." SOCAL advised the pilot that it would inform the Gillespie tower and let them know he was not feeling well, to which at 0946:19, the pilot replied "thank you." At this time the airplane was traveling westbound toward Gillespie at 7,200 feet. At 0946:21, SOCAL contacted Gillespie tower and notified the tower that the pilot "doesn't sound good." At 0947:17, SOCAL advised the pilot to contact Gillespie tower and asked the pilot if he was "feeling any better." The pilot's answer was unintelligible. According to a local Gillespie air traffic controller, at 0948:46, the pilot's voice was heard on the tower frequency. The controller described his voice as "wavering and weak." At 0948:50, Gillespie tower advised the pilot there was no need to respond, to proceed inbound, and to expect a clearance at 3 miles. In response at 0948:59, a mike click was heard. At 0950:04, the pilot broadcast "tower, get an ambulance to the field." The local controller declared an emergency for the pilot and cleared him to land. Thereafter the controller observed the airplane make a right turn and descend below radar coverage. The last radar return occurred at 0951:56, when the airplane was at 32 degrees 48.138 minutes north latitude by 116 degrees 52.275 minutes west longitude. The airplane's altitude was 4,100 feet. The Safety Board investigator received written statements from five eyewitnesses. They reported observing the airplane during its final minutes of flight. In summary, a fireman/paramedic reported hearing a report over the radio of a pilot coming into Gillespie Field with "shortness of breath." The fireman started looking skyward and observed a small airplane flying southwest in a "hard left" bank. The fireman then reported observing the airplane in a 45-degree bank angle turning south to southeast. Thereafter, the fireman lost sight of the airplane when a mountain obstructed his view. A witness walking from his house to his car on a street near the accident site heard a small airplane flying overhead and observed it at a very low altitude. The witness indicated that he watched the airplane fly in a southerly direction, circle counterclockwise to the east, and then descend. The witness lost sight of the airplane when trees obstructed his view. The witness also reported that during the time of his observations, the airplane's engine sounded "smooth." Two firefighter/paramedics traveling in a vehicle saw a small airplane flying about 500 to 600 feet above ground level. The airplane banked left and flew southward. It continued to turn sharply, losing speed and altitude. The nose began to fall, the wings became nearly perpendicular or vertical to the ground, and the airplane fell in a steep angle toward the ground and disappeared behind a hill. No smoke or fire was visible during the event. Witnesses near the scene of the crash, who were interviewed by a sheriff's deputy, also reported the airplane flying very low, banking steeply to the left and becoming nearly vertical to the ground. The witness located closest to the accident site, who was performing yard work at his residence, saw an airplane coming at him. The witness reported that the airplane's engine was very loud. The airplane's wings were initially horizontal, and then they turned vertical. The witness indicated that the airplane went through his yard, clipped his tree, and passed over his location. The airplane's left wing hit the side of his truck, which was parked in his driveway. The distance and bearing between the last radar hit and the initial point of ground impact (IPI) was 2.8 nm and 303 degrees, magnetic. PERSONNEL INFORMATION The pilot held a private pilot certificate, with an airplane single engine land and instrument ratings. The pilot's personal flight record logbook was not provided to the Safety Board investigator for examination. In an application for an aviation medical certificate in April 1995, the pilot reported that his total pilot (flight) time was 2,300 hours. In April 1997, the pilot estimated his total pilot time was 2,500 hours. In May 1998, the pilot estimated his total pilot time was 2,700 hours. In August 2000, when the pilot applied for his most recent aviation medical certificate, he indicated that his total flight time was 1,800 hours. The co-owner of the airplane verbally reported to the Safety Board investigator that he believed the pilot's total flight time was about 800 hours. During the 90 days preceding the accident, the pilot likely flew the accident airplane for 15 hours, and his total experience flying the accident airplane was 300 hours. No record of the pilot having completed a biennial flight review was found, however, the co-owner opined that the pilot had completed the review 1 year prior to the interview. METEOROLOGICAL INFORMATION At 1005, Gillespie Field reported its weather conditions as follows: scattered clouds at 5,000 feet; visibility 15 miles; wind 250 degrees at 8 knots; and temperature 25 degrees Celsius. WRECKAGE AND IMPACT INFORMATION From an examination of the accident site and airplane wreckage, the airplane was found to have collided with an unoccupied truck in the driveway of a private residence. The elevation of the accident site was about 600 feet mean sea level (msl). The global positioning satellite (GPS) coordinates for the initial point of impact (IPI) were about 32 degrees 50.256 minutes north latitude by 116 degrees 54.532 minutes west longitude. The main wreckage was located about 32 degrees 50.298 minutes north latitude by 116 degrees 54.553 minutes west longitude. Wreckage was principally observed fragmented over a 240-foot-long path between the IPI and a tree, against which the airplane's fuselage had come to rest. Additional wreckage was found 77 feet farther north. The magnetic bearing between the IPI and the main wreckage was about 349 degrees. The IPI was demarked by the presence of felled tree branches in the front yard of a private residence located at 8859 Los Coches Road, Lakeside. About 40 feet north of the felled branches was a parked pickup truck. The right side of the pickup truck was crushed inward in a northerly direction. The severed 4-foot -long outboard portion of the airplane's left wing was found near the crushed truck, and the wing's leading edge was observed accordioned in an aft direction. The deformation to the wing was geometrically similar to the deformation in the side of the truck. The angle of the principal axis of deformation in the side of the truck was measured. The crush signature was consistent with the airplane having been in a 40-degree left wing low bank angle. The airplane's pitot tube was observed imbedded in the left side of the truck. The airplane's severed left aileron was found approximately 100 feet north of the IPI. Additional fragmented components of the airplane, including the propeller, the front right seat and the cabin door, were located farther northward across the street. Additional components were found suspended from overhead tree branches and imbedded in a homeowner's fence. The airplane was found in an upright attitude. All of the airplane's flight control surfaces were found in the accident site area. The inboard portions of both wings were found broken from the fuselage in the inboard area of the wing spar attachment fittings. The right wing was found separated from the fuselage at its wing to fuselage attachment point and was observed against a tree adjacent to the main wreckage. The cockpit was observed crushed. The bottom of the engine case was broken open, and the propeller was separated from its engine-mounting flange. There was no evidence of fire. MEDICAL AND PATHOLOGICAL INFORMATION In June 1999, the manager of the FAA Aeromedical Certification Division reviewed the pilot's medical information, which revealed a history of congestive heart failure, sleep apnea, and diabetes mellitus requiring oral hypoglycemic medication. The pilot's cardiologist submitted information noting that the pilot had "an idiopathic cardiomyopathy with one vessel coronary disease; the latter of which I do not feel is significant. He is currently under treatment with good results and I believe quite stable at this point in time." The manager found that the pilot was ineligible for issuance of a third-class aviation medical certificate, but granted authorization for special issuance of a third-class medical certificate under Section 67.401 of the Federal Aviation Regulations. A stress echocardiogram performed on April 17, 2000, was normal except for mild left ventricular wall hypertrophy. On the accident date, the pilot was holding a third-class aviation medical certificate that had been issued on August 4, 2000, under the same special issuance authorization. The certificate bore the following restrictions: "Not valid after August 31, 2001. Must wear corrective lenses for near and distant vision." The FAA's manager, Toxicology and Accident Research Laboratory, performed toxicological tests on specimens from the pilot. No evidence of ethanol or any screened drugs was reported. On June 26, 2001, the Office of the Medical Examiner, 5555 Overland Avenue, San Diego, California, performed an autopsy on the pilot. In pertinent part, the medical examiner reported that the circumstances of the pilot's death indicated that the pilot was having cardiac problems and was incapacitated prior to the crash. The examiner opined that the "history of severe cardiac dysfunction and the findings of severe atherosclerosis and myocardial scarring and granulation tissue suggest that the incapacitation was likely due to an acute cardiac event." The Safety Board's medical officer reviewed the pilot's medical records on file with the FAA and the medical examiner's autopsy report. For additional information relating to the pilot's medical condition, see the medical officer's summary report which is contained in the docket for this accident. TESTS AND RESEARCH Airplane and Propeller Information. Control continuity was confirmed from the elevator and rudder assemblies in the empennage to the aft cabin area where the control cables were found crushed within cabin floor structure. The landing gear and flaps were observed in the down position. The propeller was found torsionally twisted. Engine Information. The fuel selector was found on the right tank, and the fuel strainer was observed devoid of contaminants. The flow divider was opened, and the diaphragm was found intact. Fuel was observed in the flow divider. Evidence of a fuel spill was observed below the impact damaged wings. The drive coupling of one of the engine's magnetos was rotated by hand. Spark was observed on four of six leads. No evidence of preimpact oil leaks was noted upon examination of the impact damaged engine case. GPS Information. An impact damaged handheld GPS receiver found in the wreckage was sent to its manufacturer for extraction of its non-volatile memory. According to the manufacturer, it was unable to retrieve any data from the receiver. The manufacturer indicated that the circuit board was extensively damaged and all data stored in the unit had been destroyed. WRECKAGE RELEASE The airplane wreckage was released to Southern Cal Aircraft Repair, El Cajon, California, on June 26, 2001. No airplane parts were retained.
Loss of control in flight due to cardiovascular incapacitation.
Source: NTSB Aviation Accident Database
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