Merced, CA, USA
N847DE
PIPER PA-30
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, "running like a top." Family members and business associates of the pilot reported that on the morning of the accident, he appeared in good spirits with no indications of unusual behavior. They all recounted similar observations of degradation in his general performance over the last year, reporting that during the period he exhibited increasing fatigue, and complaints about inflammation and pain in his hands and arms. AIRCRAFT INFORMATION The multiengine airplane, serial number 30-1634, was manufactured in 1967, and equipped with two Lycoming fuel injected IO-320-B1A engines. The most recent annual inspection was completed 17 days prior to the accident. At that time, the airframe had accrued a total of 2,543.99 flight hours. The right engine had accumulated 473.5 hours since overhaul, and the left engine 475.45 hours. Both engines were overhauled in 1990. METEOROLOGICAL The closest aviation weather observation station was located at Merced Airport. The elevation of the weather observation station was 155 feet mean sea level (msl). An aviation routine weather report was recorded at 1153 PDT. It reported: wind from 240 degrees at 6 knots; visibility 10 miles; skies few clouds at 5,000 feet, 6,500 feet overcast; temperature 19 degrees C; dew point 07 degrees C; altimeter 29.90 inches of mercury. WRECKAGE AND IMPACT INFORMATION The first identified point of impact was characterized by a flat, horizontal swath cut through the branches at the top of a 60-foot-tall tree, about 3 miles east of the airport. Fragments of freshly cut branches were observed at the base of the tree. The next point of impact consisted of a wood communications pole, severed at about the 60-foot-level, 120 feet beyond the tree. A 5-feet-long section of the pole was located about 30 feet west of the base. The fractured section exhibited slash markings, and fragments of light green paint, similar in color to the internal painted surfaces of the airplanes wing structure. The main wreckage was located about 600 feet west of the initial point of impact. The airplane came to rest on the highway embankment, 2.7 miles east-northeast of the arrival end of runway 30, at an elevation of about 170 feet msl. The pitch of the embankment was about 40 degrees, as it rose to an exit ramp; the airplane was positioned facing uphill, on a heading of about 210 degrees magnetic. The main cabin remained intact, and sustained crush damage to the nose cone. The tail cone had become separated aft of the cabin, with the empennage still attached and intact. The right wing sustained two semi-circular shaped indentations along its leading edge. One indentation was observed at the center wing section, between the main cabin and the right engine; the size of the indentation corresponded to the radial dimensions of the wood communications pole. The left wing sustained crush damage along its entire leading edge. The outboard wing had become folded aft, the left engine remained attached to the firewall. The engine and firewall had become separated from the spar, and were located underneath the wing. All four wing fuel tanks contained fuel up to their respective filler necks. The tanks were not breached, and no indication of fire was present. The fuel selector valves for the left and right engine were set to the main tanks. The master switch, and all four magneto switches were set to the on position, and both auxiliary fuel pump switches were in the off position. The throttle, propeller, and mixture cables for both engines were in the full forward position. Both the landing gear and the flaps appeared in the retracted position. All sections of the airplane were accounted for at the accident site. MEDICAL AND PATHOLOGICAL INFORMATION Autopsy and Toxicological Results An autopsy was conducted by the Merced County Sheriff's Office-Coroner Division. The cause of death was reported as the effect of blunt force trauma. Additionally, the autopsy found metastatic prostate carcinoma, with an enlarged multinodular prostate, periaortic lymphadenopathy, mediastinal adenopathy with compression of right subclavian vein and thrombus, and lung and bone metastases. Toxicological tests on specimens recovered from the pilot by the Coroner’s Office were performed by the FAA Civil Aerospace Medical Institute. Analysis revealed no carbon monoxide, cyanide, or ingested alcohol. The results were negative for all screened drug substances except Quinine, which was detected in urine. Refer to the toxicology report included in the public docket for specific test parameters and results. Medical History The NTSB Chief Medical Officer reviewed the pilot’s FAA and personal medical records. FAA pilot medical records dating back to 1965 revealed that the only significant medical issue ever reported by the pilot was a fall from a horse in 1999, which resulted in several broken ribs. On his last application for a medical certificate, he indicated “no” to every question regarding medical diagnosis and the use of medications; reporting only a visit to the primary physician for “general health.” Review of the pilot’s personal physician records from 2004 revealed a diagnosis of advanced metastatic prostate cancer in 2005 with involvement of lymph nodes and bone. He was initially treated, and had resolution of symptoms and normalization of his prostate specific antigen (PSA). By 2007, non-insulin dependent diabetes was diagnosed, and initially treated with dietary measures; later, diabetic medications were added. In the latter half of 2008, his prostate cancer numbers began to rise, and several other methods were attempted to treat his cancer with mixed success. In the last few months of his life, the pilot’s cancer was resurgent; his PSA had risen precipitously, and he developed pain and swelling of his hand due to cancerous lymph nodes in his chest obstructing venous flow. Postaccident Medical Records Mercy Medical Center of Merced provided treatment to the pilot following the accident. Medical records indicated that following the accident, bystanders reported to emergency medical services personnel, that the pilot was speaking or moaning after the crash. However, EMS found the pilot in cardiac arrest when they arrived, 3 minutes after the initial dispatch from 911. They initiated CPR (cardiopulmonary resuscitation), extricated him from the airplane, and transported him to Mercy Medical Center. Hospital staff attempted to revive him, with at least one period where a pulse returned. He was subsequently intubated, received medications consistent with advanced cardiac life support and CPR, but was declared dead approximately 1 hour 20 minutes after arrival to the hospital. About 1700 ml of serosanguinous fluid was removed from his chest cavity during his resuscitation attempt. On arrival, his laboratory values indicated hyperglycemia (high blood sugar; 343 mg/dl; normal is 60-120) and an anion gap of 17 (normal up to 16) with bicarbonate of 19 mmol (normal range 22-28 mmol). TESTS AND RESEARCH Airframe and Engines The airframe and engines were recovered from the accident site, and examined at a remote storage location. No anomalies were noted that would have precluded normal operation; a complete examination report is contained within the public docket. Recording Devices The airplane was equipped with both a Garmin GPSMap 296, and GPSMap 496 global position system (GPS) receiver. Extraction of the recorded flight track data revealed that neither receiver had been turned on during the accident flight, and no track data was recorded. The airplane was additionally equipped with two Electronics International, exhaust and cylinder head temperature monitors. The units were sent to the NTSB Vehicle Recorder Division for data extraction. Examination revealed that one unit had been configured with data recording disabled, and as such, no historical data was recovered. The second unit was correctly configured, however, no valid data from the accident flight was found in the unit’s memory. A complete examination report is contained within the public docket. Airplane Performance The airplane's take-off ground run distance was calculated utilizing a gross weight of 3,200 pounds, and the prevailing weather conditions. With a flap setting of
Pilot incapacitation due to the combined effect of multiple unreported medical conditions.
Source: NTSB Aviation Accident Database
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