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Sun, Apr 18, 2010

NTSB Released Probable Cause In 2008 Fremont, OH Accident

Aging Pilot's Vision Was A Factor In The Crash

The NTSB has released its probable cause report in an accident involving an 86-year-old pilot offering airplane rides at a Lion's Club "Fly-In Breakfast." Six people, including the pilot, were fatally injured in the accident. The summary of the probable cause report reads as follows:

NTSB Identification: CHI08FA156
14 CFR Part 91: General Aviation
Accident occurred Sunday, June 08, 2008 in Fremont, OH
Probable Cause Approval Date: 4/15/2010
Aircraft: CESSNA U206C, registration: N29122
Injuries: 6 Fatal.

On the day of the accident, the 86-year-old accident pilot was providing rides in his single-engine, six-seat airplane at the airport that he owned and managed. Passengers purchased tickets for the rides in the airport office. The rides were given concurrently with a Lions Club International charitable “fly-in breakfast” at the airport, which had been advertised in the local newspaper. According to a representative of the Lions Club, the air rides were a separate activity, and the money collected for the air ride tickets was not given to the charity (evidence indicates that the pilot retained the money). The accident flight was the fifth or sixth airplane ride the pilot gave that day. Videotapes of previous flights and of the beginning of the accident flight indicated that the pilot was performing nonstandard takeoffs. Rather than beginning a normal climb after lifting off from the ground, the pilot would maintain an altitude just above treetop level until reaching the departure end of the runway, at which point he would initiate a steep pitch-up maneuver followed by a pushover maneuver. Also, a witness, who was a pilot, reported that the accident pilot commonly performed a nonstandard maneuver called a “buttonhook turn” to align the airplane with final approach for landing. The maneuver involved flying the airplane at an altitude of about 300 feet above ground level perpendicular to the final approach course and then executing a 270-degree turn to the final approach. The witness stated that he observed the pilot perform this maneuver during one of the passenger-carrying flights preceding the accident flight.

About 30 minutes after the airplane departed on the accident flight, witnesses observed it returning to the airport. Witnesses near the accident site reported that the airplane was flying at a low altitude toward the runway when it banked, descended, and impacted the ground. One witness stated that the airplane “appeared to be flying very slow, almost on the edge of a stall.” This witness heard the engine “throttle up” and observed the airplane stall, with the left wing “dipping,” and then descend below the tree line.

The accident site was about 0.75 mile east of the approach end of runway 27. Ground scarring and wreckage distribution covered a relatively small area, consistent with an accident due to an aerodynamic stall. Examination of the airplane revealed no mechanical anomalies that would have precluded normal operation. During a test cell run, the airplane’s engine performed within the manufacturer’s specifications.

Review of the pilot’s personal medical records indicated that he had been treated for age-related macular degeneration in both eyes for over 2 years. About 3 weeks before the accident, his distant visual acuity without correction was recorded as 20/200 for each eye. On at least two occasions, the pilot’s retinal specialist advised him not to drive. However, the pilot continued to drive and was involved in a traffic accident, in which he turned in front of an oncoming vehicle, 10 days before the aircraft accident. The pilot’s visual deficiency would have made it difficult for him to decipher the readings on cockpit instruments and to distinguish objects on the ground. This lack of visual acuity increased the likelihood that the pilot would fly at an inappropriate speed or altitude, thus increasing the chances of a stall.

About 1 year before the accident, the pilot applied for a Federal Aviation Administration (FAA) Airman Medical Certificate and provided false information about his eye condition (he did not report his visits to the retinal specialist). Even so, the pilot’s visual deficiency, given its severity, should have been detectable during the vision examinations required before issuance of such an Airman Medical Certificate. However, the pilot's aviation medical examiner (AME) reported normal eye test results, including 20/20 uncorrected vision, and issued the pilot a second-class medical certificate. About 7 months after the accident, the FAA decertified the AME for improper issuance of medical certificates.

The pilot’s autopsy noted severe coronary artery disease, which could have increased the likelihood of a heart attack or abnormal heart rhythm, resulting in impairment or incapacitation. There was no evidence of such an event, but no such evidence would necessarily be expected if death occurred within a few minutes to an hour of the impairment or incapacitation. The pilot’s personal medical records did not indicate coronary artery disease.

File Photo

Either the pilot’s macular degeneration or his unrecognized coronary artery disease could have contributed to his failure to maintain control of the airplane. The NTSB could not conclusively determine whether either condition directly resulted in the accident. However, given the incompatibility of the pilot’s vision deficiency with safe motor vehicle operation and the pilot’s awareness of this, the pilot displayed extremely poor judgment in not only continuing to fly but in deciding to perform passenger-carrying flights. Furthermore, the pilot did not provide all of the required information on his most recent application for an Aviation Medical Certificate, and his AME did not adequately evaluate the pilot’s eyesight.

The passenger seated in the right front seat of the accident airplane was one of the accident pilot’s former student pilots who purchased a ride in the airplane. He held a private pilot certificate, but did not hold a current Airman Medical Certificate. If the accident pilot had become incapacitated, it is possible this passenger could have taken control of the airplane. There was insufficient evidence to determine whether or not this passenger was manipulating the flight controls when the accident occurred.

The local FAA flight standards district office had no records of any concerns raised or complaints about the pilot. Also, the FAA had no record of the pilot applying for a Letter of Authorization to conduct passenger-carrying flights for compensation or hire, which is required by 14 Code of Federal Regulations (CFR) 91.147 for all passenger-carrying flights not conducted under 14 CFR 91.146 (flights for the benefit of a charitable, nonprofit, or community event). Therefore, the FAA was unaware of, and provided no oversight of, the pilot’s passenger-carrying flights.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

The pilot’s failure to maintain airplane control for an undetermined reason, which resulted in an inadvertent stall. Contributing to the accident was the pilot's poor judgment in continuing to fly with his severe visual deficiency. Also contributing to the accident was the aviation medical examiner’s failure to accurately assess and report the pilot’s visual deficiency.

FMI: www.ntsb.gov

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