NYC07LA219
NYC07LA219

"THIS CASE WAS MODIFIED SEPTEMBER 26, 2008."

HISTORY OF FLIGHT

On September 7, 2007, at 1226 eastern daylight time, a North American SNJ-2, N52033, was destroyed when it impacted terrain at Oceana Naval Air Station (NTU), Virginia Beach, Virginia. The certificated commercial pilot was fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the local aerial demonstration flight, which was conducted under 14 Code of Federal Regulations Part 91.

Several persons witnessed the accident, including a Federal Aviation Administration (FAA) inspector, and a Navy Air Operations Officer. They both provided written statements, which depicted a similar series of events. The accident airplane was one of five airplanes practicing for a formation aerial demonstration. For the final maneuver of the demonstration, each of the first four airplanes performed a "pop up break," while flying in a southwesterly direction, in order to return to land on runways 14R or 14L. The fifth airplane, however, continued straight ahead in a slight descent, and did not pull up or "break." The airplane continued in a constant descent, with the wings level and in a slight nose down attitude. The airplane impacted the ground and erupted in flames. Prior to impact, the engine appeared to be functioning, and no abnormal smoke was visible.

A portion of the accident was also captured on video by a local news station. A preliminary review of the video showed that five airplanes approached the view of the camera, traveling from right to left, with their smoke generators active. They then simultaneously turned off the smoke generators for a moment, before the first airplane again activated its smoke generator, and broke away from the formation in a climbing right turn. Three airplanes sequentially followed suit. The fifth airplane, identified as the accident airplane, activated its smoke generator, but continued straight and did not begin a climbing right turn. The airplane instead began a shallow, wings level descent before it disappeared from view behind an obstruction.

A mechanic employed by the operator, and another individual associated with the promotion of the airshow, provided written statements describing the accident pilot's physical condition and demeanor prior to the accident flight. Both individuals stated that the accident pilot looked "pale." The second individual also stated that he observed the pilot "nodding off" during the morning pre-flight briefing and that he was not the same as his "usual conversational self."

PERSONNEL INFORMATION

The pilot, age 74, held a commercial pilot certificate with ratings for airplane single and multiengine land, and instrument airplane. The pilot's most recent FAA second-class medical certificate was issued in November 2006, with the limitation "valid for 12 months following the month examined." As of that date, the pilot reported 12,317 total hours of flight experience. According to the operator, the pilot had accumulated over 1,000 hours of flight experience in the accident airplane make and model.

AIRCRAFT INFORMATION

A review of maintenance records revealed that the airplane's most recent annual inspection was completed on January 1, 2007, at 6,278 aircraft hours. On September 2, 2007, the accident airplane, piloted by another individual, was involved in a ground collision with another airplane from the operator's fleet. More information about this accident can be found in Safety Board report NYC07LA209B. The airplane was repaired following the accident, which included replacing the propeller and an inspection of the engine in accordance with the manufacturer's procedures. The airplane was approved for return to service on September 3, 2007. As of that date, the airplane had accumulated 6,414 total hours of operation.

METEROLOGICAL INFORMATION

The weather conditions reported at NTU, at 1230, included winds from 110 degrees at 10 knots, 7 statute miles visibility, few clouds at 3,000 feet, temperature 81 degrees Fahrenheit, dewpoint 64 degrees Fahrenheit, and an altimeter setting of 30.23 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

The wreckage was examined at the scene by FAA inspectors. According to the inspectors, the initial impact point was located about 1,200 feet beyond the departure end of runway 23R. The wreckage path was 360 feet long and oriented in a direction about 230 degrees magnetic. The area of the initial impact was marked by two ground scars oriented perpendicular to the wreckage path, and consistent in dimension with the airplane's propeller. A larger ground scar, about 12 feet wide and 20 feet long, was located just beyond the initial ground scars. Flattened areas of grass, consistent in dimension with the left and right wing, extended from the sides of the large ground scar, and continued through its length.

Various pieces of wreckage were distributed along the wreckage path, including both airframe and engine parts. Grass and brush located along and around the wreckage path, in addition to portions of the wreckage itself, was also burned. Both wings were located on their respective sides of the wreckage path, about 280 feet beyond the initial impact point. The main wreckage was located about 300 feet beyond the initial impact point, and was comprised of the fuselage, empennage, and engine. The fuselage was burned, and was oriented 050 degrees magnetic.

The propeller remained attached to the engine crankshaft. Both propeller blades exhibited twisting and leading edge gouging. Several cylinders of the radial engine exhibited signatures consistent with a postimpact contact with the propeller.

Examination of the wreckage did not reveal evidence of any pre-impact mechanical malfunctions or failures.

MEDICAL AND PATHOLOGICAL INFORMATION

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on the pilot. The testing detected the presence of the drugs metoprolol and warfarin in both the blood and liver.

A review of the pilot's autopsy report, personal medical records, and medical records maintained by the FAA Aerospace Medical Certification Division was conducted by a National Transportation Safety Board Medical Officer.

FAA Medical Records

According to the Safety Board medical officer's review, the pilot had denied any history of heart problems or use of medication for heart problems on applications for second-class airman certificates in May 2003, May 2004, and May 2005, though the latter application did note the use of tamsulosin (an alpha-blocker). On his application for a second-class medical certificate in November 2005, the pilot noted a history of atrial fibrillation, and the use of metoprolol and warfarin to treat the condition. Accompanying that application was a letter to the pilot's FAA Aviation Medical Examiner (AME) from the pilot's cardiologist, noting that the pilot had been treated for atrial fibrillation for approximately 3 years, that he had visited physicians multiple times, and had undergone multiple diagnostic procedures during that time. The cardiologist concluded in that letter that the pilot "may continue to fly aircraft without restrictions from a medical standpoint."

In December 2005, the FAA denied the pilot's application due to his "history of falsification of multiple previous FAA examinations for failure to report atrial fibrillation and failure to report all medical visits and evaluations in the past three years on the current FAA examination (i.e. cardiac catheterization)." The pilot responded to the FAA in a letter submitted in January 2006 noting that "Because I had had many tests, felt well, and my cardiologist told me that 'he saw no reason why I couldn't fly,' I foolishly exercised poor judgment when completing my medical form."

Additional records submitted to the FAA from the pilot's cardiologist noted a history of chest pain on exertion, decreased exercise capacity, and variable blood pressure. Those records documented that the pilot underwent unsuccessful attempts to maintain normal cardiac rhythm through electrical cardioversion and through the use of medication in April 2005, and a letter from the cardiologist to the pilot's primary care physician in April 2005 had suggested that the pilot might need "to give up recreational flying, particularly given his aggressive style and performance in air shows."

Diagnostic studies were performed in 2006 and submitted to the FAA. The report submitted to the FAA of a 2006 nuclear stress test omitted any mention of chest discomfort during and an abnormal heart rhythm following the test noted in the pilot's personal medical records (see below).

The FAA issued an Authorization for Special Issuance of a (second-class) Medical Certification in July 2006 (expiring November 30, 2006) with the notation that "operation of aircraft is prohibited at any time new symptoms or adverse changes occur or if you experience side-effects, or require a change in medication."

A letter from the pilot's cardiologist to the FAA in September 2006 noted that the pilot's atrial fibrillation was stable, that he was on an adequate dose of blood-thinner, that he had no side effects from medications, and that he wore a Holter monitor on September 12, 2006, demonstrating short episodes of atrial fibrillation and no other significant abnormal rhythms. The letter omitted any mention of a brief abnormal heart rhythm (3 beats of ventricular tachycardia) on the Holter monitor as indicated in the pilot's personal medical records.

The pilot's most recent application for second-class airman medical certificate dated November 20, 2006 noted medications as warfarin (a blood thinner), metoprolol (a beta-blocker), and alfuzosin (an alpha-blocker), and indicated "No change in previously reported conditions." There were no documents in the pilot's FAA medical records dated more recently than the November 2006 application. The FAA did not place any restrictions on the pilot with regard to aerobatic flight.

The AME who issued the accident pilot's medical certificate was also a pilot. Both the AME and the accident pilot had been previously employed as formation flying (skytyping) pilots by the operator in the accident airplane make and model for more than 15 years, and the AME had flown in skytyping operations with the accident pilot.

Personal Medical Records

The pilot had been evaluated on multiple occasions for episodic symptoms including chest pain for several years, shortness of breath in April 2005 (once while flying at an airshow), and a sense of fullness in his head in February 2006. In April 2006, the pilot underwent a nuclear stress test with 7 minutes and 2 seconds of exercise and was noted to have chest tightness during the test that resolved in recovery and an abnormal heart rhythm (supraventricular tachycardia at 130 beats per minute) following resolution of his chest discomfort. In September 2006, the pilot wore a Holter monitor, results of which demonstrated short episodes of atrial fibrillation and a brief abnormal heart rhythm (3 beats of ventricular tachycardia). The episodes of shortness of breath, the head fullness, the chest tightness, the chest discomfort, and the brief run of ventricular tachycardia were not documented in records submitted to the FAA.

In March 2007, six months prior to the accident, the pilot was evaluated for chest pain and symptomatic atrial fibrillation, and treated by increasing his dose of metoprolol. He underwent a nuclear stress test at that time during which he experienced symptoms of mild chest discomfort and left arm tightness, and after this had resolved, rapid atrial fibrillation (heart rate 155) which resolved spontaneously 1 minute and 25 seconds after completing 5 minutes and 25 seconds of exercise. In April 2007, the pilot was evaluated for headaches, intermittent nausea and variably elevated blood pressure. He was again treated by increasing his dose of metoprolol.

In June 2007, three months prior to the accident, the pilot underwent an echocardiogram which demonstrated a new finding of pulmonary hypertension. On September 4, 2007, three days prior to the accident, the pilot was evaluated for multiple episodes over the previous three months of atrial fibrillation with fatigue and shortness of breath lasting anywhere from several hours to up to 36 hours at a time. He was noted as continuing to participate in air shows, and his cardiologist again noted the possible "need to consider discontinuing his activity as a pilot." The cardiologist had scheduled the pilot for evaluation for possible alternate treatment of his atrial fibrillation.

Autopsy Report

An autopsy was performed on the pilot at the Office of the Chief Medical Examiner, Norfolk, Virginia.

According to the report, under "Case Summary and Comment" it was noted, in part: "...it is possible that he [the pilot] had a serious cardiac arrhythmia which caused loss of consciousness. ...Because a cardiac arrhythmia does not leave structural signs at autopsy, it can never be proven. However, the enlarged size of his heart at 500.5 gm certainly would have predisposed him to a cardiac arrhythmia. This was likely due to long standing hypertension. A significant finding on histology (microscopic study of sections) from the muscular septum of the heart, the area of the heart where the conduction system is found, was an area of ischemic scarring which might well have affected the conduction system. This ischemic scarring might well have been the cause of a ventricular arrhythmia which could have robbed him of consciousness while flying the plane. An arrhythmia could have also been generated in any of the many areas of ischemic scarring identified in his left ventricle. ..."

Aeromedical Reference

A clinical aviation medical text (Rayman RB, Hastings JD, Kruyer WB, Levy RA, Pickard JS. Clinical Aviation Medicine, 4th ed. Professional Publishing Group, NY, 2006) noted that atrial fibrillation "...is particularly troubling with regard to physiologic responses to the high +Gz environment of aerobatic and high-performance military flight. ...paroxysmal Afib [atrial fibrillation] might be more of a concern due to its unexpected, sudden onset and immediate change from normal conditions." The text also notes that "...because of sympathetic blockade, [beta-blocker] use in high-performance aviators is considered unwise," and notes that alpha-blockers "...are not recommended for aviators who will be exposed to any measurable degree of sustained acceleration."

ADDITONAL INFORMATION

According to the operator, the airshow routine that was being practiced during the accident flight was a low-altitude formation act incorporating various six-ship and four-ship formations, and a solo act with two airplanes. The operator provided a summary of the approximate g-forces and length of time for each part of the act as it was performed, as well as an estimation of the total time spent at the maximum g-force loading for each maneuver. The airshow lasted about 13 minutes 50 seconds, prior to formation splitting, and 16 minutes 40 seconds before the first airplane landed.

Review of the maneuver summary revealed that at the time of the accident, the pilot had completed over 15 minutes of high performance flight, including nearly 2 minutes of increased g-loading (up to 2.9g's), and had just completed the longest sustained g-maneuver of the act (30 seconds of 2g loading).

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