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.