# NTSB CEN12IA050: Nusbaum Vaquero, N30CY, Hebron, IL, November 1, 2011 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: November 1, 2011, 17:30 local (22:30 UTC) - Place: Hebron, IL - Coordinates: 42.421665, -88.391387 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.4217&lon=-88.3914&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report January 15, 2013 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 82226 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN12IA050 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/82226/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=82226 - Page: https://openairdocs.org/ntsb/CEN12IA050 ## Probable cause The pilot’s operation of the airplane with known medical conditions and his subsequent heart attack during the flight. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Experience/qualifications: qualification/certification](https://openairdocs.org/ntsb-findings/02031010): Personnel issues › Experience/knowledge · Pilot; cases with it: [Nusbaum Steve VAQUERO, 1 case](https://openairdocs.org/ntsb-findings/02031010/cases.md?model=056115H), [All aircraft, 280 cases](https://openairdocs.org/ntsb-findings/02031010/cases.md) - [Health/Fitness: predisposing condition](https://openairdocs.org/ntsb-findings/02013035): Personnel issues › Physical · Pilot (probable cause); cases with it: [Nusbaum Steve VAQUERO, 1 case](https://openairdocs.org/ntsb-findings/02013035/cases.md?model=056115H), [All aircraft, 56 cases](https://openairdocs.org/ntsb-findings/02013035/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Nusbaum Steve VAQUERO, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=056115H), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Impairment/incapacitation](https://openairdocs.org/ntsb-findings/02012000): Personnel issues › Physical · Pilot (probable cause); cases with it: [Nusbaum Steve VAQUERO, 1 case](https://openairdocs.org/ntsb-findings/02012000/cases.md?model=056115H), [All aircraft, 40 cases](https://openairdocs.org/ntsb-findings/02012000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) (defining event); cases with it: [Nusbaum Steve VAQUERO, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=056115H), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Nusbaum Steve VAQUERO, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=056115H), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis The pilot experienced a medical event in-flight and landed his airplane in a field. The airplane sustained no damage. The pilot's son arrived where the airplane landed and saw the pilot lying back in the airplane’s seat; the pilot did not appear to be breathing. First responders revived and subsequently transported the pilot to a local hospital. The pilot died about two days later and the cause of death was determined to be a myocardial infarction. The pilot had previous heart conditions, including bypass surgery. The pilot last applied for a medical certificate about ten years prior to the incident flight. On the application for his last medical certificate, the pilot indicated his previously reported “heart or vascular trouble” on prior medical applications and his use of Coumadin, an anticoagulant medication. The airplane the pilot was flying required the pilot to have a current medical certificate to operate it. The investigation could not determine the exact extent of and time that the pilot experienced the medical event that he had to be revived from when the airplane landed. ## Factual narrative On November 1, 2011, about 1730 central daylight time, N30CY, an experimental amateur-built Nusbaum Vaquero airplane, operated and piloted by a private pilot, sustained no damage when the pilot performed a forced landing on an open field near Hebron, Illinois, because the pilot had experienced a medical event in-flight. The personal flight was operating under 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the incident. No flight plan was on file. The local flight originated from Hebron, Illinois, at time unknown. According to a McHenry County Sheriff’s Incident/Offense Report, the pilot’s son reported that he had been monitoring his father’s flight. The pilot’s son stated that he saw the airplane land and he went to the field where the airplane had landed. He saw the pilot lying back in the airplane’s seat and the pilot did not appear to be breathing. First responders made their way to the open farm field and two personnel performed cardiopulmonary resuscitation on the pilot. An automated external defibrillator (AED) was applied to the pilot and the AED advised a shock needed to be administered, which it administered. The pilot was subsequently transported to a local hospital. According to Federal Aviation Administration (FAA) records, the pilot held a private pilot certificate. FAA medical records showed that the pilot reported that he had accumulated 4,000 hours of total fight time on the application for his last third-class medical dated May 11, 2001. On that application, the pilot indicated he previously reported that he had “heart or vascular trouble” on prior medical applications and that, he was using Coumadin. The generic name for Coumadin is Warfarin. The FAA Forensic Toxicology's WebDrugs website description of Warfarin indicated it is an anticoagulant medication. N30CY was a high wing, two-place, tailwheel airplane. According to FAA airworthiness records, the pilot provided airplane weight and balance calculations, dated November 5, 2001, which indicated that the airplane’s the gross weight with two occupants would be 1,492 pounds. According to a McHenry County Department of Health Certificate of Death, the pilot died on November 3, 2011. The cause of death was attributed to a myocardial infarction. An autopsy was not performed. Samples for toxicological examination were not taken nor sent to the FAA Civil Aerospace Medical Institute and a Final Forensic Toxicology Accident Report was not produced. The pilot’s son indicated that the pilot had previous heart conditions to include by-pass surgery. He was sent requests to confirm the details involved in the incident and to date has not responded to the requests. ## Aircraft - Registration: [N30CY](https://openairdocs.org/aircraft/N30CY), registered now, S/N 0004 (OpenAirDocs) - Reported make and model: NUSBAUM VAQUERO - Registry model: [Nusbaum Steve VAQUERO](https://openairdocs.org/model/nusbaum-steve-vaquero) (registry code 056115H) (OpenAirDocs) - Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 0004 - Engines: AMA/EXPR UNKNOWN ENG reciprocating - Damage: No damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Departed: Hebron, IL - Destination: Hebron, IL ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: none; private; airplane ratings: single-engine land; medical: class 3; seat: rear; flight hours: 4,000 total ## Weather - Conditions: Visual (VMC), Day - Wind: 180° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 55 °F, dew point 43 °F - Altimeter: 29.97 inHg - Observed at: BUU ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Incident 20111101029419I](https://openairdocs.org/incident/20111101029419I), Nov 1, 2011: Nusbaum Steve VAQUERO, Hebron, IL, No damage, 1 fatal. [privacy data omitted] Was the pilot in command of N30CY under visual flight rules when he experienced a heart attack. He was able to land the aircraft in a… ## Docket (2 files) The files NTSB released with the investigation on November 14, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=82226. 78 KB in all. - Miscellaneous - FAA Forensic Toxicology's WebDrugs website description of Warfarin (item 1, .PDF, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40377936&FileExtension=.PDF&FileName=Miscellaneous%20-%20FAA%20Forensic%20Toxicology%27s%20WebDrugs%20website%20description%20of%20Warfarin-Master.PDF - Miscellaneous - Requests to the Pilot's Son For Confirmation of Information (item 2, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40377940&FileExtension=.PDF&FileName=Miscellaneous%20-%20Requests%20to%20the%20Pilot%27s%20Son%20For%20Confirmation%20of%20Information-Redacted.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.