# NTSB CEN19LA053: Piper PA28, N75191, Salem, SD, January 13, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: January 13, 2019, 14:25 local (20:25 UTC) - Place: Salem, SD - Coordinates: 43.61861, -97.381111 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.6186&lon=-97.3811&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Medical event](https://openairdocs.org/ntsb-events/850) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report April 20, 2020 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Piper Aircraft, Federal Aviation Administration, Lycoming Engines - NTSB case key (mKey): 98836 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19LA053 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98836/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98836 - Page: https://openairdocs.org/ntsb/CEN19LA053 ## Probable cause The incapacitating effects of an acute myocardial infarction (heart attack), which resulted in the pilot's loss of airplane control and impact with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Impairment/incapacitation: cardiovascular](https://openairdocs.org/ntsb-findings/02012050): Personnel issues › Physical · Pilot (probable cause); cases with it: [Piper PA-28-181, 1 case](https://openairdocs.org/ntsb-findings/02012050/cases.md?model=7102807), [All aircraft, 69 cases](https://openairdocs.org/ntsb-findings/02012050/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-181, 53 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102807), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Medical event](https://openairdocs.org/ntsb-events/850) (defining event); cases with it: [Piper PA-28-181, 1 case](https://openairdocs.org/ntsb-events/850/sequence.md?model=7102807), [All aircraft, 63 cases](https://openairdocs.org/ntsb-events/850/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-181, 23 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102807), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-181, 70 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102807), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis About 15 minutes after departing on a cross-country flight in day visual meteorological conditions, the pilot contacted air traffic control to report that he was having chest pain and blacking out, and was having difficulty controlling the airplane. The controller continued to communicate with the pilot for about 20 minutes before radio contact was lost. The wreckage was subsequently located in a field. Examination did not reveal any preimpact anomalies that would have precluded normal operation of the airplane. The pilot's Federal Aviation Administration medical certificate expired about 10 weeks before the accident. He had begun but not completed the requirements for operation under BasicMed. Autopsy of the pilot identified coronary artery disease including 80% stenosis of the left anterior descending coronary artery and 50% stenosis of the right coronary artery and diagnosed an acute myocardial infarction (heart attack). It is likely that the sudden, impairing effects of the heart attack and associated severe chest pain resulted in the pilot's loss of airplane control while attempting to land in a field, and its subsequent impact with terrain. ## Factual narrative The four-place, single-engine, low-wing, fixed tricycle landing gear airplane, serial number 28-7690310, was manufactured in 1976. According to maintenance records, the airplane was powered by a 180-horsepower Lycoming O-360 engine, serial number L-1039-36A, which drove a two-blade fixed pitch Sensenich propeller. On January 13, 2019, about 1425 central standard time, a Piper PA-28-181 airplane, N75191, was substantially damaged when it impacted terrain about 6 miles south of Salem, South Dakota. The private pilot was fatally injured. The airplane was owned and operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Day visual meteorological conditions prevailed in the area and no flight plan was filed for the cross-country flight, which originated from Mitchell Municipal Airport (MHE), Mitchell, South Dakota, and was destined for Mary Skie-Lincoln County Airport (Y14), Tea, South Dakota. About 15 minutes after departing, the pilot contacted Sioux Falls Approach Control and stated that he was having chest pains, was blacking out, and was having difficulty maintaining control of the airplane. About 1411, radar track data indicated the airplane was traveling southeast. The airplane then maneuvered/circled for about 6 minutes, briefly headed northwest briefly and began maneuvering/circling again. The controller continued to communicate with the pilot for about 20 minutes before radio contact was lost about 1425; the track data ended about the same time, about 2 miles southwest of the accident site. The wreckage was subsequently located in a field about 30 nautical miles east-southeast of the departure airport. The McCook County Coroner coordinated the pilot's autopsy at the Sanford Health Pathology Clinic, Sioux Falls, South Dakota. The autopsy indicated that the pilot's cause of death was multiple blunt force injuries due to an airplane crash due to acute myocardial infarction due to atherosclerotic cardiovascular disease. The autopsy identified coronary artery disease, including 80% stenosis of the left anterior descending coronary artery and 50% stenosis of the right coronary artery. Toxicology testing performed at the FAA Forensic Sciences Laboratory identified valsartan in liver and muscle, ranitidine in muscle, and amlodipine in liver and muscle. Amlodipine is a calcium channel blocker heart medication used in the treatment of hypertension. Ranitidine is used in the treatment of gastric acid secretion. Valsartan is an angiotensin II receptor antagonist indicated for treatment of high blood pressure, of congestive heart failure, and post-myocardial infarction. The pilot's personal medical records indicated that he had well-controlled hypertension and occasional visits for respiratory infections. The pilot requested his primary physician fill out the FAA physician attestation form for BasicMed and the physician did so, attesting to the pilot's ability to safely operate an aircraft. The medical records alsoincluded the history form filled out by the pilot during this process; however, the FAA had no record of receiving the pilot's BasicMed documents. The 1422 recorded weather at MHE included wind from 200° at 13 knots; 10 statute miles visibility; overcast clouds at 1,500 ft; temperature 1°C; dew point -3°C; altimeter 30.30 inches of mercury. According to Federal Aviation Administration (FAA) records, the 69-year-old pilot held a private pilot certificate with airplane single-engine land and instrument ratings. The pilot's most recent third-class FAA medical certificate was issued on October 5, 2016, with a limitation for corrective lenses, and expired on October 31, 2018. On the application for that medical certificate, he reported 2,250 total hours of flight experience, with 50 hours in the previous 6 months. The wreckage was located in a harvested crop field. Review of information and photographs provided by local law enforcement revealed that all major components of the airplane were present at the site. The airplane main wreckage was found resting upright in the field. The cockpit was crushed and the empennage was facing north. A debris field, wheel tracks, and ground scars in the field indicated that the airplane contacted the ground about 600 to 800 ft north of where it came to rest. The wreckage was removed from the scene and was placed in a secure building. The wreckage was subsequently examined by an FAA inspector and airframe manufacturer's representative. The examination revealed no preimpact anomalies that would have precluded normal operation of the airplane. ## Aircraft - Registration: [N75191](https://openairdocs.org/deregistered/N75191-2020-08-10), registration cancelled 2020-08-10, S/N 28-7690310, built 1976 (OpenAirDocs) - Reported make and model: Piper PA28 (181) - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7690310 - Year built: 1976 - Engines: Lycoming O-360-A4M reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Departed: MHE, Mitchell, SD - Destination: Y14, Tea, SD ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; toxicology performed; flight hours: 2,515.6 total, 11 in the last 90 days, 2.9 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 200° at 13 knots - Visibility: 10 statute miles - Lowest ceiling: 1,500 ft overcast - Temperature: 34 °F, dew point 27 °F - Altimeter: 30.29 inHg - Observed at: KMHE, 30 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20190113000209A](https://openairdocs.org/incident/20190113000209A), Jan 13, 2019: Piper PA-28-181, Salem, SD, Destroyed, 1 fatal. On January 13, 2019 at 14:25 central standard time a 1976 Piper PA28-181, registered to [privacy data omitted] impacted terrain during a personal pleasure… ## Docket (18 files) The files NTSB released with the investigation on March 25, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98836. 3.8 MB in all. - Memorandum for Record – Communication Summary R. Gebel, MHE FBO Manager (item 1, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481511&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Communication%20Summary%20R.%20Gebel,%20MHE%20FBO%20Manager-Master.PDF - Memorandum for Record – Communication Summary L. Alexander -- No record of wx brief (item 2, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481512&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Communication%20Summary%20L.%20Alexander%20--%20No%20record%20of%20wx%20brief-Master.PDF - Memorandum for Record – Communication Summary -- RAP FBO (item 3, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481513&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Communication%20Summary%20--%20RAP%20FBO-Master.PDF - Miscellaneous Information - Pilot Logbook Excerpts (item 4, .PDF, 677 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481514&FileExtension=.PDF&FileName=Miscellaneous%20Information%20-%20Pilot%20Logbook%20Excerpts-Master.PDF - Correspondence - CFI on BFR (item 5, .PDF, 118 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481515&FileExtension=.PDF&FileName=Correspondence%20-%20CFI%20on%20BFR-Master.PDF - Maintenance Records - Annual Inspections 9/10/18 (item 6, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481516&FileExtension=.PDF&FileName=Maintenance%20Records%20-%20Annual%20Inspections%209%2F10%2F18-Master.PDF - Air Traffic Control - FAA Report of Accident (item 7, .PDF, 862 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481517&FileExtension=.PDF&FileName=Air%20Traffic%20Control%20-%20FAA%20Report%20of%20Accident-Master.PDF - Air Traffic Control - Transcript (item 8, .PDF, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481518&FileExtension=.PDF&FileName=Air%20Traffic%20Control%20-%20Transcript-Master.PDF - Air Traffic Control - Plotted Radar Data -- B. Soper (item 9, .PDF, 408 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481519&FileExtension=.PDF&FileName=Air%20Traffic%20Control%20-%20Plotted%20Radar%20Data%20--%20B.%20Soper-Master.PDF - Miscellaneous Information - Fuel Receipt RAP (item 10, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481520&FileExtension=.PDF&FileName=Miscellaneous%20Information%20-%20Fuel%20Receipt%20RAP-Master.PDF - Miscellaneous Information - Fuel Receipt Y14 (item 11, .PDF, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481521&FileExtension=.PDF&FileName=Miscellaneous%20Information%20-%20Fuel%20Receipt%20Y14-Master.PDF - Weather Reports and Records (item 12, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481522&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Other Pertinent Forms and Reports - Medical Factual Report (item 13, .PDF, 236 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481523&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%20-%20Medical%20Factual%20Report-Master.PDF - Toxicological Report - 201900010001 (item 14, .PDF, 351 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481524&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20201900010001-Master.PDF - Miscellaneous Information - CAMI Toxicology Drug Information for Amlodipine Ranitidine Valsartan (item 15, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481525&FileExtension=.PDF&FileName=Miscellaneous%20Information%20-%20CAMI%20Toxicology%20Drug%20Information%20for%20Amlodipine%20Ranitidine%20Valsartan-Master.PDF - Reports from Parties to the Investigation - Examination Summary -- Piper (item 16, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481526&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%20-%20Examination%20Summary%20--%20Piper-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 17, .PDF, 294 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481527&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 18, .PDF, 161 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481528&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.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.