CEN22FA224

NTSB accident investigation · Schweizer SGS135 · Midlothian, TX · June 5, 2022

Accident · FatalClass 3 · FieldFinal report
Date
June 5, 2022, 16:30 local (21:30 UTC)
Place
Midlothian, TX
Injuries
1 fatal
Damage
No damage
Phase of flight
Unknown
Aircraft
N2817HSchweizer SGS135
Defining event
Unknown: Medical event
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA FSDO
FAA report
20220605022179A
Case key
105185

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot’s incapacitation by an aortic dissection (natural disease).

Findings · 1

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot was found deceased in the undamaged glider following a landing to a field near the airport. Postaccident examination revealed an improperly secured aileron connection; however, despite being partially unseated, the ailerons clevis pin remained seated adequately to facilitate operation of the aileron. No other anomalies were detected with the airframe that would have precluded normal operation. Autopsy revealed that the pilot’s cause of death was aortic dissection associated with hypertensive and atherosclerotic cardiovascular disease, with blunt force injury contributing.

Factual narrative

The glider logbooks were not located during the investigation, and the date of its most recent annual inspection was not determined. On June 5, 2022, about 1630 central daylight time, a Schweizer SGS 135C glider, N2817H, was undamaged when the pilot was found deceased after landing near Midlothian, Texas. The glider was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to members of the Texas Soaring Association (TSA), the pilot was launched via aerotow around 1500 that day. About 1700, the glider was found by another pilot as he landed at TSA Gliderport (TA11), Midlothian, Texas. The pilot was found strapped in his parachute and harness with the canopy closed despite temperatures in excess of 90°F. The glider was about 150 yards from the intended landing area in an open field. (See Figure 1.) None of the other pilots recalled hearing any landing radio calls or distress calls from the pilot. The exact time the pilot landed was not determined. Figure 1. Location of the glider as found. An autopsy was performed on the pilot by the Southwestern Institute of Forensic Sciences at Dallas, Texas. The cause of death was aortic dissection associated with hypertensive and atherosclerotic cardiovascular disease. Blunt force injuries were also noted as contributing. The manner of death was ruled as accident. An aortic dissection is a complication of chronic high blood pressure. Constant high blood pressure and turbulent blood flow cause a tear in the inner layer of the aorta (the large blood vessel that exits the heart) and blood rushes into the layers of the aorta, splitting them. In the worst cases, as in this one, it tears through all the layers and out into the mediastinum, interrupting blood flow to the rest of the body. Toxicology testing performed by the FAA’s Forensic Sciences Laboratory identified amlodipine and alfuzosin in liver; amlodipine was also identified in muscle tissue, but testing was inconclusive for alfuzosin in muscle. Testing was negative for ethanol. Amlodipine is a calcium channel blocker used to treat high blood pressure and coronary artery disease. Alfuzosin is an antagonist and is used to treat the symptoms of an enlarged prostate. The pilot’s logbook was not located during the investigation. The pilot’s total experience in gliders could not be determined; however, he was an active member of the Texas Soaring Association and owned gliders for over 14 years. The glider was located in an open field, as seen in Figure 2. Figure 2. Glider at the accident site. Examination of the glider did not reveal any damage or evidence of a hard landing. The flaps were found fully extended with the flap handle locked in the detent. Flight control continuity was confirmed from the cockpit controls to the flight control surfaces. Disassembly of the glider for transportation found that the LSP-1 safety pin was not installed to secure the clevis pin that connected the left aileron pushrod to the aileron idlerhorn. Despite being partially unseated, the clevis pin was seated adequately for operation of the aileron. (See Figure 3.) The right aileron was properly secured. No other anomalies were detected with the airframe that would have precluded normal operations. Figure 3. Aileron connection to the aileron idler horn.

Aircraft

Registration
N2817H
Reported as
Schweizer SGS135 (C)
Category
Glider
Serial number
77
Built
1977
Damage
No damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Departed
TA11 · Midlothian, TX
Equipment
None

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
84
Injuries
Fatal
Certificates
Airline transport, Commercial, Flight instructor
Airplane ratings
Single-engine sea, Single-engine land
Instrument ratings
Airplane
Seat
Single
Restraint
4-point
Toxicology
Performed
Flight hours
3,700 total

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 9 knots, gusting 17
Visibility
10 statute miles
Temperature
91 °F, dew point 72 °F
Altimeter
29.70 inHg
Observed at
KJWY, 6 nm away
METAR
KJWY 052155Z AUTO 15009G17KT 10SM SCT045 33/22 A2970 RMK AO2 T03330218

Docket · 4

The files NTSB released with the investigation on November 8, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.4 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.