# NTSB CEN22FA224: Schweizer SGS135, N2817H, Midlothian, TX, June 5, 2022 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: June 5, 2022, 16:30 local (21:30 UTC) - Place: Midlothian, TX - Coordinates: 32.387741, -97.010635 - Nearby events: https://openairdocs.org/map.md?lat=32.3877&lon=-97.0106&mi=10 - Phase of flight: [Unknown](https://openairdocs.org/ntsb-phases/990) (OpenAirDocs' grouping) - Defining event: [Unknown: Medical event](https://openairdocs.org/ntsb-events/850) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA FSDO - NTSB case key (mKey): 105185 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN22FA224 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105185/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105185 - Page: https://openairdocs.org/ntsb/CEN22FA224 ## Probable cause The pilot’s incapacitation by an aortic dissection (natural disease). ## 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: [Schweizer SGS 1-35C, 1 case](https://openairdocs.org/ntsb-findings/02012050/cases.md?model=8050151), [All aircraft, 69 cases](https://openairdocs.org/ntsb-findings/02012050/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Unknown: Medical event](https://openairdocs.org/ntsb-events/850) (defining event); cases with it: [Schweizer SGS 1-35C, 1 case](https://openairdocs.org/ntsb-events/850/sequence.md?model=8050151), [All aircraft, 63 cases](https://openairdocs.org/ntsb-events/850/sequence.md) ## 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](https://openairdocs.org/aircraft/N2817H), registered now, S/N 77 (OpenAirDocs) - Reported make and model: SCHWEIZER SGS135 (C) - Registry model: [Schweizer SGS 1-35C](https://openairdocs.org/model/schweizer-sgs-1-35c) (registry code 8050151) (OpenAirDocs) - Registry engine: [NONE](https://openairdocs.org/engine/none) (registry code 00000, none) (OpenAirDocs) - Category: Glider - Serial number: 77 - Year built: 1977 - Damage: No damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Departed: TA11, Midlothian, TX - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 84; injuries: fatal; 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 ## 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 20220605022179A](https://openairdocs.org/incident/20220605022179A), Jun 5, 2022: Schweizer SGS 1-35C, Midlothian, TX, No damage, 1 fatal. Midlothian TX: (TA11):[privacy data omitted] single seat, mid-wing glider, SGS1-35G, landed 1/2 mile short of the runway due to unknown circumstances. No ATC… ## Docket (4 files) The files NTSB released with the investigation on November 8, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105185. 1.4 MB in all. - Case findings (item 1, PDF, 4 pages, 3 photos, 625 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14461423&FileExtension=pdf&FileName=Case%20Findings%20CEN22FA224-Rel.pdf - Medical factual (item 2, PDF, 3 pages, 127 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14455208&FileExtension=pdf&FileName=CEN22FA224_Medical%20Factual%20Report-Rel.pdf - Toxicological report (item 3, PDF, 1 page, 546 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14458879&FileExtension=pdf&FileName=cen22fa224%20tox_Redacted-Rel.pdf - Friend of pilot statement (item 4, PDF, 1 page, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14458889&FileExtension=pdf&FileName=Friend%20of%20pilot_Redacted-Rel.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.