# NTSB ERA19LA197: Piper PA32, N2750Q, Crisfield, MD, June 15, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: June 15, 2019, 04:15 local (08:15 UTC) - Place: Crisfield, MD - Coordinates: 38.013332, -75.818611 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.0133&lon=-75.8186&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 99671 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA197 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99671/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99671 - Page: https://openairdocs.org/ntsb/ERA19LA197 ## Probable cause The pilot's sudden incapacitation from an undiagnosed cardiac arrhythmia while on final approach, which resulted in descent and collision with trees and terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Health/Fitness: predisposing condition](https://openairdocs.org/ntsb-findings/02013035): Personnel issues › Physical · Pilot (probable cause); cases with it: [Piper PA-32-260, 1 case](https://openairdocs.org/ntsb-findings/02013035/cases.md?model=7103206), [All aircraft, 56 cases](https://openairdocs.org/ntsb-findings/02013035/cases.md) - [Impairment/incapacitation: cardiovascular](https://openairdocs.org/ntsb-findings/02012050): Personnel issues › Physical · Pilot (probable cause); cases with it: [Piper PA-32-260, 1 case](https://openairdocs.org/ntsb-findings/02012050/cases.md?model=7103206), [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-32-260, 18 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7103206), [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. - [Approach-VFR pattern final: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) (defining event); cases with it: [Piper PA-32-260, 3 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=7103206), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Approach-VFR pattern final: Abrupt maneuver](https://openairdocs.org/ntsb-events/270); cases with it: [Piper PA-32-260, 1 case](https://openairdocs.org/ntsb-events/270/sequence.md?model=7103206), [All aircraft, 346 cases](https://openairdocs.org/ntsb-events/270/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-32-260, 30 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7103206), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot departed with the intention of remaining in the traffic pattern to perform one full-stop night landing before proceeding on a planned instrument flight rules cross-country flight. After takeoff, he remained in the traffic pattern and turned onto the final approach leg. He last recalled being about 1 mile from the runway threshold, then had a brief recollection of trees being in the cockpit. He awoke several hours later, exited the wreckage of the airplane, and walked to his house, where help was summoned. He reported that, to the best of his knowledge, there was no preimpact mechanical failure or malfunction. The pilot's description was consistent with unwitnessed temporary loss of consciousness during the landing approach. While there was no toxicology to support an alternative cause, a cardiac evaluation 2 months after the accident revealed that the pilot had intermittent complete heart block with prolonged pauses between heartbeats, which can lead to fainting. Additional cardiac tests showed normal coronary arteries but revealed that the pilot had cardiac sarcoidosis. The pilot denied having syncopal events prior to the accident and reported no symptoms before losing consciousness. His medical records contained no mention of any sarcoid disease. Given the natural course of cardiac sarcoidosis, the pilot's sudden incapacitation from complete heart block would not have been predicted. Thus, it is likely that the pilot experienced sudden incapacitation from an undiagnosed arrhythmia. ## Factual narrative On June 15, 2019, about 0415 eastern daylight time, a Piper PA-32-260, N2750Q, impacted trees and terrain while on approach to Crisfield-Somerset County Airport (W41), Crisfield, Maryland. The private pilot sustained minor injuries. The airplane was operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed at the time and no flight plan was filed for the flight that originated about 5 minutes earlier from W41. In statements provided to the Federal Aviation Administration (FAA), Maryland State Police, and also National Transportation Safety Board (NTSB), the pilot reported that he intended to perform one full-stop night landing in advance of a flight planned to depart W41 at 0430. Very light winds favored runway 32 which had an inoperative precision approach path indicator (PAPI). He departed and remained in the airport traffic pattern for runway 32. The crosswind and downwind legs of the airport traffic pattern were uneventful with the airport lights "crystal clear and fully illuminated." Shortly after turning onto the base leg of the airport traffic pattern, the airplane's altitude was between 550 and 600 ft above ground level and he had the airport in sight. He announced turning onto the final leg of the airport traffic pattern for runway 32 and was lined up perfectly with the runway with the airplane landing lights on, and the runway in sight in front of him. While on the final approach of the airport traffic pattern at what appeared to be normal altitude he "last recalled" being 1 mile from the runway 32 threshold and he had 1 flash memory that sometime between his final call and waking up in the crashed airplane, seeing red lights, and "major limbs in the cabin", adding that, "…all [of a] sudden trees came through the cabin (unseen until the impact)." The pilot regained consciousness during daylight, climbed out of the wreckage and walked to his home. The pilot indicated on the submitted NTSB Pilot/Operator Aircraft Accident/Incident Report that to the best of his knowledge there was no preimpact mechanical failure or malfunction. The FAA inspector who examined the wreckage the same day reported the fuselage was resting on its left side in a ditch with the left wing separated and in close proximity among trees, while the right wing remained attached by control cables. The ditch was adjacent to trees at the southern end of an open field, with the accident site located about 1,830 ft southeast of the runway 32 threshold. In an e-mail from the pilot to NTSB on September 12, 2019, he provided information regarding a medical finding that was significant to the investigation. He was asked for and provided the requested medical information. According to the NTSB Medical Factual Report, emergency room records, and post-accident medical records through December 27, 2019 were obtained from the pilot's internist and cardiologist. The emergency room records revealed the completeblood count and metabolic panel were not concerning and no drug panel was ordered. On his first visit to the internist about 1 month after the accident, which appeared to be his routine 6-month follow-up from an earlier exam, the pilot reported the circumstances of the accident and denied falling asleep before the crash, and stated he still had some dizziness since the crash. An electrocardiogram (EKG) at this visit showed a first degree heart block and the internist ordered a cardiac work-up that included a stress echocardiogram and a 24-hour halter monitor for the pilot. On August 15, 2019, the 24-hour halter monitor showed first degree heart block and multiple episodes of complete heart block, notably at least one episode with a 3.5 second pause between heartbeats. For additional information please see the Medical Factual Report contained in the NTSB's public docket for this investigation. ## Aircraft - Registration: [N2750Q](https://openairdocs.org/deregistered/N2750Q-2020-10-10), registration cancelled 2020-10-10, S/N 32-7700014, built 1977 (OpenAirDocs) - Reported make and model: Piper PA32 (260) - Registry model: [Piper PA-32-260](https://openairdocs.org/model/piper-pa-32-260) (registry code 7103206) (OpenAirDocs) - Category: Airplane - Serial number: 32-7700014 - Year built: 1977 - Airframe hours: 6153.8 - Engines: Lycoming O-540-E4B5 260 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 12, 2018 - Departed: W41, Crisfield, MD - Destination: W41, Crisfield, MD - Airport: W41, Crisfield-Somerset County Arpt, runway 32, 2,397 × 75 ft, asphalt - Equipment: Handheld GPS, Onboard weather, Stall warning system, ADS-B, Auto-pilot, Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: minor; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review June 4, 2019; seat: left; restraint: 3-point; flight hours: 1,253.5 total, 193.8 in this make and model, 1,127 as pilot in command, 33.7 in the last 90 days, 18 in the last 30 days, 0.1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night - Wind: 190° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 57 °F, dew point 54 °F - Altimeter: 30.15 inHg - Observed at: MFV, 22 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 20190615007029A](https://openairdocs.org/incident/20190615007029A), Jun 15, 2019: Piper PA-32-260, Crisfield, MD, Destroyed. Pilot was attempting to do a touch and go in W41 (Crisfield, MD) at night. The pilot undershot the runway and hit trees. The impact destroyed the aircraft.… ## Docket (6 files) The files NTSB released with the investigation on October 9, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99671. 3.2 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 683 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9162773&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Pilot initial statement to Maryland state police (item 2, PDF, 2 pages, 514 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9172546&FileExtension=pdf&FileName=Pilot%20Statement%20to%20Maryland%20State%20Police_Redacted-Rel.pdf - Pilot initial statement to federal aviation administration (item 3, PDF, 2 pages, 624 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9171793&FileExtension=pdf&FileName=Pilot%20E-mail%20Statement%20to%20FAA%20IIC%206%2017%202019_Redacted-Rel.pdf - Record of NTSB conversations (item 4, PDF, 7 pages, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9198036&FileExtension=pdf&FileName=Record%20of%20NTSB%20Conversations_Redacted-Rel.pdf - Medical factual report (item 5, PDF, 4 pages, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9162676&FileExtension=pdf&FileName=ERA19LA197_Crisfield_MD_Medical_Factual_FINAL_022120-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 6, PDF, 1 page, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9196533&FileExtension=pdf&FileName=Fully%20Executed%20Wreckage%20Release_ERA19LA197_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.