ERA22LA414

NTSB accident investigation · Piper PA-39 · Caldwell, NJ · September 9, 2022

Accident · No injuriesClass 3 · LimitedFinal report
Date
September 9, 2022, 11:32 local (15:32 UTC)
Place
Caldwell, NJ · Runway 4 at CDW
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N8925YPiper PA-39
Defining event
Takeoff-rejected takeoff: Medical event
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20220909017039A
Case key
105928

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 acute cerebrovascular event, which caused symptoms that diminished his situational awareness and prompted him to abort the takeoff, resulting in a runway excursion.

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 84-year-old pilot and the passenger made two attempts to take off on a cross-country flight. According to the passenger, once she and the pilot boarded the airplane, the pilot said he forgot where they were going and had to ask the name of the airport. After informing the pilot of their destination, the pilot taxied to the runway and began to accelerate for takeoff. The pilot aborted the takeoff because he thought the passenger’s door was open. The door was secured, and the pilot taxied back to the runway. Just before taking off again, the pilot asked a second time where they were going. The passenger again had to tell the pilot their destination. The pilot initiated the takeoff roll, but aborted because he felt something was wrong with the airplane. The airplane went off the end of the runway, resulting in substantial damage to the left wing. When first responders arrived on scene, they noted the pilot was confused and had memory problems. The pilot was hospitalized for neurological evaluation and consultation. Magnetic resonance imaging of the pilot’s brain performed the day after the accident demonstrated an acute-to-subacute lacunar stroke in the right medial temporal lobe. The pilot was discharged from the hospital with a diagnosis of transient global amnesia. As such, the pilot most likely experienced an acute cerebrovascular event. Impairing symptoms of this event likely diminished his situational awareness and prompted him to intentionally abort the takeoff, resulting in the runway excursion.

Factual narrative

On September 9, 2022, at 1132 eastern daylight time, N8925Y, a twin-engine Piper PA 39 airplane was substantially damaged when it was involved in an accident at the Essex County Airport (CDW), Caldwell, New Jersey. The pilot and the passenger were not injured. The airplane was being operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the passenger, she and the pilot were flying to Maine to visit friends. They arrived at CDW around 1000. Once she and the pilot boarded the airplane, the pilot said he forgot where they were going and had to ask the name of the airport. After informing the pilot of their destination, the pilot taxied to the runway and began to accelerate for takeoff. The pilot aborted the takeoff because he thought the passenger’s door was open. The door was secured, and the pilot taxied back to the runway. Just before taking off again, the pilot asked for the second time where they were going. The passenger said she again had to tell the pilot their destination. The pilot initiated the takeoff roll but aborted because he felt something was wrong with the airplane. The passenger said the pilot shut off both engines and “locked up” the brakes, but the airplane went off the runway into the grass. The airplane swerved right and came to rest upright. The left main landing gear collapsed, and the left wing was substantially damaged. The pilot stated that he did not recall any details of the accident. He could only remember pulling the airplane out of the hangar before the flight, then later being in the hospital. The 84-year-old male pilot’s most recent aviation medical examination before the accident was on October 4, 2021. At that time, he reported a medical history including chronic lymphocytic leukemia (CLL) in remission. His reported medications did not include any medications that are generally considered impairing. The Aviation Medical Examiner issued the pilot a third-class medical certificate, in accordance with an FAA Authorization for Special Issuance for CLL. The medical certificate was limited by a requirement to wear corrective lenses and carried a time limitation, which had not expired as of the crash date. In July 2022, the pilot submitted additional reports to the FAA indicating that his CLL remained in remission. Following the accident, when first responders arrived at the accident scene, they noted that the pilot seemed confused and had memory problems. The pilot was hospitalized for neurological evaluation and consultation. Magnetic resonance imaging of the pilot’s brain performed the day after the accident demonstrated an acute-to-subacute lacunar stroke in the right medial temporal lobe. The pilot was discharged from the hospital the day after the accident with a diagnosis of transient global amnesia. The 84-year-old pilot said that he did not recall any details of the accident. He could only remember pulling the airplane out of the hangar before the flight, then later being inthe hospital.

Aircraft

Registration
N8925Y
Reported as
Piper PA-39
Category
Airplane
Serial number
39-81
Built
1970
Airframe hours
4,333.6
Engines
Lycoming LIO-320-B1A, 160 hp, reciprocatingLycoming IO-320-B1A, 160 hp, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · March 17, 2022
Destination
IZG · Fryeburg, ME
Flight plan
IFR
Airport
CDW · Essex County, runway 4, 4,552 × 80 ft, asphalt
Equipment
Stall warning system, ADS-B, Auto-pilot, Electronic flight bag or handheld device, Handheld GPS

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
None
Certificates
Private, Commercial
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
October 9, 2021
Seat
Left
Restraint
3-point
Flight hours
2,186 total · 915 in this make and model · 1,891 as pilot in command · 17 in the last 90 days · 8 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
77 °F, dew point 50 °F
Altimeter
30.10 inHg
Observed at
KCDW
METAR
METAR KCDW 091553Z 10SM CLR 25/10 A3010

Docket · 5

The files NTSB released with the investigation on May 16, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.4 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.