# NTSB FTW95LA298: Bradley Dragonfly, N826DB, Silver City, NM, July 15, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: July 15, 1995, 10:40 local (16:40 UTC) - Place: Silver City, NM - Coordinates: 32.780033, -108.260459 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.7800&lon=-108.2605&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report July 15, 1996 - Report: Approved by Office Director - NTSB case key (mKey): 19499 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW95LA298 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/19499/pdf - Page: https://openairdocs.org/ntsb/FTW95LA298 ## Probable cause PILOT INCAPACITATION DUE TO A HEART ATTACK. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - vfr pattern - final approach - aircraft control - uncontrolled, pilot in command (cause) - incapacitation(cardiovascular), pilot in command (cause) - lack of certification, pilot in command - In flight collision with object, approach - vfr pattern - final approach - object - approach light/navaid ## Analysis THE PILOT WAS MAKING TOUCH-AND-GO LANDINGS. DURING THE FINAL APPROACH, THE AIRCRAFT WAS OBSERVED TO INCREASE ITS ANGLE OF DESCENT AND CRASH 240 FEET SHORT OF THE RUNWAY INTO THE APPROACH LIGHTS. AFTER GOING THROUGH FIVE ROWS OF LIGHTS, THE AIRCRAFT BECAME AIRBORNE WITH THE ENGINE OPERATING AND THEN CRASHED INTO THE GROUND NEXT TO A TAXIWAY. THE FIRST PERSONS ON THE SCENE FOUND THE PILOT SLUMPED OVER IN THE COCKPIT WITH NO OBVIOUS SIGNS OF INJURY, AND EFFORTS AT RESUSCITATION WERE UNSUCCESSFUL. THE PILOT HAD A HISTORY OF HEART DISEASE. THE AUTOPSY REVEALED AN ADVANCED GENERALIZED ARTERIOSCLEROTIC CARDIOVASCULAR DISEASE, BUT NO LETHAL INJURIES. HIS MEDICAL CERTIFICATE ISSUED 5/17/93 HAD EXPIRED. ## Factual narrative On July 15, 1995, at 1040 mountain daylight time, a homebuilt Bradley Dragonfly, N826DB, landed short of the runway at Silver City, New Mexico. The pilot received fatal injuries and the aircraft sustained substantial damage. No flight plan was filed for this 14 CFR Part 91 local area personal flight and visual meteorological conditions prevailed. According to statements provided to the Federal Aviation Administration (FAA) inspector, the pilot was doing touch and go landings and operating in the local traffic pattern. He reportedly was making a final landing. Witnesses stated that the aircraft angle of descent increased during final approach and touch down was approximately 240 feet short of the runway in the approach lights. Propeller slashes were present in this area. Following initial touchdown, during which the aircraft went through five rows of approach lights, the aircraft became airborne with the engine operating and impacted terrain adjacent to a taxiway. The pilot was wearing a four point restraint and persons who arrived on the scene within a few minutes of impact found the pilot slumped over in the cockpit. According to the sheriff's department deputy who responded, the pilot was unresponsive and attempts at resuscitation were unsuccessful. Toxicological tests performed by the state of New Mexico, Medical Examiner's Office, were negative for substances of abuse and alcohol. FAA records and the autopsy performed by the New Mexico Medical Examiner's Office, provided evidence that the pilot had a history of heart disease. FAA records also provided information that at a point in the past, the pilot had his medical certificate denied for a period of time due to heart abnormalities and hypertension. His medical certificate issued May 17, 1993, had a restriction which made it valid for a period of 24 months following the month of examination. The New Mexico Medical Examiner's opinion is quoted below from the Autopsy Report: There is a question as to whether the decedent suffered a cardiac irregularity due to his severe heart disease which resulted in the accident, or whether he suffered the injury during the accident which resulted in cardiac arrest because of his severe heart disease. The injuries, by themselves, would not ordinarily be lethal. It is more likely the latter sequences occurred since the airplane seemed, according to a reliable witness, to be under good control right up to the point of landing." ## Aircraft - Registration: [N826DB](https://openairdocs.org/deregistered/N826DB-2013-08-21), registration cancelled 2013-08-21, S/N 334 (OpenAirDocs) - Reported make and model: BRADLEY DRAGONFLY - Registry model: [Bradley Delbert C DRAGONFLY](https://openairdocs.org/model/bradley-delbert-c-dragonfly) (registry code 05644LT) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 334 - Engines: VOLKSWAGEN reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Leonard T. Griffin - Airworthiness certificate: Special, Experimental (Special) - Departed: SVC - Airport: SVC, Grant County, runway 26, 6,800 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 78; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: rear; toxicology performed; flight hours: 120 total, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 300° at 6 knots - Visibility: 60 statute miles - Lowest ceiling: none - Temperature: 61 °F, dew point 57 °F - Altimeter: 30.00 inHg - Observed at: DMN, 37 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 19950715018489A](https://openairdocs.org/incident/19950715018489A), Jul 15, 1995: Amtr DRAGONFLY, Silver City, NM, Substantial damage, 1 fatal. Landed short of runway. Ran thru approachlights. Became airborne. Impact caused heart attack. History heart disease. 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.