Dr. Mydin's Rim Asia (Pacific) Aircraft Accidents of Medical Cause

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Civilian Air-crew Medical Standards

13111981.jpg

Date of event:

02 February 2005.

Location & aircraft:

New Zealand, 8 km north-east of Taupo Aerodrome. Piper PA34-200T Seneca II (ZK-FMW).

Human Factors:

No obvious cause for the accident could be determined. Autopsy reports showed the pilot had consumed cannabis, probably between 12 and 24 hours before the accident. While cannabis can adversely affect a person's ability to operate an aircraft, its effects can vary greatly so this could not be conclusively identified as a cause of this accident. Safety issues identified included: The lack of a test regime to identify the use of illicit drugs and alcohol in the transport industry; Inadequate medical standards for pilots with an aortic valve replacement; The urgent need to have terrain awareness warning systems installed in Part 135 aircraft.

Brief description of event:

On Wednesday 2 February 2005, ZK-FMW, a Piper PA34-200T Seneca, was on an air transport charter flight from Ardmore to Taupo with a pilot and 2 passengers on board. During the instrument approach to Taupo Aerodrome the aircraft deviated left of the published final approach track and at 1154 struck Mount Tauhara, 8 km from the aerodrome. The 3 occupants were killed on impact and the aircraft was destroyed.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

2

2

-

-

-

-

Aircraft total:

3

3

-

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

1.

Accident or Incident Report (New Zealand Transport Accident Investigation Commi): TAIC report summary 05/003.

2.

Accident or Incident Report (New Zealand Transport Accident Investigation Commi): TAIC report 05/003.

 

Date of event:

22 November 2004.

Location & aircraft:

Malaysia, Pontianak, Borneo. Boeing 737-500 (Flight GA501).

Human Factors:

Copilot landed aircraft as pilot suffered heart attack.

Brief description of event:

The pilot of a Garuda Indonesia Airlines Boeing 737 collapsed at the controls, minutes after take-off from Pontianak, on the island of Borneo, forcing his copilot to take the controls and make an unassisted landing back at the airport in Borneo, according to local news reports. None of the 107 passengers on board was hurt.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

7

1

-

-

6

-

Passengers:

107

-

-

-

107

-

Aircraft total:

114

1

-

-

113

-

Ground:

-

-

-

-

-

-

Resources & references:

 

 

27061982.jpg

Date of event:

23 October 2004.

Location & aircraft:

New Zealand, Omihi Station, North Canterbury. Cessna A188 Agwagon (ZK-CSM).

Human Factors:

The post-mortem report, when read in conjunction with the evidence gathered during the accident investigation, provides grounds to conclude that the pilot suffered a medical incapacitating cardiac event that rendered him unable to maintain control of his aircraft.Post-mortem examination found that the pilot had sustained fatal injuries associated with a high-energy impact. Also discovered was "profound pulmonary oedema and evidence of a component of chronic congestive heart failure". The pathologist explained in his report: "while the pulmonary oedema might in part or entirely represent neurogenic pulmonary oedema in response to head injury, the time course is very short. I prefer the interpretation that there has been an acute cardiac event, most likely cardiac arrhythmia, resulting in sudden onset (acute), severe congestive cardiac failure prior to impact. Such an event would likely render him incapable of control of the aircraft in the take off run".In light of the fact that no medical certificate record could be found for the periods of December 2002 to 11 June 2003 and December 2003 to 16 June 2004 it appears that the pilot may have operated his aircraft for hire and reward without a current Class 1 medical certificate for two periods of 6 months within the 2 years and 3 months preceding the accident.Although the pilot had a current medical certificate at the time of the accident, accurate medical assessment of the pilot for risk of an incapacitating cardiac event was not possible, as the pilot had declared on his medical certificate application that he was a non-smoker. The accurate assessment of pilot cardiovascular risk depends on complete information being made available to the CAA medical examiners. Whether or not an applicant for a CAA medical certificate smokes cigarettes is an important factor in the calculation of cardiovascular risk. When an applicant's cardiovascular risk exceeds a certain level further investigations, usually an exercise stress electrocardiogram (stress ECG), are undertaken to exclude the presence of reversible myocardial ischaemia. Had the pilot declared,at the time of his most recent medical certification application in June 2004, that he had continued smoking he would have been required to undertake a stress ECG. While it may not have been conclusive in predicting the risk of an in-flight incapacitation, a stress ECG may have identified significant cardiac disease.

Brief description of event:

The Civil Aviation Authority was notified of the accident at 1800 hours on Saturday 23 October 2004. The Transport Accident Investigation Commission was in turn notified shortly thereafter but declined to investigate. A CAA site investigation was commenced the next day. The pilot was conducting an agricultural operation engaged in spreading solid fertiliser in suspension with water. The pilot appeared to commence his take off normally and continue out of line of sight of the ground crew, who were alerted to the accident by smoke coming from the direction of the end of the sloping airstrip. The first persons on the scene found that the aircraft was on fire and could see no signs of life.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

-

-

-

-

-

-

Aircraft total:

1

1

-

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

 

Accident or Incident Report (New Zealand Civil Aviation Authority): Aircraft Accident Report 04/3396.

Date of event:

01 October 2003.

Location & aircraft:

Australia, 1 km WSW Mareeba Aerodrome, West of Cairns, QLD. PA-23-250 Aztec (VH-WAC).

Human Factors:

The reason for the loss of control could not be conclusively established, however the circumstances of the accident and the available evidence was consistent with pilot incapacitation associated with coronary artery disease. Post-mortem examination of the pilot, who held a valid medical certificate, identified significant narrowing of the coronary arteries.

Brief description of event:

The pilot, his wife and three children were conducting a private flight from Mareeba, to Roma, Queensland, in the Piper Aztec aircraft, registered VH-WAC. Witnesses reported that shortly after the aircraft took off from runway 28, it started to bank to the left. The left bank gradually steepened, after which the aircraft rapidly descended to the ground. Witnesses close to the aerodrome described engine noises consistent with normal operation. The aircraft was destroyed by impact forces and post-impact fire.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

4

1

-

-

-

-

Aircraft total:

5

5

-

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

1.

Accident or Incident Report (Australian Transport Safety Bureau,): Investigation Report BO/200304091 of 13 January 2005.

2.

News website (The Australia AAP): CASA takes health check.

3.

Media release (Australian Transport Safety Bureau MEDIA RELEASE): 2005/50, Pilot incapacitation led to fatal aircraft accident at Mareeba (13 January 2005).

Date of event:

30 April 2000.

Location & aircraft:

New Zealand, Napier. Bantam microlight (ZK-TKF).

Human Factors:

Post-mortem examination determined that death was due to ischaemic heart disease.

Brief description of event:

The Bantam microlight was on a dual training exercise to the west of Napier. After practising forced landings, the pilot and instructor decided to return to Napier. On the return flight, the student noticed that the instructor appeared to be unconcious, and was unable to obtain a response from him. The student reported the situation to Napier Tower, and emergency services were called to meet the aircraft. The student landed the aircraft, and after examination by emergency services personnel, it was found that the instructor had died in flight.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

1

-

Passengers:

1

-

-

-

-

-

Aircraft total:

2

1

-

-

1

-

Ground:

-

-

-

-

-

-

Resources & references:

 

Accident or Incident Report (New Zealand Transport Accident Investigation Commi): TAIC Investigation 00-1180 (Report not published).

 

26091989.jpg

Date of event:

02 April 1999.

Location & aircraft:

New Zealand, Rowallan Forest, near Tuatapere, Southland. Aerospatiale AS 350B (ZK-HBH).

Human Factors:

The cause of the loss of control was not conclusively established, but the pilot's ability to control the helicopter may have been medically impaired by the sudden onset of a cardiac event.

Brief description of event:

On Good Friday the aircraft was on a charter flight from Clifden, carrying a hunting party into Fiordland when some loss of control occurred. The helicopter collided with trees and the ground in the Rowallan Forest, killing all five occupants.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

4

4

-

-

-

-

Aircraft total:

5

5

-

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

1.

Accident or Incident Report (New Zealand Transport Accident Investigation Commi): TAIC 99-003.

2.

Accident or Incident Report (New Zealand Civil Aviation Authority): Accident Brief 99/768.

 

 

Date of event:

26 April 1998.

Location & aircraft:

Australia, 16 km W Eucumbene, NSW. Cessna 210R (VH-IOR).

Human Factors:

The possibility of pilot incapacitation cannot be excluded as a contributing factor in the occurrence. The reported operation of the aircraft engine to the point of impact, together with the uncontrolled nature of the descent, indicates that there had been no effective response initiated to counter the rapid descent of the aircraft. Although this testing (stress electrocardiogram) did not return an abnormal result, post-mortem examination of the pilot did reveal that he was suffering severe coronary artery disease. The examining pathologist commented that the stress associated with operating the aircraft in difficult weather conditions could have precipitated a sudden deterioration in his cardiac condition, possibly resulting in a sudden medical incapacitation.

Brief description of event:

The planned route was over mountainous terrain, in adverse weather conditions, and at an altitude above the forecast freezing level. Moderate to severe turbulence had been forecast in the vicinity of the Snowy Mountain ranges and the meteorological conditions were conducive to the formation of mountain waves. At the time radar contact with the aircraft was lost, the pilot was attempting to climb the aircraft to an altitude of 10,000 ft and appeared to be flying it at a lower than normal climb speed. The reason for the observed loss of climb performance as the aircraft approached 9,000 ft could not be positively determined. The aircraft impacted the ground in an attitude consistent with a loss of control.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

5

5

-

-

-

-

Aircraft total:

5

6

-

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

 

Accident or Incident Report (Australian Transport Safety Bureau): ATSB 199801415.

 

 

01121984.jpg

Date of event:

06 June 2003.

Location & aircraft:

New Zealand, 1.2 nm shot of runway at Christchurch. Piper PA 31-350 Navajo Chieftain (ZK-NCA).

Human Factors:

Safety issues identified by the accident investigation included: The desirability of adoption of TAWS equipment for smaller IFR air transport aircraft; The need for VFR/IFR operators to have practical procedures for observing cellphone rules during flight; The need for pilots on single-pilot IFR operations to use optimum procedures during instrument approaches.Other matters inquired-upon during the subsequent coronial inquest included cardiovascular risk assessment, and the use of over-the-counter reading spectacles by pilots.

Brief description of event:

On Friday 6 June 2003, Air Adventures New Zealand Limited Piper PA 31-350 Navajo Chieftain aeroplane ZK-NCA, was on an air transport charter flight from Palmerston North to Christchurch with one pilot and 9 passengers. At 1907 it was on an instrument approach to Christchurch Aerodrome at night in instrument meteorological conditions when it descended below minimum altitude, in a position where reduced visibility prevented runway or approach lights from being seen, to collide with trees and terrain 1.2 nm short of the runway. The pilot and 7 passengers were killed, and 2 passengers received serious injury. The aircraft was destroyed.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

9

7

2

-

-

-

Aircraft total:

10

8

2

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

1.

Accident or Incident Report (New Zealand Transport Accident Investigation Commi): TAIC report 03-004.

2.

Accident or Incident Report (Christchurch Coroner's Court inquest): .

 

 

Date of event:

24 November 2000.

Location & aircraft:

Australia, 53 km NE Oakey, Aero, Queensland (QLD). Amateur Built Aircraft RV-6A (ZK-VBC).

Human Factors:

Specialist medical opinion was that the possibility of the pilot suffering a heart attack induced by high stress levels after the propeller failed could not be excluded.

Brief description of event:

The owner/builder of the the Vans RV-6A aircraft was conducting a flight from Townsville to Toowoomba. The aircraft departed Townsville at 0846 local time. The pilot subsequently contacted Oakey Approach at 1324, and the aircraft was identified on radar at 3500 feet. The pilot was instructed to maintain that altitude. When the aircraft was about 26 nautical miles from Toowoomba, the pilot transmitted a mayday distress message stating that the aircraft's engine had failed. A short time later he reported that a propeller blade had failed. No further transmissions were heard from the aircraft. About 30 minutes later, a searching helicopter located the wreckage in a flat clear area amongst hilly, tree covered terrain.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

-

-

-

-

-

-

Aircraft total:

1

1

-

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

 

Accident or Incident Report (Australian Transport Safety Bureau): Occurrence Brief 200005572 dated 22 June 2002.

07032007.jpg

Date of event:

12 September 2000.

Location & aircraft:

Australia, 9 km NW Inverell Aero, NSW. Cessna A152 (VH-ADU).

Human Factors:

The reason for the loss of control of the aircraft could not be positively established. Pilot incapacitation leading to a loss of control was a likely factor. Due to his medical condition, the pilot might have suffered a coughing fit in flight that impaired his ability to fly the aircraft. Alternatively, the concentration of doxylamine in his system might have led to drowsiness or even disorientation associated with aerobatic manoeuvres. Other possible reasons for a loss of control of the aircraft include pilot incapacitation for some other reason, and loss of consciousness, or partial loss of consciousness, due to the onset of g loadings when conducting an aerobatic manoeuvre.

Brief description of event:

The Cessna A152 Aerobat aircraft was engaged on an aerobatics training flight with the pilot the sole occupant of the aircraft. The pilot was practising for an aerobatic competition and had been having problems conducting stall turn manoeuvres. Before the accident flight, the pilot had completed an aerobatic practice flight with an instructor. The pilot then decided to fly a solo flight to practise stall turns without the effect of a second person's weight on aircraft performance in aerobatic manoeuvres. He then intended to practise his full aerobatic sequence, which the instructor later stated was well within the pilot's capabilities. Between flights the pilot refuelled the aircraft and consumed a bottle of soft drink. After takeoff for the solo flight, the pilot discussed with his instructor by radio, his intentions for the flight and the criticisms of his manoeuvres during the dual flight. The instructor later reported that during the discussion, everything concerning the pilot and the aircraft seemed normal. Witnesses some distance away heard the aircraft fly over. They later heard a thump and noticed smoke rising from the same direction as the source of the sound. There were no witnesses to the impact.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

-

-

-

-

-

-

Aircraft total:

1

1

-

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

 

Accident or Incident Report (Australian Transport Safety Bureau): ATSB 200004191.

Date of event:

02 April 1999.

Location & aircraft:

New Zealand, Rowallan Forest. Aerospatiale AS 350B (ZK-HBH).

Human Factors:

The cause of the loss of control was not conclusively established, but the pilot's ability to control the helicopter may have been medically impaired by the sudden onset of a cardiac event.

Brief description of event:

On Good Friday the aircraft was on a charter flight from Clifden, carrying a hunting party into Fiordland when some loss of control occurred. The helicopter collided with trees and the ground in the Rowallan Forest, killing all 5 occupants.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

4

4

-

-

-

-

Aircraft total:

5

5

-

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

1.

Accident or Incident Report (New Zealand Transport Accident Investigation Commi): TAIC 99-003..

2.

Aircraft accident website (PlaneCrashInfo.com): Accident details.

Date of event:

04 January 1999.

Location & aircraft:

New Zealand, Maramarua. Schempp-Hirth Ventus B/16.6 (ZK-GTR).

Human Factors:

A post-mortem examination of the pilot found severe coronary artery disease, which probably resulted in an in-flight incapacitation and loss of control. No indication was found of any pre-impact aircraft defect.

Brief description of event:

The glider was on a club-contest task that comprised two laps of a triangular course originating from, and terminating at, Drury. On the fourth leg, the glider was in company with two other aircraft, but near Maramarua the 59 year old male pilot reported that he was going to land. He did not, however, give any reason for his intention to land. A ground witness observed the glider pitch up from level flight and enter a steep nose-down spiral from which it did not recover before striking the ground.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

-

-

-

-

-

-

Aircraft total:

1

1

-

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

 

Accident or Incident Report (New Zealand Civil Aviation Authority): Accident Brief 99/1.

07032007a.jpg

Date of event:

24 August 1996.

Location & aircraft:

New Zealand, 8 km South of New Plymouth. Jodel D11 (ZK-EJP).

Human Factors:

The pilot had a known medical deficiency, evidenced by severe coronary artery disease, which invalidated his CAA Medical Certificate. Pilot impairment or distraction as a result of the deficiency was a possible contributory factor in the accident.

Brief description of event:

At about 1040 hours, at the conclusion of a local flight, the aircraft made an approach and go-around over the farm airstrip where it was based. The aircraft subsequently flew downward at a lower height than usual and was seen to bank steeply to the left in an apparent attempt to land on the airstrip or in adjacent paddocks. It levelled momentarily then rolled to the right, descended rapidly, and struck the hillside. The pilot sustained fatal injuries on impact. The injured passenger escaped from the burning wreckage and was assisted to safety by farm workers who had observed the accident.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

1

-

1

-

-

-

Aircraft total:

2

1

1

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

 

Accident or Incident Report (New Zealand Transport Accident Investigation Commi): TAIC 96-017.

 

Crew incapacitation - Busselton Aerodrome, WA, 13 February 2007, VH-SQF, Beech Aircraft Corporation 58 Baron

Adjust font size:

Occurrence Details
Occurrence Number: 200700765 Location: Busselton
Occurrence Date: 13 February 2007 State: WA
Occurrence Time: 1830 WST Highest Injury Level: None
Occurrence Category: Serious Incident Investigation Type: Occurrence Investigation
Occurrence Class: Operational Investigation Status: Completed
Occurrence Type: Significant Event Release Date: 15 April 2008

Aircraft Details
Aircraft Manufacturer: Beech Aircraft Corp Aircraft Model: 58
Aircraft Registration: VH-SQF Serial Number: TH-1560
Type of Operation: Flying Training
Damage to Aircraft: Nil
Departure Point: Jandakot, WA Departure Time: nk
Destination: Jandakot, WA
Crew Details: Role Class of Licence Hours on Type Hours Total
  Pilot-in-Command Commercial nk nk

On 13 February 2007 at 1830 Western Daylight-saving Time, a Beech Aircraft Corporation 58 Baron was being used for instrument flight training. The flight was being conducted under the visual flight rules (VFR), with the pilot flying, simulating flight under the instrument flight rules (IFR). A second pilot was on board to act as a safety pilot and to lookout for other aircraft. During the conduct of a Busselton, WA non-direction beacon (NDB) approach, the pilot flying became incapacitated and the safety pilot assumed control of the Baron. The safety pilot landed the aircraft on runway 21 at Busselton and the incapacitated pilot received treatment from attending ambulance officers. The pilot was a 22 year old, Grade 2 flying instructor, with 1,422 hours total flying experience. Following a check by a Designated Aviation Medical Examiner and 4 days rest, the pilot was approved to return to work.

The pilot stated that about 12 months previously, he had experienced a similar event and after a number of medical tests that did not find any physical problems, it was established that he had been dehydrated.

Initial medical testing following the event found no health problems and it is possible that the pilot's sustenance and fluid intake was inadequate. The pilot changed his eating and fluid intake habits, including using a water bottle while flying.

The Civil Aviation Safety Authority (CASA) Aviation Medicine section subsequently suspended the pilot's Class 1 medical and requested the pilot undergo further testing. That testing found that the pilot had epilepsy and CASA revoked the pilot's medical.

Date of event:

24 August 1996.

Location & aircraft:

New Zealand, Near New Plymouth. Jodel D11 (ZK-EJP).

Human Factors:

Possible incapacitation of pilot (coronary artery disease) contributing to inadvertent stall.

Brief description of event:

At about 1040 hours, on Saturday 24 August 1996, at the conclusion of a local flight, Jodel D11 ZK-EJP made an approach and go-around over the farm airstrip where it was based. The aircraft subsequently flew downward at a lower height than usual and was seen to bank steeply to the left in an apparent attempt to land on the airstrip or in adjacent paddocks. It levelled momentarily then rolled to the right, descended rapidly, and struck the hillside. The pilot sustained fatal injuries on impact. The injured passenger escaped from the burning wreckage and was assisted to safety by farm workers who had observed the accident.A loss of power due to an undetermined engine malfunction and incapacitation of the pilot may have contributed to the inadvertent stall. Conditions were conducive to carburettor icing. The pilot was probably medically unfit to fly. The pilot had a known medical deficiency, evidenced by severe coronary artery disease, which invalidated his CAA Medical Certificate. Pilot impairment or distraction as a result of the deficiency was a possible contributory factor in the accident.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

1

-

1

-

-

-

Aircraft total:

2

1

1

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

 

Accident or Incident Report (New Zealand Transport Accident Investigation Commi): TAIC 96-017.

 

 

Date of event:

01 November 1995.

Location & aircraft:

New Zealand, 18 nm North of Wairoa. Fletcher FU24-954 (ZK-EUG).

Human Factors:

In-flight incapacitation of the pilot was identified as the probable cause. [As a result of the investigation of this and a previous similar accident (see TAIC Report 95-010)] a safety recommendation pertaining to medical advice was made to the Aviation Industry Association.

Brief description of event:

The aircraft collided with the terrain during topdressing operations on Rongoio Station, 18 nm north of Wairoa. An intense fire ensued and the pilot lost his life in the accident.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

-

-

-

-

-

-

Aircraft total:

1

1

-

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

 

Accident or Incident Report (New Zealand Transport Accident Investigation Commi): TAIC 95-018.

 

 

Date of event:

07 June 1995.

Location & aircraft:

New Zealand, Near Lake Grassmere. Fletcher FU 24A-954 (ZK-EMU).

Human Factors:

Pilot incapacitation was the probable cause of this accident. The incapacitation was sufficient to cause loss of situational awareness and loss of aircraft control at a critical phase of flight. (See also similar accident at TAIC Report 95-018)

Brief description of event:

At approximately 1100 hours on Wednesday 7 June 1995 a Fletcher FU24A-954, ZK-EMU, collided with the face of a hill during a sowing run and caught fire. The aircraft was destroyed, and the pilot lost his life in the accident. Pilot incapacitation was the probable cause of this accident. The incapacitation was sufficient to cause loss of situational awareness and loss of aircraft control at a critical phase of flight. No safety issues were identified as a result of this investigation.[A subsequent investigation 95-018 resulted in reference to this accident 95-010, and a recommendation 007/96]

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

-

-

-

-

-

-

Aircraft total:

1

1

-

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

1.

Accident or Incident Report (New Zealand Transport Accident Investigation Commi): TAIC 95-010.

2.

Accident or Incident Report (New Zealand Transport Accident Investigation Commi): TAIC 95-018 (Mentioned in the accident report above).

 

Date of event:

14 April 1991.

Location & aircraft:

New Zealand, Near Warkworth. Rotec Rally 3 Microlight (ZK-WAC).

Human Factors:

The loss of control which led to the accident was probably caused by medical incapacitation of the pilot during the flight. The pilot suffered from a medical condition which could cause incapacitation. The pilot's medical condition was probably discoverable by medical examination. The prescribed medical certification process did not result in detection of the pilot's medical condition. The pathological report disclosed that the pilot had severe coronary artery disease. The pilot was overweight and being treated for high blood pressure.

Brief description of event:

Possible in-flight incapacitation of the pilot of Rotec Rally 3, microlight aircraft ZK-WAC near Warkworth on 14 April 1991. The safety issues discussed are the maintenance of a minimum fabric strength on microlight aircraft and measures for improving the monitoring of microlight pilots' fitness to fly.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

1

1

-

-

-

-

Aircraft total:

2

2

-

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

 

Accident or Incident Report (New Zealand Transport Accident Investigation Commi): TAIC 91-011.

Date of event:

12 June 1988.

Location & aircraft:

New Zealand, In the sea near Beachlands, North Auckland Province. Piper PA28-235 Cherokee (ZK-DBO).

Human Factors:

The probable cause of the accident could not be determined although there was significant circumstantial evidence of a loss of control following the sudden incapacitation of one of the front seat occupants. Post mortem examination of the pilot's coronary arteries revealed severe narrowing due to atherosclerosis involving the left anterior descending artery and a diagonal branch of the left anterior descending artery. There was approaching severe disease involving the left circumflex artery and moderate disease involving the right coronary artery. No acute coronary lesions were evident and sections of the myocardium showed no scarring.

Brief description of event:

During a scenic flight over Auckland City at night, the pilot turned the aircraft around and headed it, unexpectedly, back towards the departure aerodrome. A short time later the aircraft entered a steep dive which terminated in the sea.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

2

2

-

-

-

-

Aircraft total:

3

3

-

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

 

Accident or Incident Report (New Zealand Office of Air Accidents Investigation,): OAAI 88-047

 

 

Date of event:

31 March 1975.

Location & aircraft:

New Zealand, Waimate, South Canterbury. DH82A Tiger MOth (ZK-AKH).

Human Factors:

The accident resulted from a stall and ensuing steep dive from which recovery was not effected before the aircraft struck the ground. Both incurrence of that stall and absence of visible indications of an attempt to recover from that dive by a pilot of the deceased'd considerable experience strongly suggests that he suffered some form of physical incapacitation productive of loss of control.Autopsy established that the pilot had died in the fire and had been in good health prior to the accident, with the exception of a moderately advanced calcific stenosis of the aortic valve of the heart. That heart condition had been recognised during the pilot's medical examination for private pilot licence renewals from 1968 onward but evaluation by the civil aviation medical staff, aided by routine electrocardiogram readings, resulted in opinion that the pilot's heart condition provided no bar to his fitness to fly as a private pilot.

Brief description of event:

During formation flying, with another Tiger Moth, the aircraft was seen to drop slowly astern and to lose height. The aircraft subsequently stalled and entered a steep dive from which it did not recover.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

-

-

-

-

-

-

Aircraft total:

1

1

-

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

 

Accident or Incident Report (New Zealand Office of Air Accidents Investigation,): OAAI 75-047.

 

 

Date of event:

02 September 1974.

Location & aircraft:

New Zealand, Whitianga. Piper PA31 Navajo Chieftan (N54357).

Human Factors:

Autopsy of the pilot revealed acute interstitial myocarditis conducive toward destruction of the cardiac muscle fibres. It is a silent disease prone to cause irregularities in cardiac rhythm, fainting, and occasionally sudden death. The possibility that the pilot had become physically incapacitated to some degree could not be entirely discounted. Probable cause: The pilot was unable to cope with an in-flight emergency initiated by a powerplant malfunction and compounded by poor weather conditions, as a consequence of which the aircraft stalled and the pilot lost control at too low an altitude to effect recovery.

Brief description of event:

Delivery flight from US-based manufacturer to British owner. Pilot stopping-over in New Zealand for several days. During take-off, for a flight from Whitianga to Auckland, the aircraft suffered an engine failure and impacted vertically behind the beach at Whitianga.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

1

1

-

-

-

-

Aircraft total:

2

2

-

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

 

Accident or Incident Report (New Zealand Office of Air Accidents Investigation,): OAAI 74-097.

Date of event:

30 August 1972.

Location & aircraft:

New Zealand, Fairlie. Fletcher FU24 (ZK-CFQ).

Human Factors:

Autopsy disclosed a coronary occlusion due to arteriosclerotic heart disease. It was felt that there were two possible causes: a heart attack prior to or at the time of impact; and traumatic asphyxia.The accident was caused by loss of control (precipitated by circumstances undetermined but in which the consequences of a coronary occlusion cannot be excluded) while the aircraft was in a steeply banked attitude close to the ground.

Brief description of event:

The aircraft was ngaged in an agricultural aviation operation and was seen making a sowing run above a valley floor. A few seconds later flames and smoke were seen in the area where the aircraft had been working. Shortly afterward, the aircraft was found burning on a hillside and its pilot apparently dead.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

-

-

-

-

-

-

Aircraft total:

1

1

-

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

 

Accident or Incident Report (New Zealand Office of Air Accidents Investigation,): OAAI 72-077.

 

Date of event:

24 December 1970.

Location & aircraft:

New Zealand, Waitemata Harbour. Grumman G44 Widgeon (ZK-BAY).

Human Factors:

The accident was caused by loss of control (resulting from an undetermined circumstance) while the aircraft was in a steeply banked turn and at a height below regulation minimum safe height, which made recovery impossible before the aircraft struck the sea.Autopsy revealed 50% atheromatous occlusion of the left cronary artery, but no evidence of complete occlusion. Whether or not control loss resulted from an attack of angina pectoris brought on by stress must accordingly remain a matter for conjecture and cannot be eliminated entirely as a possible contributory factor.

Brief description of event:

The aircraft was carrying a TV news team to photograph a launch burning on the harbour near Brown's Island. It alighted near the launch and then taxied around it several times whil photographs were taken, then took off and made a low pass around the vessel while further pictures were taken. It was then seen to climb away and return to make a steep right-hand turn around the launch. During that turn, the aircraft's nose was observed to drop suddenly and the aircraft dived almost vertically into the sea. All four occupants lost their lives.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

3

3

-

-

-

-

Aircraft total:

4

4

-

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

 

Accident or Incident Report (New Zealand Office of Air Accidents Investigation,): OAAI 2185.

 

 

Date of event:

06 August 1966.

Location & aircraft:

Japan, Haneda International Airport, Tokyo. DC-8, (PH-DCD).

Human Factors:

Pilot-in-command suddenly collapsed due to coronary arteriosclerosis; co-pilot carried out landing. Coronary occlusion established on autopsy.

Brief description of event:

PIC (age 48) collapsed while making visual final approach after trans-Pacific flight, but was restrained by shoulder harness. Flight engineer called to COP, who took over at approximately 150 feet altitude to left of centreline of runway, executed overshoot and climbed to 3000 feet, where he changed to LH seat. After briefing crew, landed aircraft. PIC given all first-aid measures by cabin staff but dead on landing. No accident resulted.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

-

1

-

-

-

-

Passengers:

-

-

-

-

-

-

Aircraft total:

-

1

-

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

1.

Aviation newsletter (International Civil Aviation Organization: Aircraf): No 16, Vol II, 1968 (Circular 82-AN/69): 85-86.

2.

Journal article (Aerospace Medicine): Buley LE. Incidence, causes and results of airline pilot incapacitation while on duty. Aerospace Medicine. 40:64-70, 1969.

3.

Book (Airlife's register of aircraft accidents): Airlife's register of aircraft accidents, Compiled by A Bordoni, Airlife Publishing UK, 1997 (Page 110).

Date of event:

21 October 1963.

Location & aircraft:

New Zealand, Owhakatoro Station, Taneatua, Bay of Plenty. Fletcher FU-24 (ZK-BIN).

Human Factors:

For reasons which have not been determined, the aircraft struck the ground in the course of a steep diving turn. Loss of control consequent upon physical incapacitation of the pilot appears to be the most likely cause. Investigation made into the pilot's background pointed toward a recent state of nervous tension, and it was learned that he had confided to a few intimate friends that he "was not happy about his heart". Post mortem examination revealed no evidence of CO contamination, and there appeared to be no abnormality which could have caused sudden incapacity.

Brief description of event:

In the course of a topdressing operation the aircraft was seen to make a steep diving turn to starboard which took it into the ground. Fire did not occur. The pilot was killed instantly.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

-

-

-

-

-

-

Aircraft total:

1

1

-

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

 

Accident or Incident Report (New Zealand Accidents Investigation Branch, Air De): AIB 25/3/1361.

 

 

Date of event:

21 October 1963.

Location & aircraft:

New Zealand, Owhakatoro Station, Taneatua, Bay of Plenty. Fletcher FU-24 (ZK-BIN).

Human Factors:

For reasons which have not been determined, the aircraft struck the ground in the course of a steep diving turn. Loss of control consequent upon physical incapacitation of the pilot appears to be the most likely cause. Investigation made into the pilot's background pointed toward a recent state of nervous tension, and it was learned that he had confided to a few intimate friends that he "was not happy about his heart". Post mortem examination revealed no evidence of CO contamination, and there appeared to be no abnormality which could have caused sudden incapacity.

Brief description of event:

In the course of a topdressing operation the aircraft was seen to make a steep diving turn to starboard which took it into the ground. Fire did not occur. The pilot was killed instantly.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

-

-

-

-

-

-

Aircraft total:

1

1

-

-

-

-

Ground:

-

-

-

-

-

-

Resources & references:

 

Accident or Incident Report (New Zealand Accidents Investigation Branch, Air De): AIB 25/3/1361.

 

 

CEREBROVASCULAR)

 

 

 

 

 

  Date of event:

 

 

 

 

 

 

12 August 2005.

Location & aircraft:

Australia, En-route (Auckland - Melbourne). Boeing 767-338 ER (VH-OGP).

Human Factors:

The pilot reported a history of stress-related difficulties over several years. He had received treatment for anxiety through a combination of a stress management and medication, in the form of a selective serotonin reuptake inhibitor (SSRI). The pilot was also being treated for hypertension. It is possible that the incapacitation of the PIC was related to an anxiety reaction precipitated by a combination of factors including low blood pressure due to hypertension medication, fatigue and a head cold.The CASA policy of granting medical certification to some private and commercial pilots and air traffic controllers who are taking medication such as SSRIs differs from that of most other Civil Aviation Authorities. However, the approach taken by CASA is in line with that recommended by the Aerospace Medical Association. In 2005, CASA published a safety evaluation of the policy. The report concluded that the policy was appropriate and that there were no safety concerns relating to the practice.

Brief description of event:

The Boeing 767 aircraft was conducting an international passenger flight from Auckland to Melbourne. During cruise the pilot in command (PIC) felt increasingly fatigued, and while outside the flight deck his condition deteriorated. He felt shaky and nauseous, and had pain in the back of his head and neck. He was administered oxygen by a member of the cabin crew. The PIC was relieved of duty and the flight continued to the destination with the copilot at the controls. An alert phase was declared. After landing the PIC was taken to hospital for observation. Subsequent tests proved inconclusive, but no evidence was found of a heart-related problem.

 

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

9

-

-

-

8

-

Passengers:

177

-

-

-

177

-

Aircraft total:

186

-

-

-

185

-

Ground:

-

-

-

-

-

-

Resources & references:

(Situational Awareness, Disorientation)

 

 

Date:

11 DEC 1998

Time:

19:10

Type:

Airbus A310-204

Operator:

Thai Airways International

Registration:

HS-TIA

C/n / msn:

415

First flight:

1986-03-03 00:00:00

Engines:

2 General Electric CF6-80C2A2

Crew:

Fatalities: 11 / Occupants: 14

Passengers:

Fatalities: 90 / Occupants: 132

Total:

Fatalities: 101 / Occupants: 146

Airplane damage:

Written off

Location:

ca 4 km SW of Surat Thani (Thailand)

Phase:

Approach

Nature:

Domestic Scheduled Passenger

Departure airport:

Bangkok-Don Muang International Airport (BKK/VTBD), Thailand

Destination airport:

Surat Thani Airport (URT/VTSB), Thailand

Flightnumber:

261

Narrative:
Thai Flight 261 left Bangkok at 17:40 for a 1 55min flight to Surat Thani, where its was due to land at 18:55. Weather in the Surat Thani area was poor with limited visibility and heavy rainfall. The Airbus was on it's third landing attempt when it stalled and crashed about three to five km southwest of the airport in a rubber plantation.

PROBABLE CAUSE: Spatial disorientation when the nose pitched up sharply during a night time approach in stormy weather.

Sources:
Mark Stephenson, Mike Robinson

Sample newspaper article from Newspaperarchive.com
ATC transcript Thai Airways Flight 261
Bangkok Post May 4, 2001 - Pilot error, bad weather to blame
Bangkok Post Thursday 29 November 2001 - Officials want Airbus firm to share blame

Statistics

4th loss of a Airbus A.310
2nd worst accident involving a Airbus A.310 (at the time)
4th worst accident involving a Airbus A.310 (currently)
2nd worst accident in Thailand (at the time)
2nd worst accident in Thailand (currently)

figures explained

 

Date:

09 FEB 1982

Time:

08:44

Type:

McDonnell Douglas DC-8-61

Operator:

Japan Air Lines - JAL

Registration:

JA8061

C/n / msn:

45889/291

First flight:

1967

Engines:

4 Pratt & Whitney JT3D-

Crew:

Fatalities: 0 / Occupants: 8

Passengers:

Fatalities: 24 / Occupants: 166

Total:

Fatalities: 24 / Occupants: 174

Airplane damage:

Written off

Location:

Tokyo-Haneda Airport (HND) (Japan)

Phase:

Approach

Nature:

Domestic Scheduled Passenger

Departure airport:

Fukuoka Airport (FUK/RJFF), Japan

Destination airport:

Tokyo-Haneda Airport (HND/RJTT), Japan

Flightnumber:

350

Narrative:
JAL Flight 350 took off from Fukuoka (FUK) runway 16 at 07:34 for a regular flight to Tokyo-Haneda (HND). The aircraft climbed to the cruising altitude of FL290. At 08:22 the crew started their descend to FL160. After reaching that altitude, they were cleared to descend down to 3000 feet. The aircraft was cleared for a runway 33R ILS approach and 5deg of flaps were selected at 08:35, followed by 25 degrees of flaps one minute later. The landing gear was lowered at 08:39 and 50 degrees of flaps were selected two minutes after that. At 08:42 the aircraft descended through 1000 feet at an airspeed of 135 knots with wind from a direction of 360deg at 20 knots. The co-pilot called out "500 feet" at 08:43:25 but the captain did not make the "stabilized" call-out as specified by JAL operational regulations. The airspeed decreased to 133 knots as the aircraft descended through 300 feet at 08:43:50 and the co-pilot warned the captain that the aircraft was approaching the decision height. At 08:43:56 the radio altimeter warning sounded, followed by the flight engineer calling out "200 feet", which was the decision height, three seconds later . At 08:44:01 the aircraft descended through 164 feet at 130KIAS. At that moment the captain cancelled autopilot, pushed his controls forward and retarded the throttles to idle. The co-pilot tried to regain control but the aircraft crashed into the shallow water of Tokyo Bay, 510m short of the runway 33R threshold. The nose and the right hand wing separated from the fuselage. The captain had recently suffered a psychosomatic disorder; preliminary reports suggested that the captain experienced some form of a mental abberation. He had been off duty from November 1980 to November 1981 for these reasons.

Sources:
Aircraft Accident in Japan by SAKUMA Mitsuo

Date of event:

24 August 1996.

Location & aircraft:

New Zealand, 8 km south of New Plymouth. Jodel D.11 (ZK-EJP).

Human Factors:

The pilot was probably medically unfit to fly. The pilot had a known medical deficiency, evidenced by severe coronary artery disease, which invalidated his CAA Medical Certificate. Pilot impairment or distraction as a result of the deficiency was a possible contributory factor in the accident.

Brief description of event:

At about 1040 hours, on Saturday 24 August 1996, at the conclusion of a local flight, Jodel D11 ZK-EJP made an approach and go-around over the farm airstrip where it was based. The aircraft subsequently flew downwind at a lower height than usual and was seen to bank steeply to the left in an apparent attempt to land on the airstrip or in adjacent paddocks. It levelled momentarily, then rolled to the right, descended rapidly, and struck the hillside. The pilot sustained fatal injuries on impact. The injured passenger escaped from the burning wreckage and was assisted to safety by farm workers who had observed the accident. A loss of power due to an undetermined engine malfunction and incapacitation of the pilot may have contributed to the inadvertent stall. Conditions were conducive to carburettor icing.

Injury profile:

 

Total on board

Fatal injuries

Serious injuries

Minor injuries

Uninjured

Injury severity not known

Crew:

1

1

-

-

-

-

Passengers:

1

-

1

-

-

-

Aircraft total: