Friday, May 16, 2014

ABC 6 INVESTIGATORS: State Says Federal Aviation Administration Dropped Ball In Deadly Plane Crash: Cessna U206C Stationair, Eugene Damschroder, N29122; accident occurred June 08, 2008 in Fremont, Ohio

COLUMBUS -- It remains one of the deadliest plane crashes in Ohio history.

Six people died when a single-engine Cessna crashed in a field in
Fremont. The pilot - an 86-year-old former Ohio state lawmaker - was
selling airplane rides at a small airport he owned. 

ABC 6 Investigators will show you why this deadly accident should
have never happened. And how the federal agency that oversees air travel put Ohioans at risk on the ground.


And jumping for joy.

The last video images of four-year-old Emily Gerwin. Just 30
minutes after takeoff, the plane she was riding in crashed in a field
less than one football field shy of hitting several homes. 

All six people aboard, including Emily and her mother died, on the

The National Transportation Safety Board blamed the accident on
three factors:

Investigators say the pilot, 86-year-old Gene Damschroder - failed
to maintain control of the airplane, which resulted in the aircraft
stalling. The former Ohio state lawmaker, according to NTSB
reports, also  used poor judgment in continuing to fly with severe
visual deficiency. Damschroder suffered from macular degeneration.

The other contributing factor? A former FAA aviation medical
examiner, and Ohio emergency room doctor. The agency says Dr. Jerome McTague "failed to accurately assess and report" Damschroder's failing eyesight. At the time of the crash, records show that Damschroder was legally blind.

The accident happened June 8, 2008. ABC 6 Investigators learned
the State Medical Board of Ohio didn't learn about it until two years
later when a staff member read about it in the Toledo Blade newspaper.

Long after lawsuits were filed, and the FAA terminated Dr. McTague as an aviation medical examiner.

The FAA declined to be interviewed on camera for this investigation.

A spokesperson told ABC 6 Investigators it's not required to contact a state medical board regarding its doctors. But "under certain circumstances involving misconduct such a report might be

The Executive Director of the State Medical Board of Ohio says this
 was one of those circumstances.

"What if he's (Dr. McTague) doing physicals for athletes? What if
he's doing it for student athletes? And does it in the manner he's doing
 these and there's a heart murmur or heart condition that they're
suppose to be able to detect when doing these sort of examinations and  the kid collapses on the floor?"

What we do know is this:

2003 and 2007 - FAA reversed Dr. McTague's decision to clear two
pilots to fly based on overlooked medical conditions.

April 2008 - FAA noted significant errors in one of Dr. McTague's

May 1 2008 - FAA reported Dr. McTague cleared some pilots to fly
who were hypertensive.

 May 6 2008 - FAA discovered "significant aerospace medical
certification errors on airmen" Dr. McTague examined. He was grounded as  an FAA aviation medical examiner.

One month later - the Fremont plane crash.

ABC 6 Chief Investigator asked Haslam "do you believe the FAA
dropped the ball?" "Absolutely. Absolutely," says Haslam.

 "If we would have been contacted there's a good chance that this
particular pilot may not have had the opportunity to fly that plane and
cause that accident that caused those six deaths that day."

The FAA says "all of our records indicate Gene Damschroder was
reported to have vision that was correctable to 20/20." The agency says Damschroder also withheld medial information about his failing eyesight.

During his ten years with the FAA, Dr. McTague did 1,036 airmen
physicals. Following the Fremont crash, the agency reviewed his records
and uncovered "serious concerns" with 102 cases that required action.

Information Haslam says FAA should have shared. "We could have
checked it out and made certain that he was practicing medicine to the
standards that Ohio demands."

In February, following a lengthy investigation of its own, the
Medical Board took action. Dr. Jerome McTague is banned from practicing medicine for a minimum of two years. Melinda Snyder, a lawyer with Ohio
Attorney General's Office told the Board "Dr. McTague certified a
legally blind man to fly an airplane. Maybe he was sloppy. Maybe he
missed the red flags. Maybe he didn't do the examination."

Dr. McTague received his Ohio medical license in 1992. His record
free of any other complaints or disciplinary action. Unlike his years
with the FAA.

"He failed to be the gatekeeper," says Haslam. "He failed to
prevent this individual who should not have been flying from flying and
ultimately that decision helped lead to six deaths."

Between 2011 and 2013, FAA aviation medical examiners cleared about
 1.1 million pilots to fly. During that time, the agency reversed nearly
 400 cases and grounded pilots for medical reasons. Six doctors were
terminated for "poor performance."

Not once, did the FAA notify any state medical boards.


NTSB Identification: CHI08FA156 
 14 CFR Part 91: General Aviation
Accident occurred Sunday, June 08, 2008 in Fremont, OH
Probable Cause Approval Date: 04/15/2010
Aircraft: CESSNA U206C, registration: N29122
Injuries: 6 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On the day of the accident, the 86-year-old accident pilot was providing rides in his single-engine, six-seat airplane at the airport that he owned and managed. Passengers purchased tickets for the rides in the airport office. The rides were given concurrently with a Lions Club International charitable “fly-in breakfast” at the airport, which had been advertised in the local newspaper. According to a representative of the Lions Club, the air rides were a separate activity, and the money collected for the air ride tickets was not given to the charity (evidence indicates that the pilot retained the money). The accident flight was the fifth or sixth airplane ride the pilot gave that day. Videotapes of previous flights and of the beginning of the accident flight indicated that the pilot was performing nonstandard takeoffs. Rather than beginning a normal climb after lifting off from the ground, the pilot would maintain an altitude just above treetop level until reaching the departure end of the runway, at which point he would initiate a steep pitch-up maneuver followed by a pushover maneuver. Also, a witness, who was a pilot, reported that the accident pilot commonly performed a nonstandard maneuver called a “buttonhook turn” to align the airplane with final approach for landing. The maneuver involved flying the airplane at an altitude of about 300 feet above ground level perpendicular to the final approach course and then executing a 270-degree turn to the final approach. The witness stated that he observed the pilot perform this maneuver during one of the passenger-carrying flights preceding the accident flight.

About 30 minutes after the airplane departed on the accident flight, witnesses observed it returning to the airport. Witnesses near the accident site reported that the airplane was flying at a low altitude toward the runway when it banked, descended, and impacted the ground. One witness stated that the airplane “appeared to be flying very slow, almost on the edge of a stall.” This witness heard the engine “throttle up” and observed the airplane stall, with the left wing “dipping,” and then descend below the tree line.

The accident site was about 0.75 mile east of the approach end of runway 27. Ground scarring and wreckage distribution covered a relatively small area, consistent with an accident due to an aerodynamic stall. Examination of the airplane revealed no mechanical anomalies that would have precluded normal operation. During a test cell run, the airplane’s engine performed within the manufacturer’s specifications.

Review of the pilot’s personal medical records indicated that he had been treated for age-related macular degeneration in both eyes for over 2 years. About 3 weeks before the accident, his distant visual acuity without correction was recorded as 20/200 for each eye. On at least two occasions, the pilot’s retinal specialist advised him not to drive. However, the pilot continued to drive and was involved in a traffic accident, in which he turned in front of an oncoming vehicle, 10 days before the aircraft accident. The pilot’s visual deficiency would have made it difficult for him to decipher the readings on cockpit instruments and to distinguish objects on the ground. This lack of visual acuity increased the likelihood that the pilot would fly at an inappropriate speed or altitude, thus increasing the chances of a stall.

About 1 year before the accident, the pilot applied for a Federal Aviation Administration (FAA) Airman Medical Certificate and provided false information about his eye condition (he did not report his visits to the retinal specialist). Even so, the pilot’s visual deficiency, given its severity, should have been detectable during the vision examinations required before issuance of such an Airman Medical Certificate. However, the pilot's aviation medical examiner (AME) reported normal eye test results, including 20/20 uncorrected vision, and issued the pilot a second-class medical certificate. About 7 months after the accident, the FAA decertified the AME for improper issuance of medical certificates.

The pilot’s autopsy noted severe coronary artery disease, which could have increased the likelihood of a heart attack or abnormal heart rhythm, resulting in impairment or incapacitation. There was no evidence of such an event, but no such evidence would necessarily be expected if death occurred within a few minutes to an hour of the impairment or incapacitation. The pilot’s personal medical records did not indicate coronary artery disease.

Either the pilot’s macular degeneration or his unrecognized coronary artery disease could have contributed to his failure to maintain control of the airplane. The NTSB could not conclusively determine whether either condition directly resulted in the accident. However, given the incompatibility of the pilot’s vision deficiency with safe motor vehicle operation and the pilot’s awareness of this, the pilot displayed extremely poor judgment in not only continuing to fly but in deciding to perform passenger-carrying flights. Furthermore, the pilot did not provide all of the required information on his most recent application for an Aviation Medical Certificate, and his AME did not adequately evaluate the pilot’s eyesight.

The passenger seated in the right front seat of the accident airplane was one of the accident pilot’s former student pilots who purchased a ride in the airplane. He held a private pilot certificate, but did not hold a current Airman Medical Certificate. If the accident pilot had become incapacitated, it is possible this passenger could have taken control of the airplane. There was insufficient evidence to determine whether or not this passenger was manipulating the flight controls when the accident occurred.

The local FAA flight standards district office had no records of any concerns raised or complaints about the pilot. Also, the FAA had no record of the pilot applying for a Letter of Authorization to conduct passenger-carrying flights for compensation or hire, which is required by 14 Code of Federal Regulations (CFR) 91.147 for all passenger-carrying flights not conducted under 14 CFR 91.146 (flights for the benefit of a charitable, nonprofit, or community event). Therefore, the FAA was unaware of, and provided no oversight of, the pilot’s passenger-carrying flights.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

The pilot’s failure to maintain airplane control for an undetermined reason, which resulted in an inadvertent stall. Contributing to the accident was the pilot's poor judgment in continuing to fly with his severe visual deficiency. Also contributing to the accident was the aviation medical examiner’s failure to accurately assess and report the pilot’s visual deficiency.

No comments:

Post a Comment