Saturday, July 12, 2014

National Transportation Safety Board says Federal Aviation Administration contributed to air show crash at Eastern West Virginia Regional Airport (KMRB), Martinsburg, West Virginia

MARTINSBURG, W.Va. — The Federal Aviation Administration's "willingness to allow an airman with well-documented, severe coronary artery disease to perform high-risk, low-altitude aerobatic maneuvers" contributed to the 54-year-old pilot's fatal crash during the 2011 air show at Eastern West Virginia Regional Airport, the National Transportation Safety Board has concluded.

The probable cause of pilot John "Jack" Mangan's crash at the Thunder Over the Blue Ridge Open House and Air Show on Sept. 17, 2011, was due to his "impairment or incapacitation that occurred during a low-altitude aerobatic maneuver due to complications from a recent heart attack, resulting in his inability to maintain control of the airplane," the NTSB said in its final report filed Dec. 5, 2013.

The Concord, N.C. man was flying with the Trojan Horsemen Demonstration Team when his 1958 T-28C plane stopped rolling during a maneuver and continued in a "right-wing-down, nose-low altitude" until it crashed, the independent federal agency said.

An autopsy report by the state medical examiner's office indicated the cause of death was multiple blunt force injuries due to a plane crash, but also states "a possibly contributory factor causing pilot incapacitation was evidence of a fresh heart attack," according to the NTSB's report.

None of the thousands of spectators who were watching the show from the West Virginia National Guard 167th Airlift Wing base at the airport were injured as a result of the crash.

"Review of the video revealed no separation of airplane parts and no obvious attempt by the pilot to recover," the NTSB's report said. "Post-accident examination of the airframe and flight controls and a cursory examination of the engine revealed no evidence of pre-impact failure or malfunction that would have precluded normal operation."

In a statement released via email this week by FAA spokesman Jim Peters, the agency noted it is the pilot's responsibility to "accurately complete their medical applications and report cardiac or medical history."

"Failure to do so is a violation of federal regulations."

The FAA statement cites the requirement that pilots must have medical certificates in order to fly and that periodic medical examinations are conducted by FAA-designated Aviation Medical Examiners - private physicians with a special interest in aviation safety and training in aviation medicine.

The NTSB said Mangan's medical records indicate he suffered a heart attack in 2003 at age 46 and subsequently underwent bypass surgery. Following his surgery, Mangan applied for a special issue of his medical certificate, but did not indicate he intended to fly aerobatics.

Currently, there are no limitations to permitted flight characteristics for special issuance medical certificates, including those issued for cardiac disease, the NTSB said in its report.

As a result of several investigations involving pilot incapacitation, including accidents during air show performances, the NTSB recounted in its report on Mangan's crash that it asked the FAA in 1999 to "restrict all pilots" who have special issue certificates due to cardiac conditions that could affect their g-tolerance, or ability to withstand forces caused by higher levels of acceleration. The NTSB also noted that it asked the FAA to restrict pilots who are taking medication that reduces their g-tolerance from engaging in aerobatic flight.

The NTSB noted that the FAA subsequently determined after reviewing previous crashes that the NTSB's two recommendations would "probably not have changed the outcome of any of the accidents."

During the T-28 demonstration team's practice the day before the crash, the NTSB said several FAA inspectors who monitored the air show noticed that Mangan's airplane was flying low following a roll.

Following the practice flight, the team's manager indicated Mangan had reported there were birds in the area when he flew through.

"He did a knee-jerk maneuver to pull, and as a result he dished out of the maneuver," the NTSB report said. "The team manager also reported that the maneuver being performed at the time of the accident was "eerily similar" in some aspects to the maneuver performed the day before."

The team manager, who was flying with the team at the time of the accident, also reported there were no birds in the aerobatic box, according to the NTSB report.

Team members who were with Mangan the previous day for the practice session, that same evening, and the following day up to and including the pilot's last flight, reported he was in good spirits, the NTSB report said.

Nic Diehl, who was instrumental in organizing the 2011 air show said this week he wonders whether the NTSB's findings will cause the FAA to reconsider the procedures they currently follow.

"Historically, the air show industry has trusted the FAA's medical judgement and evaluation of industry performers," Diehl said.

"We currently don't have the ability to question the FAA's evaluation of performers."

With that being said, Diehl noted that the FAA's show box more than adequately separates performers from the audience, noting the impact area of the 2011 crash was more than 3,500 feet from the nearest spectator.

Prior to the NTSB's final report being filed, Diehl said it was his understanding that Mangan died from a heart attack while flying. Diehl said he was told by other pilots that Mangan died doing something he loved and would have wanted the show to go on.

"Air shows are filled with excitement, but there is always an element of danger for the pilots much like drivers in motor sport racing," Diehl said.

Since the last air show was held in partnership with the West Virginia National Guard 167th Airlift Wing in 2012, there have been discussions about doing another show on the civilian side of Shepherd Field like previous events in 2005, 2006 and 2008, "but there are no immediate plans," Diehl said.

Story and Photo:   http://www.heraldmailmedia.com



http://registry.faa.gov/N688GR

NTSB Identification: ERA11FA495
14 CFR Part 91: General Aviation
Accident occurred Saturday, September 17, 2011 in Martinsburg, WV
Probable Cause Approval Date: 12/05/2013
Aircraft: NORTH AMERICAN T-28C, registration: N688GR
Injuries: 1 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.

After takeoff for an airshow performance, the pilot performed maneuvers consisting of a barrel roll, loop, and an opposing pass with another airplane, culminating with an aileron roll. Witnesses and recorded video indicated that after the two airplanes crossed, the accident pilot began an aileron roll to the left, which degraded into a barrel roll. After completing about 270 degrees of the roll, the airplane stopped rolling and continued in a right-wing-down, nose-low attitude until impact. Review of the video revealed no separation of airplane parts and no obvious attempt by the pilot to recover. Postaccident examination of the airframe and flight controls and a cursory examination of the engine revealed no evidence of preimpact failure or malfunction that would have precluded normal operation.

According to the pilot's medical records, he developed early onset coronary artery disease and suffered a heart attack (myocardial infarction) at age 46, requiring urgent four-vessel coronary artery bypass graft (CABG) surgery in 2003. One of his grafts failed in the first year, and further intervention by surgery or angioplasty was deemed impossible. The pilot was aggressively treated for high cholesterol following his heart attack and also developed diabetes. Even with intensive treatment, atherosclerosis will predictably continue to develop. Thus, the risk of death and other major adverse cardiovascular events following CABG is significant and increases over time. Studies indicate that by 8 years following CABG surgery, approximately 30 percent of diabetic patients have died; this increases to nearly 40 percent by 12 years.

Following his surgery, the pilot applied for a special issuance of his medical certificate. During that process, he did not indicate that he intended to fly aerobatics. The pilot received a special issuance third class medical certificate, which was renewed annually. However, he was not asked again about the types of flying he was doing or intending to do. Although the pilot routinely passed regular exercise stress testing as part of the special issuance requirements, his personal medical records indicated that he had a small area of his heart muscle that was repeatedly identified as at risk on nuclear imaging studies.

The sudden changes in cardiac work associated with g-loading and unloading may be an independent risk factor for cardiac arrhythmia in the setting of a scar resulting from previous infarction. Even without g-loading, the risk of arrhythmia is highest in the first minutes, hours, and days after a heart attack. According to autopsy results, the medical examiner found a "fresh" area of myocardial infarction (heart attack) on the gross pathology; however, no microscopic analysis was performed. That the medical examiner was able to identify an area of grossly abnormal tissue suggests the event occurred hours to a couple of days previously. A closer approximation of the timing of the pilot's final myocardial infarction could not be determined.

The evidence indicates that the pilot likely became impaired or incapacitated while flying a low-altitude aerobatic maneuver soon after suffering a heart attack. The FAA knew about the pilot's medical condition and appropriate procedures had been followed during the evaluation for his aerobatic competency card. Currently, there are no limitations to permitted flight characteristics for special issuance medical certificates, including those issued for cardiac disease.

In January 1999, as a result of several investigations involving pilot incapacitation, including accidents during airshow performances, the NTSB issued Safety Recommendations A-99-1 and -2 asking the FAA to, respectively, "restrict all pilots with special issuance certificates due to cardiac conditions that could affect their g-tolerance from engaging in aerobatic flight" and "restrict all pilots taking medication that reduces g-tolerance from engaging in aerobatic flight." In evaluating these recommendations, FAA personnel reviewed an NTSB-supplied list of accidents using the following criteria: a) the accident must have occurred during aerobatic flight as defined by applicable FAA advisory circulars and regulations; b) the aerobatic maneuver must have been intentional; c) the aircraft must have been certified for aerobatic flight; d) the maneuver must have been authorized under FAA regulations; and e) the airman's cardiac or medication history must have been documented in his/her FAA medical record at the time of the event. Based on the criteria, the FAA determined that the NTSB recommendations would "probably not have changed the outcome in any of the accidents." Further, the FAA indicated in its review that if there had been a significant number of properly identified pilots experiencing aircraft accidents during authorized aerobatic maneuvers, the recommended actions would be justified. The NTSB classified the recommendations, "Closed--Reconsidered." However, this accident flight meets all five criteria stipulated by the FAA.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's impairment or incapacitation that occurred during a low-altitude aerobatic maneuver due to complications from a recent heart attack, resulting in his inability to maintain control of the airplane. Contributing to the accident was the Federal Aviation Administration's willingness to allow an airman with well-documented, severe coronary artery disease to perform high-risk, low-altitude aerobatic maneuvers.


http://www.ntsb.gov

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