Sunday, May 19, 2019

Medical Event: Piper PA-22-150, N3664Z; fatal accident occurred August 09, 2017 near San Miguel Ranch Airport (NM53), Las Vegas, San Miguel County, New Mexico

Mike Shaver, 70, of Pine Mountain Lake, pictured inside the cockpit of a Piper PA-22-150P at Outlaw Field in Clarksville, Tennessee, days before he died after crashing in rural New Mexico on August 9th, 2017. Steve Wilson (yellow shirt), a certified flight instructor, flew with Shaver for about an hour on August 3rd, 2017 while testing the plane. 

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Albuquerque, New Mexico

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms



Aviation Accident Data Summary - National Transportation Safety Board:  https://app.ntsb.gov/pdf

http://registry.faa.gov/N3664Z


Location: Las Vegas, NM
Accident Number: CEN17FA315
Date & Time: 08/09/2017, 1025 MDT
Registration: N3664Z
Aircraft: PIPER PA 22-150
Aircraft Damage: Substantial
Defining Event: Miscellaneous/other
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis 

The private pilot departed on a cross-country flight in day visual meteorological conditions. When he did not arrive at his destination as planned, a search was initiated, and the airplane was subsequently located in wooded, mountainous terrain near a private airport about 73 miles short of the destination. The orientation of the wreckage was consistent with the airplane impacting terrain following an aerodynamic stall. Examination of the airplane and engine did not reveal any anomalies that would have precluded normal operation, and there was evidence of fuel at the accident site.

The pilot was not in contact with air traffic control during the flight. Radar information showed the airplane maneuvering near the airport before radar contact was lost; the pilot may have been attempting to divert to the airport when the accident occurred. An autopsy of the pilot revealed severe coronary artery disease with 90% stenosis of the left coronary artery as well as evidence of scarring from a previous heart attack. Each of these conditions placed the pilot at significantly increased risk for the sudden development of symptoms from an acute cardiac event, which may have led him to divert. It is likely that, while maneuvering for landing, the pilot was either impaired or incapacitated by the symptoms of an acute cardiac event, which subsequently resulted in a loss of control.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's impairment or incapacitation by symptoms of an acute cardiac event, which resulted in a loss of control.

Findings

Personnel issues
Cardiovascular - Pilot (Cause)

Factual Information

History of Flight

Enroute-cruise
Medical event (Defining event)
Aerodynamic stall/spin

Uncontrolled descent
Collision with terr/obj (non-CFIT) 

On August 9, 2017, about 1025 mountain daylight time, a Piper PA-22-150 airplane, N3664Z, was substantially damaged when it impacted terrain near Las Vegas, New Mexico. The private pilot was fatally injured. The airplane was privately owned and was operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed in the area, and no flight plan was filed for the flight, which departed Dalhart Municipal Airport (DHT), Dalhart, Texas, at 0640, and was en route to Santa Fe Municipal Airport (SAF), Santa Fe, New Mexico.

The pilot had recently purchased the accident airplane and took possession of it in Tennessee. On August 3 and 4, the pilot received 1.5 hours of local instruction in the accident airplane. According to personnel at the DHT fixed base operator, the pilot departed DHT for SAF the day before the accident but returned due to weather. The pilot again departed for SAF the morning of the accident.


The pilot was not in contact with air traffic control during the flight; however, a search of radar data found targets correlated to the accident airplane. The data captured the airplane as it departed from DHT and flew southwest until it passed Obar, New Mexico, when it turned west. After passing Bell Ranch, New Mexico, the airplane continued west, then northwest. The airplane made several large s-turns and flew east of San Miguel Ranch Airport (NM53) before turning north and continuing a right turn until radar contact was lost. The last radar return was about 1.4 miles southwest of runway 4 at NM53. A search was initiated after the airplane was reported overdue, and the wreckage was located on August 11.


Mike Shaver 

Pilot Information

Certificate: Private
Age: 70, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None 
Restraint Used: Lap Only
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: BasicMed
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent: 05/22/2017
Flight Time: (Estimated) 344.9 hours (Total, all aircraft), 19.1 hours (Total, this make and model), 10.1 hours (Last 90 days, all aircraft), 10.1 hours (Last 30 days, all aircraft) 

The pilot's logbook was found in the wreckage. His most recent flight review was completed on May 22, 2017, in a Cessna 172. The pilot did not hold a current Federal Aviation Administration (FAA) medical certificate and was operating under the provisions of BasicMed. His most recent BasicMed medical examination was conducted on May 9, 2017. The pilot's previous FAA medical certificate was issued on May 17, 2012.

Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: N3664Z 
Model/Series: PA 22-150 160
Aircraft Category: Airplane
Year of Manufacture: 1960
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 22-7562
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 06/03/2017, Annual
Certified Max Gross Wt.: 2000 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 2495.66 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: Installed, activated, aided in locating accident
Engine Model/Series: O-320-A2B
Registered Owner: On file
Rated Power: 150 hp
Operator: On file
Operating Certificate(s) Held: None

A review of the airplane's logbooks did not find any record of significant maintenance issues. Notes found in the wreckage indicated that the pilot departed on the accident flight with full fuel at a tachometer time of 2509.08 hours. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KLVS, 6874 ft msl
Distance from Accident Site: 29 Nautical Miles
Observation Time: 1005 MDT
Direction from Accident Site: 291°
Lowest Cloud Condition: Scattered / 1100 ft agl
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 9 knots /
Turbulence Type Forecast/Actual: None /
Wind Direction: 210°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.32 inches Hg
Temperature/Dew Point: 19°C / 15°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: DALHART, TX (DHT)
Type of Flight Plan Filed: None
Destination: SANTA FE, NM (SAF)
Type of Clearance: None
Departure Time: 0640 CDT
Type of Airspace: Class G

No significant weather was recorded in the vicinity of the accident.

Airport Information

Airport: SAN MIGUEL RANCH (NM53)
Runway Surface Type: N/A
Airport Elevation: 6300 ft
Runway Surface Condition:
Runway Used: 04
IFR Approach: None
Runway Length/Width: 5600 ft / 100 ft
VFR Approach/Landing: None 

NM53 was a private airfield located about 73 miles west of SAF and had no services available. 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 35.486944, -104.593611 

The wreckage came to rest inverted in a wooded area in mountainous terrain. Portions of the right wing suspended in a tree; near the tree's base was a small crater filled with rain water, and the airplane's propeller was located in the crater. Areas of the cockpit contained an odor of fuel.

Examination of the flight controls did not identify any preimpact anomalies. Both propeller blades displayed leading edge damage and polishing. One blade displayed s-bending and curling, and its leading edge displayed gouges and deformation.

The airplane was recovered to a secure facility in Phoenix, Arizona. An examination of the engine did not reveal any preimpact anomalies. 

Medical And Pathological Information

The State of New Mexico, Office of the Medical Investigator, Albuquerque, New Mexico, performed an autopsy of the pilot. The pilot's heart was enlarged and weighed 470 grams (average heart weight given the pilot's weight is 387 grams) with mild four chamber dilation. The proximal left anterior descending coronary artery had 90% stenosis, and both the circumflex and right coronary arteries had 50% stenosis. Fibrosis was identified on the left ventricular free wall. Left concentric ventricular hypertrophy was mentioned, but the recorded wall thicknesses were average. Microscopy demonstrated a focus of increased fibrosis with cardiac myocyte dropout consistent with a scar. The remaining heart had increased interstitial and perivascular fibrosis. Due to the severity of injuries, a detailed examination of the brain could not be conducted. The autopsy noted chemical burns on the pilot consistent with exposure to aviation fuel. The report listed the cause of death as blunt force injuries.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens of the pilot. Testing identified ethanol at 0.151 gm/hg in muscle, and 0.037 gm/hg in liver tissue. Another alcohol commonly produced in tissues after death, N-propanol, was detected in muscle. In addition, metoprolol was found in lung and muscle. Specimens were marked as putrefied.

Ethanol is the intoxicant commonly found in beer, wine, and liquor. It acts as a central nervous system depressant. Because ingested alcohol is distributed throughout the body, levels from different postmortem tissues are usually similar. Ethanol may also be produced in body tissues by microbial activity after death. In these cases, levels among different tissues tend to vary considerably. The alcohol levels in the pilot's tissues are consistent with postmortem production.

Metoprolol, doxazosin, and losartan were found among the pilot's belongings at the accident site. Metoprolol is a blood pressure medication that can also help prevent recurrent heart attacks. It is not generally considered impairing and is commonly sold with the names Lopressor and Toprol.   Doxazosin and losartan were not detected in the toxicology. Both medications are used in the treatment of high blood pressure.

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