This September 2007 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.

Aircraft: North American SNJ-2.

Location: Virginia Beach, Va.

Injuries: 1 Fatal.

Aircraft damage: Destroyed.

What reportedly happened: The airplane was one of five practicing for a formation aerial demonstration. In the final maneuver of the demonstration, each of the first four airplanes performed a “pop up break” to return for landing. The fifth airplane, however, continued straight ahead in a slight descent, and did not pull up or “break.” The airplane continued in a constant descent until it hit the ground and erupted in flames.

Examination of the wreckage did not reveal evidence of any pre-impact mechanical malfunctions or failures. During the investigation it was determined that the pilot became incapacitated by a previously known cardiac condition during the the flight.

A review of the pilot’s personal and FAA medical files revealed that the pilot had falsified information on at least three applications for medical certification regarding his evaluation and treatment for cardiac conditions. The FAA had once denied his application for a medical certificate when it became aware of the falsification, and the pilot submitted medical records to regain his medical certificate. Those medical records documented, in part, a long history of chest pain, an enlarged heart, intermittent atrial fibrillation treated with a blood thinner and a beta-blocker medication to reduce heart rate, and use of an alpha-blocker medication that also reduced blood pressure. After submission of those records, the pilot was granted an Authorization for Special Issuance of a medical with a requirement to not operate an aircraft if he had new symptoms or changed medication. No restrictions were placed on the pilot with regard to aerobatic flight, though records submitted to the FAA clearly noted the pilot’s participation in aggressive flying at air shows.

The AME who issued the pilot’s most recent medical certificate approximately eight months before the accident was also a pilot who had previously participated in formation flights with the accident pilot. There was additional information pertinent to the pilot’s condition available prior to his most recent medical certification that was not submitted to the FAA or the AME by the pilot or his cardiologist. Following his most recent medical certification, in the six months prior to the accident, the pilot had experienced increasing symptoms and had received at least one new diagnosis  of pulmonary hypertension. Additionally, the pilot had visited his cardiologist three days before the accident, complaining of multiple episodes of atrial fibrillation over the previous three months with fatigue and shortness of breath lasting anywhere from several hours to up to 36 hours at a time.

At the time of the accident, the pilot had completed more than 15 minutes of high performance flight, including nearly two minutes of increased G-loading of up to 2.9 Gs and had just completed the longest sustained-G maneuver of the show, which was 30 seconds of 2G loading.

Probable cause: The pilot’s inability to maintain control of the airplane due to physical incapacitation. Contributing to the accident was the failure of the FAA to deny or restrict the pilot’s medical certification, and the pilot’s improper decision to perform the flight given his recent history of worsening symptoms.

For more information: NTSB.gov