L2016-01 Pilot incapacitation during landing at Vampula Aerodrome on 24 September 2016

The accident occurred on Saturday, 24 September 2016 to the pilot of a Cessna 172N aircraft. At 12.21 the pilot took off from Tuulikki-Vampula aerodrome for a local flight with two passengers. The pilot decided to abort the flight because he did not feel well. Following the landing the aircraft drifted off the runway into a ditch at 12.36. The pilot died soon after the landing as a result of a heart attack. One passenger had a sudden attack, requiring hospitalisation.

The pilot suffered from multi-vessel coronary heart disease and sleep apnoea. Within the five years prior to the accident he had had three heart attacks which were treated with coronary angioplasty.

On the basis of the investigation the pilot’s higher overall risk of a recurring heart attack, as regards flight safety, was not recognised. The European guidance material only partly provides for decision-making associated with overall risk assessment.

The pilot was unaware of the privileges of a medical certification and the validities of the licence. Moreover, while the public health care system was aware of the pilot’s flying hobby, national legislation does not lay down any duty of notification associated with medical certification to doctors treating licence holders.

On the basis of the investigation Safety Investigation Authority, Finland issues four safety recommendations:

The International Civil Aviation Organization (ICAO) should include such a risk assessment model in the Manual of Civil Aviation Medicine that can be used in aeromedical decision-making for assessing the risk of pilots who have had recurring heart attacks.

The European Aviation Safety Agency (EASA) should improve AME risk assessment competency in aeromedical decision-making through training and by increasing their competency in consultation and in the use of limitations.

The Finnish Ministry of Transport and Communications should standardise the duty of notification between aviation and road transport associated with a person’s state of health as part of advancing the safety of flight.

The Finnish Transport Safety Agency should see to it that the practitioners of general and sport aviation receive clarifying information pertaining to the privileges associated with the pilot’s licence and the significance of the requirement to report medical issues.

L2016-01 report (pdf, 1.67 Mt)

L2016-01 accimap (pdf, 0.08 Mt)