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On September 17, 2011, a North American T-28C collided with terrain while performing a low altitude aerobatic maneuver during the Thunder Over the Blue Ridge Open House and Air Show at the Eastern WV Regional Airport/Shepherd Field (MRB), in Martinsburg, West Virginia. The NTSB determined that the probable cause of this accident was “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.”
TO THE FEDERAL AVIATION ADMINISTRATION: Restrict all pilots with medical conditions that could affect their g-tolerance from performing aerobatic maneuvers or air racing at events requiring a certificate of waiver or authorization for an aviation event.
Original recommendation transmittal letter:
Open - Acceptable Response
Martinsburg, WV, United States
Addressee(s) and Addressee Status:
FAA (Open - Acceptable Response)
Safety Recommendation History
In our letter issuing this recommendation, we discussed the actions recommended in Safety Recommendations A-99-1 and -2, which were issued to the FAA on January 14, 1999, and we recommended that the FAA take similar actions to address Safety Recommendation A 15-11. In response to Safety Recommendations A-99-1 and -2, the FAA performed an extensive analysis that found that systems currently in place had prevented pilots with cardiovascular disease from becoming incapacitated while performing aerobatic maneuvers; this study was unable to find any accidents or incidents where these pilots had become incapacitated. On March 25, 2002, after reviewing the results of the analysis, we said that we continued to believe that there was a valid cause for concern about pilots with diagnosed cardiovascular conditions performing aerobatic maneuvers; however, because the FAA’s analysis had convinced us that Safety Recommendations A-99-1 and -2 were not necessary at that time, they were classified “Closed?Reconsidered.” In issuing Safety Recommendation A-15-11, we discussed three recent fatal accident investigations involving pilots with serious medical conditions that were either known to their FAA-designated aviation medical examiner or were well-documented in their official FAA medical certification file. These pilots became incapacitated while performing aerobatics. We note that you are reviewing Safety Recommendation A-15-11 and these three accidents to determine what actions you should take to address this safety issue. Pending the completion of action that satisfies Safety Recommendation A-15-11, it is classified OPEN—ACCEPTABLE RESPONSE.
-From Michael P. Huerta, Administrator: in response to Safety Recommendations A-99-01 and -02, which are similar to this recommendation, the Federal Aviation Administration (FAA) previously reviewed the Board's investigation of airplane accidents involving acrobatic airshow pilots with previously diagnosed medical conditions. In Safety Recommendations A-99-01 and -02 (both Closed-Reconsidered). The FAA reviewed the basis for justification of increasing medical restrictions on airmen participating in acrobatic flight. We reviewed 23 1 cases involving pilots with special issuance medical certificates due to cardiac conditions that could affect their G-tolerance and pilots who were taking medications that reduced G-tolerance. Only 153 of the 231 cases appeared to actually involve aerobatics and seven of the 153 met the selection criteria specified by the Board. These 7 accidents were investigated by the Civil Aeromedical Institute (CAMI). Based upon findings, the CAMI Accident Research Team determined that hypertension and special issuance medical certificates were not good predictors of fatal accidents in acrobatic flight and did not provide a justifiable basis for restricting thousands of airmen from participating in airshows involving acrobatic maneuvers. The FAA is reviewing this recommendation, in light of the three identified accidents cited in the Board's initial correspondence, to determine the best feasible course of action to address the Board's current concerns. I will keep the Board informed of the FAA's progress on this safety recommendation and provide an update by February 2016.
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