Pilot Incapacitation Cited In Oregon Citation Crash


The NTSB has determined the pilot of a Citation involved in a high-profile crash in Oregon in early 2021 became incapacitated at the controls but it can’t say why. It listed the probable cause as “a loss of airplane control due to pilot incapacitation for reasons that could not be determined.“

The 72-year-old pilot was taking his first solo flight in the recently acquired Citation 560 when he stopped talking to ATC. The flight originated in Portland and was bound for Boise. The board said that after contact was lost the plane entered an eight-minute tight spiral that closely matched Cessna’s test flights of an uncontrolled flight from altitude. It slammed into the side of a mountain near Warm Springs and was reduced to fragments.

Given the state of the wreck and the pilot’s body, there wasn’t much useful evidence at the crash site. From what they could tell, investigators said there likely wasn’t anything wrong with the plane, including any evidence of cabin depressurization. The pilot was not type rated in the aircraft, although he had numerous other ratings in jets and other types. He had taken type training but failed to complete the course. 

The board noted that he had a variety of health issues that were being treated and which wouldn’t have led to incapacitation, but said there may have been an undiagnosed issue and “his age, gender, high blood pressure, and hypertension placed him at risk for a heart attack or stroke.” 

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  1. OH NO! The AME’s in Oklahoma City and the lawyers in D.C, will read this and be “on” it pronto. What we need is a mandatory retirement age for recreational pilots … why don’t we just make it a nice round 30. Between aging aircraft and aging pilots … we have a major problem on our hands. Airplanes are falling out of the sky faster than we can build more.

    And just how did investigators determine that there wasn’t anything wrong with the airplane or its pressurization system from an airplane destroyed totally upon impact? Just from the sounds of things — to ME — I’d say this is a Payne Stewart moment. “Likely,” the pilot shoulda donned his O2 mask and asked for a descent.

    • Thinking about it some more … I’d be asking if this pilot ever had any recent altitude chamber training? During my USAF time, I had multiple chamber rides and (re)learned my personal hypoxia symptoms which were quite insidious.

      • I’m curious, Larry. In your altitude chamber exposures, did they simulate both gradual hypoxia and sudden decompression? If so, were the symptoms different? I can see a gradual situation sneaking up on a pilot, but I would think a sudden event would immediately be recognized and give at least a little time to grab the mask. That’s assuming it was within reach and ready to go, not wrapped up and in a box. I haven’t had an opportunity to go through altitude training, but would definitely like to do so.

        • When I did my initial altitude chamber ride in the early 70’s, it was at Beale AFB in the SR-71 altitude chamber. At that time, both RD (rapid decompression) and a gradual ascent were simulated along with task performance degradation examples which could be funny, at times (acting goofy OR outgassing). As you opined, the RD was a major event taking the participants from — I think — ~10K to 43K almost instantly in an interlock chamber. You would notice that. For me, I learned that my nails turned blue and I started feeling very warm and comfy prior to loss of ability to function. Also, I have a complex ear canal which is very tough to clear with the valsalva maneuver. The gradual ascent IS far more important and insidious IMHO.

          On a couple of occasions, I’ve had to climb my 172 up very high for weather reasons. Knowing my personal hypoxia symptoms made a BIG difference.

          I would advise every pilot who flies up high to take altitude chamber rides or that new FAA thingie they have in their hangar at Airventure. I’d also opine that age IS related to ones ability to deal with hypoxia.

          • I learned that to clear my ears on the way down vs filling the oxygen mask up with snots (sic), I had to remove my mask and pinch my nose very hard with two hands to get the ear canal to open. Using the holes in the O2 mask could provide the necessary closure pressure. The ear pain can be quite bad if you don’t clear your ears. On one occasion, I had to call for a halt to the descent until I got my ears cleared. It was the flight surgeon who told me I had a complex ear canal … I didn’t know that prior.

      • I “flew” in an Altitude Chamber years ago (when I was in my late 20’s) at Willie AFB. (When it was operational here in AZ.)

        First, while I learned that I get a headache when hypoxic – and I never get headaches – I don’t know that that symptom would be enough in real life, flying a jet, to get my attention. And even in the rarefied setting of the Chamber (pun intended), where I wasn’t busy concentrating/distracted flying, even then I fumbled to put my mask on and flip the Regulator to Full Pressure.

        Second, my airplane partner was the text book case of the person who doesn’t – or, more likely in her case, refuses to – recognize their symptom. (To be fair, there was another guy there – a weight lifter – who also did same.)

        My airplane partner turned out to be the text book “happy drunk.” She just smiled at the Instructor as he yelled in her face to put her mask on. (Whereas the weight lifter reluctantly put his mask on.)

        It was terrifying to see how easy it can be to crash as a chain-reaction side effect of hypoxia.

        All this to say, while knowing your symptoms is better than not knowing your symptoms, I don’t know how much it prevents accidents.

        Today we have inexpensive Oximeters and I’m a bit horrified to see that my O2 Sat at a mere 9000′ drops below 90%. (66 years old, in good health, no meds, slim, hike and exercise routinely. (It’s called “getting older.))

        I think it best to know when you’re too old to be flying. Or at least too old to be soloing in something more challenging than a 152/172.

        Or if you must fly, to always fly with another pilot.

        Isn’t that what an older, wiser pilot would do?

    • I read the report. The investigators found a passenger oxygen mask still in its compartment amidst the wreckage. Had the cabin depressurized, the masks would have been deployed. The CVR was broken and didn’t record anything from the flight.

    • They didn’t conclude that there were no mechanical problems with the aircraft. They just couldn’t find any evidence of such.

      From the report, it sounds like the pilot was having difficult even before taking off, so it doesn’t sound like a payne stewart decompression incident. It sounds more like a possible stroke, or just general brain fog.

      I wouldn’t worry too much about the FAA instituting a recreational pilot “retirement” age, though. The private insurance industry is more likely to do that anyway (which they effectively have already done by refusing to insure pilots over a certain age).

  2. 2017 at Wright Pat. The chamber was part of a 3 day physiology class. Lots of great info in that class that I would have liked to have known at the beginning of my career. Ear protection was interesting and was a big take-away for me. The anxiety leading up to the decompression experience was worse than the chamber itself. The part about expelling chunky (or soupy) gas at the moment of explosive decompression the most concerning. Never happened tho. Survived with dry pants thankfully. As I recall our decompression occurred at Between FL250 and FL300. The USAF was no longer doing decompressions at extreme altitudes.

    The chamber looked like something out of a Jules Verne movie or perhaps 20,000 Leagues Under The Sea. Big rivets.

    The 3 day class was great. Thanks to the many great folks at WPAFB. Strongly recommend for all.

  3. Here is a word of advice, especially for non-pressurized cockpits. Buy a portable oxygen system and use it any time you fly over about 8,000 feet, especially if you are older than about 50. You will feel better when you get there and filling the bottles is a trivial expense.
    No idea whether that was an issue in this case. I had a good friend who augered in in his Mooney. They found no evidence of smoke in his lungs even though there was a fire, and determined he died of a coronary event before the crash happened. This is likely what happened here and there could be evidence in his medical records, or not.

  4. How about, “The pilot was not type rated in the aircraft, although he had numerous other ratings in jets and other types. He had taken type training but failed to complete the course.”

    Not a mystery why an airplane crashes when the solo pilot is not qualified (insured?) to fly it.

  5. I have had an experience with CO poisoning (in a car, not a plane) and I had the same symptoms as Era P. I got a headache which I also never get. I suspect I might have similar effects from hypoxia. I do have a pulse oximeter in my flight bag and rarely fly close to 10,000 feet.