On April 14th, 2020, the NTSB released the docket for the fatal crash of an Icon A5 piloted by baseball star Roy Halladay. In this video, AVweb’s Paul Bertorelli comments on the docket findings. You can find the full report on the NTSB site at https://tinyurl.com/y8srdpmc. If drugs were an issue, they were hardly the only one.


  1. As usual, a very balanced analysis… The reality, though, is that if this had been a regular Joe, we would all be calling this “natural selection”. A disease? I’m not of the opinion there either. I had a motorcycle accident when I was 16. Broke my neck and have limited motion with my right upper extremities. In pain everyday. I have yet to take a Tylenol. That is a choice (usually, a disease you don’t get to choose from…). Drug abuse, (along with all sort of other abuses) is also a relative thing and it’s up to us whether we want to go sliding that downward path or not. I choose to not take medication, I choose to not drink, I choose not to eat bad food. I also choose to fly responsively. If I don’t is that a disease as well? Do careless pilots get a “free ticket” and so its not their fault?

    • L R, I don’t disagree, but to your point there is a continuum of control a person may have when it comes to addiction. Without being in their shoes and knowing their full story, I don’t know where they’re at, and try to give them the benefit of the doubt. I personally believe aviators are more likely to seek treatment if they feel support from their peers. Perhaps such treatment could have changed the outcome of Roy’s last flight.

      At the risk of ranting… unfortunately, the FAA doesn’t help – the system is such that pilots are incentivized to NOT report things like depression or addiction. A buddy of mine was prescribed a certain medication for anxiety, but the doc mentioned “depression” in the paperwork. The number of hoops he had to jump through to get his third class medical renewed was incredible, including multiple evaluations by a psychiatrist… all so he could go fly a 172, most of the time solo, and all because he sought treatment for an extremely common and often transitory condition. Yet all the while he could drive a minivan filled with passengers with no evaluation or restrictions. It’s nuts.

      • Yeah… Roy probably was pushed to take pain killers so that he could do his job at the high expectation he did. But that’s the risk of it… Related to the FAA, a friend purchased a 172 from me. Started to solo but could not get a 3rd class medical because he reported he was diagnosed with ADHD when he was a young boy. Now, he can’t get a sport’s pilot license. The FAA rewards dishonesty…

      • I am an AME and in some cases I cannot disagree with you, Hunter and L.R. I ran into this issue with and was astonished that the FAA would refuse to budge on a very high functional exec diagnosed with adhd as a child, went through OCS, retired from the military and went to medical school and residency after retiring from the navy. Perfect driving record, not even a speeding ticket.

        What I counsel airmen if they have any question or might need a special issuance, I can help by “pre-qualifying” them. I do this before we meet for the FAA medical and before the FAA application so we can get all the paperwork the FAA is likely to ask about, all tests that might be required together before we actually schedule an appointment for the flight physical. That way, there are no surprises, and it makes the SI (if one is possible, which it is most of the time), much quicker because all of the documents that OKC will need are there in one packet at the time of the initial exam.

        • Okay, Dr. Art, I have a question for you. What is with the FAA’s paranoia over ADHD, especially if diagnosed as a child? For one thing, children are often misdiagnosed by a teacher or school counselor because they are disruptive in class. I personally know several adults who have ADHD and are very intelligent and high functioning. If it is because of the drug issue, most ADD adults have developed coping mechanisms that allow them to be drug free and still lead a normal life. Furthermore, the FAA’s rule of not allowing a person to fly sport pilot if they get denied a 3rd class medical is just idiotic.

          I flew under a SI for several years, but switched to BasicMed as soon as it was approved because I got tired of jumping through all the ludicrous hoops to keep Oklahoma City happy for the SI. The FAA not only encourages dishonesty in their medical exams, they actually punish honesty. A person with a medical condition that would prevent them from solo flying in a 152, can legally get a commercial driver’s license and drive a bus full of people down the interstate at 70 mph. Considering they are all under the jurisdiction of the Department of Transportation, how does that make sense?

          • All correct about OKC. there is a doctor there just waiting to find a way to keep you from flying and he is faceless and non accountable!! Yes, because of the lugubrious and faceless bureaucracy a pilot must NOT be truthful sometimes. Best thing ever is Basic Med…no FAA in your flying life.

  2. Thank you Paul for a thoughtful video analysis. Thank you for the links you provided. I looked over very carefully the complete NTSB report in addition to your well-crafted video.

    In it contained witness interviews and the interview with his dad, Big Roy. Big Roy is quite an aviator, aircraft restorer, military pilot, and accomplished professional civilian pilot. He made his assessment based on a very close, lifelong relationship with Little Roy. To say, Big Roy was Little Roy’s major source of motivation for his pitching and aviation career would be a massive understatement. To say he was a distant, disengaged father who did not know his son would be an equal understatement.

    His wife’s initial reluctance for purchasing the Icon A5, followed with a complete change of heart once she had a chance to fly in one prior to the delivery, explains…at least to me…why she was with Roy when he flew under the bridge not once, but twice ( Roy noted his wife being present in his logbook entry describing flying under the bridge ). She had a very front row seat to his decision-making mindset a few days before the accident. The NTSB onboard GPS data recreation of that flight revealed much about his risk taking assessment and overall judgement.

    The toxicology report was a big surprise to the world but not to the family. I am not suggesting anyone sanctioned any of his drug use. My heart grieves for them as they continue living with what they knew, didn’t know, and had little to no control of any of it. Now, with this release by the NTSB, they are re-living it again. I am sad, such a passionate aviator, and up to the bridge incident, seemed to be a vibrant GA advocate, general aviation ambassador, and good stick, ending up flying with this cocktail of drugs. I am sad how Little Roy, like untold others, was in an addiction battle he had not gained victory over.

    We can arm-chair quarterback, about AOA data, did he stall, did he not stall. We can analyse power settings, bank angles, risk assessment, ICON training/ICON branding and marketing. We can talk about this toxic stew Little Roy had in his system and argue about addictions, their source, the solutions, the war on drugs, and prescription drug abuse. I don’t really want to be a part of that. Just offering a comment puts me partially in that camp.

    For me, I am sad for anyone in this position of addiction because it’s easy to have key-board courage talking about what should have and could have been done, banned, regulated, or opined. I am sure, there are many readers, which includes myself, that this accident investigation really hits close to home for many reasons. I think Paul’s video offers enough information for all of us to see the probable cause to this accident was a combination of things, events, circumstances, and unknown internal, personal battles. This resulted in an airplane being flown beyond its flight envelope. And another pilot got killed. I mourn the loss of a fellow aviator. I am sad his wife is now a widow. I am sad for the entire family. I am sad for the untold millions in a similar, dark situation.

    • Let’s just keep this “fighter pilot simple”
      1. He liked to take risks…flat hatting…wings would be removed if he was in a military aircraft.
      2. He was maneuvering low over water….learned from early flying of every naval aviator…cannot judge
      your height. wings would be removed if he was in a military aircraft.
      3. Thank you that he did not take someone with him
      4. Drugs…a national dilemma

  3. This will sound harsh and it is. It’s intended to be for the audience I’ve repeated it to.

    I always told flight students, “Pilots die almost always because they did something stupid.” This was no exception.

    You don’t get to the point this pilot did in his personal and professional life without a decent level of decision making along the way. It’s not all that difficult to realize when something is not a good choice. That would be the abusive use of medications. It’s a step further when one chooses to go flying while on the plethora of medications ingested.

    His wife and family won’t state any of her observations. But, the use noted in the report would be hard to miss if it were an ongoing issue and they were living together. My wife knows when I’m having heartburn.

    I’m just glad he was over water and did not kill anyone ashore.

  4. This brings to mind the saying from the old aviation poster: “Aviation in itself is not inherently dangerous. But to an even greater degree than the sea, it is terribly unforgiving of carelessness incapacity or neglect.” Modern professional athletes push themselves to perform at the highest level, which often means playing while injured. In later life the wear on their bodies results in almost constant pain that they have learned to self-medicate. Athletes are also adrenaline junkies and thrill seekers that sometimes overrides their better judgement in pursuit of the next thrill. Roy was not the first athlete to die in that pursuit, and unfortunately, he won’t be the last. Not sure if there is any way to change it, but far be it for me to sit in judgement.

  5. Hi Paul,

    Thank you for handling so appropriately the issues surrounding this accident. All GA accidents are difficult for the entire General Aviation family, especially those who personally knew the deceased. It is truly a shame another pilot died, another manufacturer takes a hit raising “questions” for the entire period of the investigation and at a terrible time to slow down on their sales.

    In retrospect we all wish we would or could have avoided this situation. So what needs to happen?
    Here are my recommendations:
    1. Manufacturers should NOT position their product (in videos, flyers, etc.) in any risky, bad or dangerous flight conditions. I believe this has been done and adrenaline junkies will gravitate and imitate this behavior given the opportunity. If you have witnessed the YouTube videos of the ICON videos of the A5 may agree with me that they display risky flying habits.
    2. In general, I believe all CFI’s are great people; mine have become lifelong friends so I am not saying anything negative about these hero’s. My point is, given the situation of a cocky, over confident and somewhat careless student…albeit able to pass all the tests…would it not be prudent to throttle the training process or in this case likely the transition training into a new aircraft to include a tough, heart to heart conversation around a cup of coffee or two? A CFI needs to have the fortitude to say “no” and be supported by pilot community when the CFI stands up and makes the right non-the-less tough decision. When was the last time anyone heard of this in our hedonistic society?
    3. Lastly, as pilots here in the USA, we bare some of the responsibility too. I have lost friends to GA accidents, not one of them was the fault of a manufacturer either. All three were stupid, and I mean stupid, pilot errors in judgement. One in particular I took off to the side at a show and read the riot act…and a month later he was killed doing the same stupid things; I regret not doing more. So what can we do? I think it can begin with a call to your local FAA office. Call the local airport manager where the plane is based and file a concern with the Airport Manager. Get a group of pilots together and make a time when you can coral the pilot in question. Why is it after the fact that we all wish we would have done “something”….been there and done that!
    you on YouTube and their marketing efforts . The question I have is at what point are manufacturers, CFI’s and “flying friends” going to

  6. Paul,

    Great article prompting a reflection point for all of us. Clearly this conversation highlights “Bold Pilots Old Pilots, no OLD BOLD Pilots”. While reflecting on your article, I remembered a funeral I attended for one of our flying club members. Not wanting to speak poorly of the dead, but his actions are another learning point.

    He was a newly licensed VFR pilot, low time, with a recently purchased Mooney. He launched for a trip from the North East to Florida and the Bahamas. At a fuel stop at Buffalo, the weather forecasts were not looking favourable for a VFR flight over mountainous regions. Pilots at the FBO told him to reconsider, stay the night and wait for better weather. His girl friend pleaded with him to reconsider. He had a type A personality, being young and feeling (I suppose) a bit indestructible. He launched with his girl friend in the Mooney. Somewhere over the Appalachia’s he got into cloud and was picking up ice. The flight ended with the aircraft leaving a smoking hole in the hills.

    Attending the funeral, the eulogies where about all his wonderful achievements, his love of life, etc. I couldn’t help but think about his girl friend’s two small children who’s lives were now changed forever. Completely irresponsible.

    The teaching moment is about the great responsibility that we, as pilots, shoulder for our passengers and of course the folks on the ground. I suppose it’s the same issue of drinking and driving, where the driver takes the life of others. Action and Accountability really needs to be part of the on going learning process, with instructors and fellow pilots helping to re-adjust actions and a pilot Behavior.

    The real question is our ability to change people’s thinking or is that an effort in futility, like changing someone’s DNA?

  7. I’ll take the other side of the argument. I don’t want anyone telling me what I can do and what I can’t do. All that does is to [gradually or quickly] turn everyone into a supporter of totalitarian dictatorship in every aspect of life and existence. Screw that!

    Stop telling others how to live their lives and what level of risks they can take. The fact of the matter is this. Even those people who seem to have the most “crazy” behavior care more about themselves than you. In fact, much more. And since they are in danger every single time they take any action, they are almost infinitely more endangered by their actions than you or I are.

    You and I and everyone is thousands or millions of times more at risk from people going out in public while infected by some contagious disease than we are from even the most wild, crazy, careless pilot. That’s a fact, and you can verify this easily by researching basic statistics. And oh, by the way, most of those people you might catch and die from catching a disease from them … do not feel any symptoms from what infects them, and may in fact be immune or resistant to what infects them.

    Sadly, this and almost all authors never bother to consider the wider context that ACTUALLY impacts rational judgement about the topic they discuss. Which leads to the tendency to promote the INSANE notion that everyone should be prohibited from doing anything.

    That is not an exaggeration. If just going shopping is thousands or millions of times more likely to get your killed than a random airplane accident smashing into you … and you want to create laws and rules and regulations against pilots who may present some level of danger … then you also agree that endless predators-that-be should lock you and everyone else in a room permanently, and never let you go anywhere or do anything. THIS IS LITERALLY TRUE. SO WAKE UP AND ACKNOWLEDGE THIS.

    The danger presented to you and I by people who take risky actions is EXTREMELY TINY. This is in fact an inherently self-limiting problem. Why so? Because people who take risky actions KILL THEMSELVES FIRST. And the number of others killed by them in the process of taking risky actions is so many thousands or millions or billions of times less than the risk you suffer by shopping at the store, that you are just being stupid by making a big deal of this “problem”.

    So stop being stupid. Enjoy life. And from time to time, enjoy doing things that are a bit risky … if you wish.

  8. Read the articles, read the comments, entered all the data derived therefrom into the computer model, which has been updated with the latest algorithms. Oddly, the usual answer emerged: “Face it, human. Stuff happens to you bios.” Annoying device, that.