Sudden Incapacitation Due to Cardiovascular Disease in Elderly Pilots: Lessons Learned from Two Fatal Accidents of Elderly General Aviation Pilots in Finland

Abstract

Investigations of aviation accidents are based on provisions of the International Civil Aviation Organization (ICAO) Annex 13 agreement. A safety recommendation may be addressed to international aviation organizations, such as the European Aviation Safety Agency (EASA) and the ICAO, by the Accident Investigation Agency of any country, following a safety investigation into an occurrence. This process also promotes learning from smaller aviation accidents internationally. This article highlights two relatively small aviation accidents in Finland from 2016 and 2021, respectively, both of which fall under general aviation and have led to significant aeromedical safety recommendations for the EASA and the ICAO. In the 2016 accident, a general aviation pilot, who had previously suffered heart attacks, suffered another heart attack and died shortly after landing. This incident led to a recommendation issued to EASA calling for additional training of aeromedical officers in aeromedical risk assessment on pre-existing health conditions. The 2021 accident involved an elderly general aviation pilot who became incapacitated due to health issues. The recommendations resulting from this investigation were brought further to the ICAO and EASA in order for them to emphasize the importance of the age of a pilot in current aviation health assessment guidelines.

1. Introduction

Potential root causes of aircraft accidents in general and commercial aviation have been investigated extensively. For example, Voogt et al. [1] have studied ultralight accidents in the U.S., UK, and Portugal. Bye et al. [2] have analyzed Norwegian commercial offshore and onshore helicopter operations and provided insight on how the international helicopter industry could reduce the accident level significantly. We analyzed recent commercial aircraft-assisted suicide accidents and emphasized that in aircraft accident investigations, a detailed psychological autopsy of pilots can help the accident investigation [3]. Boyd and Stolzer [4] have analyzed the aging of pilots and whether their declined cognitive function is a predictor for fatal accidents. Their findings question automatic disqualification of air transport pilots at 65 years of age. These studies and many more on the causes of accidents are invaluable to develop better criteria and tests of pilots to continue to reduce errors and other factors that may contribute to the causes of serious and often fatal accidents.

International standards for aircraft accident investigations are derived from Annex 13 of the Chicago Convention on International Civil Aviation [5]. In the European Union (EU), the investigations of accidents and serious incidents are based on EU Regulation No. 996/2010 of the European Parliament, which is also in its turn based on the aforementioned ICAO Annex 13 [6]. The aim of these standards and regulations is that independent national civil aviation safety investigation authorities investigate accidents and incidents to improve aviation safety without apportioning blame, thus fostering a better safety culture.

The Annual Safety Review by the European Union Aviation Safety Agency (EASA) introduces new safety recommendations that are annually assigned to the EASA. The EASA Annual Safety Recommendations Review 2024 showed that 60% of safety recommendations in 2023 were related to procedures or regulations, 13% were related to aircraft, and 17% were related to personnel [7]. Safety recommendations regarding aviation health are scarce. In 2023, the EASA published 56 safety recommendations, none of which were directly related to aviation health assessment. The Germanwings investigation conducted by Bureau d’Enquêtes et d’Analyses pour la Sécurité de L’aviation Civile (BEA) in the year 2015 can be considered internationally the most significant aircraft accident investigation that led to substantial recommendations for improving health assessment in aviation [8]. This accident investigation led to six recommendations related to mental health in aviation, the assessment of pilots’ psychological fitness, and supporting pilots in mental stress. The number of recommendations reflect Sidney Dekker’s observation that the more tragic an accident is, the more it generates safety recommendations [9]. But it is also possible to gain insight and issue safety recommendations stemming from recreational aviation. What is more, the safety recommendations issued on the basis of these aircraft accidents may be utilized in commercial aviation.

In fact, the Safety Investigation Authority, Finland, has actively introduced aviation-health-related safety recommendations since 2013 [10]. Based on an aircraft accident that occurred in 2013, it was recommended that: in the training of especially psychiatrists, neurologists, and cardiologists, it is advised the practice to consult the pilot’s aeromedical examiner (AME) regarding aviation health problems which may impact the pilot’s flying performance.

In the article herein, two relatively small aviation accidents are highlighted that occurred in Finland in 2016 and 2021, respectively. They both occurred in general aviation and led to significant aeromedical safety recommendations addressed to the EASA and the ICAO [11,12]. Both accidents led to the sudden incapacitations of an elderly pilot, resulting from cardiovascular disease. Although these two accidents occurred in general aviation, sudden incapacitations caused by a cardiovascular disease are also very significant in commercial aviation [13]. In fact, in Europe, acute myocardial infarction (AMI) has been reported to be the leading cause of sudden incapacitation [14]. It can be argued that the impact of cardiovascular diseases as a contributing factor for aircraft accidents requires continuous attention in aviation accident investigations, especially when involving, but not limited to, elderly pilots [15,16,17,18]. For example, the study of 534 fatal fixed-wing general aviation aircraft accidents’ autopsy reports showed the presence of cardiovascular abnormalities among 234 pilots (44%) [15].

Studies show the importance of carrying out cardiovascular risk assessments when recruiting aircrew [18,19]. Currently, cardiovascular risk assessment are actively carried out on commercial aircrew and attempts are made to diagnose symptomless coronary heart diseases [20]. However, cardiovascular risk assessment and follow-up is less successful among general aviation pilots due to less stringent health requirements.

Interestingly, it has been indicated that light sport aircraft accident rates are higher compared to general aviation aircraft accidents in the U.S. [21]. A comparison of U.S. medically certified and uncertified Class III pilots showed that the risk of an adverse medical event in general is reduced in pilots who are certified [22]. These studies demonstrate the importance of regular aeromedical fitness assessments. In the near future, challenges are expected to arise regarding the health status of advanced air mobility pilots and its impact on accidents [23]. If their aeromedical fitness is not studied, the same problems as those shown in the study by Ricaurte et al. [22] can follow.

In this article, we discuss aviation cardiovascular health and the need to develop requirements that take aging into consideration. The article is based on the extracted findings of cardiovascular health problems found in the two aforementioned recent aircraft accident reports published by the Safety Investigation Authority, Finland [11,12].

2. Aircraft Accident in Vampula, Finland, in 2016

Pilot Incapacitation During Landing at Vampula Aerodrome, Finland, 2016

The accident occurred on 24 September 2016 involving a pilot of a Cessna 172N aircraft [11]. The flight lasted for approximately 15 min. During the flight, the pilot reported that he was not feeling well and intended to land earlier than planned and, during the attempted landing, the aircraft almost collided with a trench and landed off the runway. At the taxiway intersection, the pilot failed to sufficiently turn the aircraft. The right wing of the aircraft collided with the ground. Almost immediately after disembarking, the aircraft pilot collapsed. When the ambulance arrived, the pilot was pronounced dead.

Prior to the accident, the pilot had suffered three AMIs, in 2011, 2013, and 2015 (Figure 1). The pilot was 59 years of age when the first AMI occurred, and an angioplasty was performed. The pilot suffered the second AMI at 62 years of age. The affected coronary artery, which was narrowed and blocked, was not the one involved in the previous AMI. Again, an angioplasty was performed. One year later, the pilot was diagnosed with severe sleep apnea. At the age of 63, the pilot suffered his third AMI. The coronary artery that was narrowed and blocked was the same involved in the first AMI. Stenting was carried out. In the post-mortem examinations, it was found that the pilot suffered his fourth AMI during the landing. In the toxicological tests, drugs prescribed for the previous cardiovascular conditions were present.

3. Aircraft Accident in Hyvinkää, Finland, in 2021

3.1. Pilot Incapacitation in the Accident at Hyvinkää Aerodrome in Finland, 2021

On Monday 27 September 2021, a pilot instructor and a pilot receiving instruction were departing for a refresher flight from the Hyvinkää aerodrome [12]. The aircraft was a tandem-seat Van’s RV-8 amateur-built airplane. The purpose of the flight was to extend the validity of the Light Aircraft Pilot License (LAPL) held by the pilot receiving instruction. The final portion of the flight was a simulated forced landing. The pilot reduced power and initiated a turn toward the runway. During the turn, the aircraft’s speed fell rapidly, and control was lost. The airplane crashed. It is likely that the pilot receiving instruction became incapacitated during the landing.

3.2. Medical History of Pilot Receiving Instruction

The pilot was a smoker and had a faulty aortic valve, ascending aortic aneurysm, and was on blood pressure medication. He had a Class 2 medical certificate from an aeromedical examination dating back to January 2015. In the follow-up examinations, the pilot’s general condition had remained essentially unchanged, except for progression of the aortic aneurysm. The following assessment was to be carried out six months later (Figure 2).

In the subsequent aeromedical examination, no progress of the aortic vessel disease was found, and the Class 2 certification was extended to 12 months starting from April 2016. However, soon after validation, the pilot had cardiac symptoms and was diagnosed with a severe coronary artery disease, requiring an operation. In 2017, a triple bypass surgery, the replacement of the aortic valve, and aortic aneurysm grafting were carried out. The pilot suffered neurological complications requiring extended hospitalization. The operation also caused aortic dissection and arrythmia symptoms. An MRI examination, however, showed that the surgery had achieved the desired results. After the medical examination, the pilot was granted a 12-month LAPL aeromedical certificate, which was valid until February 2019. After this period, the following LAPL aeromedical certification was granted for additional 12 months in July 2019. The pilot started to suffer claudication, and an exercise test assessment needed to be carried out in a hospital using a test in which heart rate is increased by medication. The last medical assessment before the accident was carried out in July 2021, which resulted in granting a LAPL certificate for 12 months.

3.3. Medical Issues on the Accident Day

The pilot receiving instruction had felt normal prior to the flight. He spoke on the radio a minute before the accident. However, he became suddenly incapacitated after the radio transmission. A forensic autopsy determined that the cause of death was the rupture of the thoracic aorta and aortic dissection. Additionally, a previously undiagnosed heart attack was discovered. Forensic chemistry analysis showed no presence of alcohol or medical substances that could have affected the central nervous system.

4. Discussion

Recently, the health challenges of aging pilots and possible related flight safety risks through sudden incapacitation have sparked discussions [24]. These age-related concerns have been partly associated with general aviation pilots, but even more so with Helicopter Emergency Medical Services pilots, whose age limit was recently extended to 65 [25].

In general, there are several concerns associated with the health and the possibility of sudden incapacitation of aging pilots. A recent study investigated the causes of fatal general aviation accidents among pilots over 70 years of age in the U.S., and identified several age-related health factors that may have contributed to the accidents [26]. Vuorio et al. [26] conducted a study on people over the age of 70 and analyzed health-related causes that may have contributed to the accidents based on accident investigation reports. According to the study, approximately 19% of accidents entailed health-related causes that contributed to the accidents. For pilots aged 60 to 63, the respective figure was 6% (proportion ratio 3.04, 95% confidence interval 1.19–7.74). The study also found that pilots over 70 years compared to pilots aged 60–63 years, who died in plane crashes during the same period, were statistically more likely to be taking three or more medications. Such polypharmacy indicates that these older pilots had multiple medical conditions that could potentially affect their health—a factor less associated with younger pilots. However, in this study, the occurrence of the cardiovascular disease was not separately analyzed.

Sudden incapacitation of general aviation single-flying pilots is more critical than sudden incapacitation of commercial pilots because the latter are crewed in pairs. Thus, a level of redundancy reduces the risk of accidents caused by health-related factors compared to single-piloted aircraft. An Australian study found that commercial pilots have been well trained on the handover to the non-impaired pilot in the event of incapacitation [27]. In general aviation, similar maneuvers are seldom practiced, even though in some cases there may be another pilot on board.

4.1. Cardiovascular Health and Pilots

Cardiovascular disease is the leading cause for pilots being grounded or being denied a medical certificate [28]. A recent study examined findings in the autopsy reports of 602 pilots who died in U.S. aircraft accidents from April 2013 to March 2016 [29]. In this study, cardiovascular abnormalities were discovered in approximately 85% of the cases, making them the most common finding. There were 31 accident cases in which a medical issue was a probable cause or a contributory factor in the accident. In 19% of these cases, a cardiac disease had been diagnosed. This finding that cardiovascular etiology is the most frequent reason for acute incapacitation is supported by a cross-sectional study that was performed on 856 pilots employed in an Oceania-based airline [30]. They reported that instead of relying only on exercise electrocardiograms, a more accurate cardiovascular assessment is needed for those pilots having excessive cardiovascular disease risk. Additionally, diet counseling for unhealthy nutrition is regularly needed [28]. The nutritional counselling is infrequently registered after cardiac event hospitalization [31].

4.2. Risk of Recurrent Acute Myocardial Infarction After Stenting for a Pilot with Additional Risk Factors

Impact of chronological aging on vascular diseases across various arteries can be considered an estimation of the overall pattern of cardiovascular disease aggravation caused by aging [32]. Currently, AMI is most often treated by stenting to reduce the risk of recurrent AMI [33]. The risk of recurrent AMI is highest during the first year after the attack but remains elevated for many years, increasing with age [34]. When assessing a general aviation pilot’s age-dependent health, it is not uncommon for an AME to assess the risk of a recurrent myocardial infarction in a general aviation pilot who has had one or even two previous myocardial infarction(s). In these cases, it may not be appreciated that, based on a recent registry study, the cumulative incidence of recurrent AMI even after successful PCI was 3.6% [35]. The current European aeromedical guidelines do not sufficiently support the aeronautical doctor’s assessment, because they do not address a medical risk assessment separately after a first or repeated myocardial infarction [36]. In fact, the challenge of a risk assessment relating to a recurring AMI not considered separately after stenting is also related to aeromedical guidance in general [37]. In the investigated flight accident that occurred in Vampula, the pilot developed sleep apnea, which, in turn, complicated the risk assessment, because even if treated, it would not have decreased the risk of a recurring AMI [38].

4.3. Aortic Diseases and Aging

In the Hyvinkää aircraft accident, the pilot had an aortic aneurysm. The ICAO aeromedical guidance provides more information for AMEs about aortic diseases compared to the European guidance [36,37]. The ICAO manual indicates that an aortic aneurysm is more common in men over 55 years than in women of the same age. Age, coronary artery disease, and high blood pressure impair prognosis of an aortic aneurysm. The U.S. Preventive Services Task Force recommends that every male in the U.S. between 65 and 75 years of age with a history of smoking should undergo a one-time abdominal aortic aneurysm screening with ultrasonography. This guidance is not mentioned in the ICAO or EASA documents [36,37,39]. Guettler et al. [40] found the importance of a close co-operation between the cardiothoracic surgeon, cardiologist, and AME, especially in the follow-up of aortic aneurysm post-surgery assessments, to be of importance. Additionally, the authors in this article emphasize that aortic dissection is incompatible with commercial aircrew duties and that pilots suffering from it should not be predisposed to elevated acceleration force.

4.4. Decision-Making and Aging Pilots with Multiple Diseases

Aeromedical assessments regarding working-age pilots often focus on evaluation of only one disease (Figure 3). This process is routine, and usually there is available evidence-based research providing data of the prognosis and follow-up of the specific disease [41]. An AME can also consult a specialist, if needed.

If a working-age pilot has several diseases, the assessment becomes more challenging (Figure 2). In this situation, evidence-based research and aeromedical guidance do not provide the necessary guidance for the assessment process and ultimately risk estimation. However, the AME could seek additional help with the risk estimation from a specialist who is more experienced in given specific field.

Regardless, the assessment would still be extremely challenging, or even impossible, to achieve adequately, when an elderly pilot has multiple diseases. Neither aeromedical guidelines nor evidence-based research commonly address elderly pilots. In this situation, the medical specialist may have limited knowledge of specific challenges related to elderly pilots. In particular, accountability and follow-up by the pilot, AME, and the licensing authority could reduce risk and determine whether high-risk pilots should continue to fly.

5. Findings of the Accident Investigations

The findings in the two cases dealt with above are illustrative of gaps in the assessment processes that led to high-risk individuals continuing to fly. More attention should be given to ensuring that all parties are accountable for meeting and documenting necessary medical fitness requirements.

5.1. Findings: Aircraft Accident in Vampula, Finland, in 2016

• The pilot suffered his first heart attack in March 2011, at the age of 59. Balloon angioplasty was performed.
• In March 2012, the licensing authority issued the medical certificate with the condition that, in addition to the aeromedical examination, the pilot produce the results of an exercise ECG and a cardiologist’s evaluation.
• The patient suffered his second heart attack in September 2013, at the age of 62. The narrowed left coronary artery was treated with balloon angioplasty.
• In early 2014, the pilot was diagnosed with severe obstructive sleep apnea. In response to this, continuous positive airway pressure (CPAP) treatment was initiated.
• The AME granted the medical certification in October 2014 and finalized the examination in January 2015.
• The patient suffered his third heart attack in late January 2015, at the age of 63.
• On Saturday 24 September 2016, the day of the accident, the pilot had to hand-start the engine by swinging the propeller. During the start process, the pilot took a 15 min break because he was out of breath.
• The pilot took off for a second flight. During the flight, the pilot reported that he would land earlier than planned because he did not feel well.
• The pilot found it difficult to control the aircraft during the approach and landing. While taxiing, the aircraft ended up in a ditch next to the taxiway.
• Almost immediately after disembarking, the pilot collapsed to the ground and died.

5.2. Findings: Aircraft Accident at Hyvinkää Aerodrome on 27 September 2021

• The pilot receiving instruction was 78 years of age. Despite his age, he wanted to continue flying. Over the years, he had been diagnosed with a growing number of diseases and his medication had been increased.
• The pilot receiving instruction and the instructor departed on a refresher flight in an airplane that was not fitted with instruments and rudder pedals in the rear cockpit. The airplane was not suitable for refresher training.
• The airplane commenced a simulated forced landing close to the runway centerline at an unusually low altitude, and a steep turn to align the airplane with the runway was necessary. While airspeed dropped, stalling speed increased.
• The pilot receiving instruction suffered a bout of illness either very close to the ground or upon impact. The event caused sudden incapacitation.

6. Safety Recommendations

The below safety recommendations were derived from the two abovementioned aircraft accident investigations. The Safety Investigation Authority, Finland, has issued recommendations with the intention to prevent the same types of accidents from occurring in the future.

Providing safety recommendations is based on ICAO Annex 13 [5], requiring that States address safety recommendations arising out of its investigations to the accident investigation authorities and organizations, like EASA and ICAO.

6.1. Recommendations of Aircraft Accident in Vampula in 2016 by the Safety Investigation Authority, Finland

Based on the aircraft accident that occurred in Vampula in 2016, the Safety Investigation Authority, Finland, issued safety recommendations for the EASA and the ICAO to consider.

Table 1. Safety recommendations issued for the EASA and the ICAO based on the investigations of the Vampula aircraft accident [11].

Safety Recommendation	Target Organization
To provide an international health assessment process for a risk assessment after heart attack	ICAO to review the existing guidance material contained in the Manual of Civil Aviation Medicine to include a risk assessment model to facilitate aeromedical decision-making in the evaluation of pilots at risk from recurrent heart attacks.
Aeromedical examiners’ competency-based recurrent training	EASA to enhance AME risk assessment competency through safety promotion, competency-based recurrent training, and specific training on the national procedures for referral and consultation, as well as the limitations of assessments.

summarizes these recommendations.

6.2. Recommendations of Aircraft Accident in Hyvinkää in 2021 by the Safety Investigation Authority, Finland

Based on the aircraft accident investigations in Hyvinkää 2021, the Safety Investigation Authority, Finland, provided safety recommendations for the EASA and the ICAO.

Table 2. Safety recommendations provided to the EASA and the ICAO based on the investigations of the Hyvinkää aircraft accident [12].

Safety Recommendation	Target Organization
Training of aeromedical examiners in health assessment of elderly pilots	EASA to enhance aeromedical examiners’ knowledge and skills in the assessment of the state of health of elderly comorbid pilots.
Updates to International Aviation Medicine Guidelines	ICAO to update its Manual of Civil Aviation Medicine to better address age-related factors.

summarizes these recommendations.

7. Follow-Up of the Safety Recommendations

The Safety Investigation Authority, Finland, has a legal obligation to monitor the status of given recommendations for ten years upon their publication. The addressees of the safety recommendations pertaining to the two incidents studied in this article aim at implementing given recommendations, as follows:

• The ICAO intends to include a risk management model in its aeromedical manual that aviation doctors can use as a reference point when assessing the aeromedical decision-making of pilots who have experienced recurrent myocardial infarctions. Document 8984 will be revied to include the risk assessment model.
• The EASA enhances the risk management skills of aviation doctors in aeromedical decision-making by providing specialized training and promoting the use of consultation and prudent judgment in their assessments.
• In addition, the EASA has initiated a legislative project, the scope of which is to enhance the capability of aviation doctors to assess the effect of aging on pilots in health checks. Commission Regulation (EU) No. 1178/2011 Annex IV (Part MED) will be revisited upon completion of the project.

8. Conclusions

The pilot population is aging, and it is becoming more common that pilots in general aviation wish to continue flying until up to 70 or 80 years of age [26,42,43]. In most cases in general aviation, periodical health assessments’ traditional cardiovascular risk scores (CVRS) are used. However, these CVRS have limited value when assessing cardiovascular risks in elderly asymptomatic pilots. There is a need to use, for example, coronary tomography angiography (CCTA) [44]. The cost of these special imaging methods, however, limits their applicability. Another cost-effective option is to offer pilots effective preventive medication for elevated blood pressure and cholesterol, which are traditional risk factors for cardiovascular diseases [45,46]. To address the increasing risk, it is essential that AMEs continue education and training in risk assessment regarding old pilots, especially those with cardiovascular diseases. There is also a need to give more age-specific aviation health assessment guidance. A good example of this type of guidance material is the European Union Aviation Safety Agency guidance regarding health assessment of Helicopter Emergency Medical Service (HEMS) pilots up to 65 years of age [25,47]. Typically, HEMS operations are carried out by single pilots. As in general aviation, the risk of incapacitation of a single pilot causes greater risk than in commercial aviation, where a second pilot can carry out the operation during an incapacitation emergency [48,49].

We have recommended that it would be useful to obtain a health statement of an attending general practitioner who is responsible for assessing and advising on a pilot’s everyday health [26]. The effective aeromedical health assessment also requires knowledge of specific cardiovascular diseases and other health-related problems among the elderly population [50]. Also, the multimorbidity related to cardiovascular diseases among older pilots causes complexity in health assessment when trying to manage fluctuating aviation health [51]. Even if there is a need to improve aeromedical assessments of elderly pilots, the FAA in 2016 carried out a third-class reform, which means that most pilots who have held a valid medical certificate at any time in the decade prior to 15 July 2016 need not take another medical exam, and an aeromedical examination is substituted by visiting a state-licensed physician at least once every four years [52]. It has been demonstrated, when comparing U.S. medically certified and uncertified Class III pilots, that the risk of an adverse medical event in general is reduced in pilots who are certified [22]. It should be evident that relaxing the aeromedical assessment protocol could be harmful, especially among older pilots.

In the current situation, with the aging general aviation population, aircraft accident investigation plays a key role in examining accidents involving older pilots. These investigations require deeper aeromedical understanding of the relevant health problems potentially related to older pilots’ flight performance. In this article, we have discussed cardiovascular health in aviation and the need to develop requirements that take aging into consideration. While we have only discussed two accidents involving small aircrafts in this article, the safety investigations carried out for these accidents demonstrate the risks related to aging pilots, especially to those suffering from cardiovascular diseases. These investigations are also a helpful learning tool and can help mitigate the risk of large aircraft accidents. Accountability and follow-up by the pilot, AME, and the licensing by aviation authorities may reduce the risk of aircraft accidents and help to decide whether high-risk pilots should continue to fly.