Incident Overview
On 29 June 2022, a Piper PA-28-161 (registration G-BORL) operated as a private flight from Blackpool Airport, Lancashire. The aircraft carried two crew members: a 57-year-old flying instructor and a qualified pilot. Shortly after takeoff from Runway 28, the instructor became unresponsive. The pilot completed a circuit and landed the aircraft safely. Emergency services, including airport fire crew and an air ambulance medical team, attempted resuscitation but were unsuccessful. A post-mortem determined the cause of death as acute cardiac failure.
Flight History
The qualified pilot had intended to fly solo to another airfield but deemed the crosswind above his personal limit. To maintain recency requirements, he asked the instructor to accompany him for a single circuit. After the instructor finished a trial lesson, they met at the aircraft. The pilot taxied to the runway, and during taxi, they conversed normally. The pilot recalled telling the instructor he would keep the aircraft into wind for power checks, and the instructor replied, "looks good, there is nothing behind you." No further communication from the instructor was recalled. Shortly after takeoff, the pilot noticed the instructor's head roll back but initially thought he was joking. As the aircraft turned onto base leg, the instructor slumped over, resting his head on the pilot's shoulder. The pilot continued the approach and landed on Runway 28. While taxiing back, the instructor remained unresponsive, prompting the pilot to signal for help.
Post-Mortem and Medical History
A post-mortem examination revealed that the instructor died from acute cardiac failure. His coronary arteries showed diffuse atheromatous disease, and a coronary thrombus occluded the left main stem artery. Toxicology tests were unremarkable. The instructor had a medical history of hypertensive disease and had been taking blood pressure medication since 2002. He held a valid Class 1 Medical certificate, last renewed on 10 February 2022, approximately four months before the incident. He was a non-smoker and had been under regular review for hypertension by his general practitioner. Routine ECGs had been normal. His QRISK2 score, calculated in January 2022, was 12.2%, but no further investigation or treatment had been undertaken at the time.
CAA Medical Department Review
The AAIB requested a review by the CAA's medical department. They observed that the evidence was consistent with a fatal arrhythmia due to oxygen starvation of heart muscle following coronary artery occlusion, likely occurring at takeoff without preceding cardiac symptoms. The instructor had known risk factors (high blood pressure, elevated blood lipids, overweight) but no complications. The CAA noted that the levels of coronary stenosis seen at post-mortem would have been disqualifying if symptomatic and investigated. The CAA stated it would review the circumstances at its cardiac panel to determine if any changes to current guidance are warranted.
Analysis
The instructor suffered a sudden fatal heart attack during takeoff. Because a qualified pilot was present, the aircraft was landed safely. Cardiac events are a known cause of sudden incapacitation in aviation. In multi-pilot operations, the risk is mitigated by the second pilot, but single-pilot operations remain vulnerable. The CAA continually reviews its cardiac guidance, noting that no tests provide 100% reliable detection of cardiac issues and that additional assessments carry risks of unnecessary licence loss. The rarity of accidents caused by cardiac events suggests the current balance is appropriate and subject to ongoing review.