2 fatalities

Pilot Incapacitation Due to Hypoxia Following Pressurization System Issue (N414MT)

Guyton, United States of AmericaFlight

On December 29, 1997, a Cessna 414 Chancellor (registration N414MT) operated by Valley Forge Manufacturing Corporation was involved in an aviation accident near Guyton, United States of America in flight. 2 people were killed. Investigators recorded the probable cause as: Inadequate maintenance of the cabin pressurization system, which resulted in inadequate pressurization and incapacitation of the pilot due to the hypoxia. Also causal was the pilot's failure to adequately monitor the cabin pressurization system. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A).

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 2026-06-11Data APIEditorial standards

A pilot became incapacitated due to hypoxia after a pressurization system malfunction, leading to multiple departures from controlled flight and impact with terrain. Investigation found inadequate maintenance of the pressurization system.

Background

Approximately 26 minutes after takeoff, while cruising at 21,500 feet, the pilot requested a non-existent route from air traffic control. Seven minutes later, the passenger—who held a former student pilot certificate and had accumulated 73 flight hours in Cessna 150/152 aircraft about five years earlier—reported that the pilot felt lightheaded and was fading, and subsequently lost consciousness.

Events

Air traffic controllers and other pilots on the frequency attempted to assist the passenger. She was advised to administer oxygen to herself and the pilot but was unable to do so. The airplane continued climbing to 34,200 feet, where it departed controlled flight, recovered, and then departed controlled flight several more times before initiating a nose-low descent. Witnesses reported hearing the airplane orbiting multiple times while above a cloud layer, then observed it orbiting beneath the clouds. The aircraft impacted the ground in a descending right-wing-low attitude and came to rest submerged in a pond.

Investigation Findings

Examination of the flight controls, engines, and propellers revealed no evidence of preimpact failure or malfunction. However, a discrepancy with the regulating valve was noted. Two small holes were found in the cabin door seal. The left wing pressurization duct had been replaced approximately eight years earlier, but the right wing pressurization duct had not been replaced; both ducts are classified as on-condition components. No preimpact failure or malfunction was found with the barometric pressure switch, cabin altitude annunciator bulbs, safety valve, solenoid valve, or differential pressure/cabin altitude gauge. Testing for carbon monoxide was negative for both the pilot and passenger.

Probable Cause

The official probable cause was stated as: Inadequate maintenance of the cabin pressurization system, which resulted in inadequate pressurization and incapacitation of the pilot due to hypoxia. Also causal was the pilot's failure to adequately monitor the cabin pressurization system.