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12


but until quantitative descriptions are more gen-
erally available, a general analysis of post mor-
tem data will necessarily be limited.

We would like to stress that the post mortem
examination pertaining to aircraft accidents is
both a “flight performance” examination and a
forensic pathology examination. The findings
may well be related to significant legal consid-
erations, It is noted that if it is found that the
large majority of pilots over the age of 40 con-
tain significant coronary artery disease, then we
must improve our physical examination method-
ology to enable detection of those persons who
apply for medical certification who have ad-
vanced previously unknown disease.

We also emphasize that although significant
pathology is divulged through the post mortem
examination in a specific case, the role of this
pathology (with respect to the cause of or as a
contributor to the actual accident) can be deter-
mined only when all of the circumstances are
reviewed and evaluated. It will often be con-
cluded as in the majority of the cases reviewed

Post mortem data is essential in order that the
physical standards required for pilots can be
routinely monitored for effectiveness.

II. Conclusions and Recommendations.

The next advance in aviation pathology studies
is seen as the standardization of post mortem
format and terminology. Especially needed to-
day is a quantitative measure for the degree and
extent of atherosclerosis. It is recommended
that a standard format be promulgated by pa-
thologists and utilized for the conduct of avia-
tion post mortem examinations. It is also
recommended that pathologists develop and
utilize a quantitative scale for assessing the de-
gree and extent of atherosclerosis, particularly
that found in the coronary arteries.

Taste 1—Summary of Sequential Post Mortem Data,
Pilot Fatalities, 1/03/68 to 3/05/68 (Coronary
Atherosclerosis)

Coronary atherosclerosis

here, that pathological findings are incidental to Age group
the specific accident (other than those findings Absent Present | No mention
resulting from the impact or fire).

An important additional consideration bearing 20-29 2 3 1
upon the need for post mortem information con- 90-39 3 6. 3
cerning pilots of general aviation aircraft is that 50-60 1 2 0
of the requirements for aeromedical certification.

REFERENCES

1. Rears, WiuiaM J. (Editor); Medical Investigation
of Aviation Accidents, College of American Patholo-
gists. Chicago, Illinois 1968, pp. 1-150.

2, Procer, Samuet; Comment on “Coronary Heart Dis-
ease Terminology” Journal of the American Medical
Association, Vol. 209, No. 8, August 25, 1969, pp.
1229-1230.



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panuyuog—(2{dueg esuanbeg [exodway,) SLNACIQOV NOLLVIAV IVUANGD IVLV 8961-1 XIGNGddV


ABDOMEN:

1%) Peitoneum
Retroperitoneum
liver—Weight 1700 gu
Extrahepatic Ducts
Gallbladder
Spleen—wt. 250 ga.
Esophagus
Stomach

&

5

5 Duodenum
Small Bowel

Large Bowel
Pancreas

R

Adrenals
Right Kidney—wt. 140 ga,
length 123.5 cn,
Cortex «7 ca,
Left Kidney—wt. 140 gn.
length 11.6 ca,
Cortex 9 Be

Right Ureter

Left Ureter

Bladder

Urethra

Prostate—Wt.

Testicles—Wt.

Uterus—Wt.
(0 Fallopian Tubes
0 Ovaries

VASCULATURE:

C Ascending Aorta
C] Thoracic Aorta
( Abdominal Aorta
C] Great Branches, Aorta

¥ Great Veins

CENTRAL NERVOUS SYSTEM:

[) Not Examined

Leptomeninges
(TL) Ventricular Fluid
Dural Sinuses
(T)Pituitary Gland
(PT) C.N.S. Arteries

(C})Coronal Brain Sections

Grade I athorowntosis of aorta, patchy.

Xs ne mamgecant
abrowhality

O = pee ruippte maaber 4
when

Fieure 2. This page is from a standard format used by a pathologist to assist in the uniform and systematic
collection of post mortem information. It helps assure that no system or organ is overlooked.

5



INTERNAL EXAMINATION: AUTOPSY NO.
oP ate

RT. PLEURA__O_CC.
i FIBR. ADHES.

LEFT PLEURA
MF/BR. ADHES.

MEDIASTINUM:

oO

?
PERICARDIUM. cc.

W F/BR. ADHES.

PERITONEAL CAVITY —2__ cc.
TQ FIBR. ADHES.

RETROPERITONEUI: Mo Miheteo

QMGUIES DEMCHSTRALN:
Na
—_

ARTERIOSCLEROSIS

AORTA wa |
CORONARY a
CEREBRAL | {|

CARDIOVASCULAR
SYSTEM.

@ Access. RT.
CORONARY A.

YU

SuGNT Her rmk
THK MS DEmees Rin

Ale oF pis Conesingy
PRE RS PAVE LXRUS/
Laeehbinetr OF ye

CAMS Bf AVERILL

MUER GEESE AEs
Fire nila Vitae,

Yor:
ZO
fo

Se
al \*

Ficure 1. This form was devised by a pathologist to enable a more consistent and graphic portrayal of athero-
sclerosis findings. It is one of several pages completed by the pathologist for each post mortem examination.

Té WERK Pity B=-9O7-
Woda. bwnnne Pith reas,
No Fann Levis steey (5 PEM

4


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AM 69-18

THE SAFETY SIGNIFICANCE OF AIRCRAFT ACCIDENT
POST MORTEM FINDINGS

P. V. Siegel, M.D.
S. R. Mohler, M.D.
A. Cierebiej, M.D.

Approved by Released by
oe
Stemkey & “Mehl [U Sege€ wo
Srantey'R. Mouter, M.D. P. V. Srecrn, M.D.
Cuter, ArRoMEDICAL APPLICATIONS Fevers, Am Surcron
Drviston
October 1969

Department of Transportation

FEDERAL AVIATION ADMINISTRATION
Office of Aviation Medicine



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10


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serve as examples (there are several similar cases
each year in the U.S.) :

Case History Number One

A 44-year-old male pilot with 9,500 hours of
flight experience and a commercial pilot’s license
was flying solo in a Cessna 210, February 21,
1968. As the airplane neared its destination (a
midwest airport), the pilot called the airport
tower controller and reported “having difficulty
breathing and seeing.” The airplane was ob-
served to turn into the base leg somewhat fast
and then to turn to the final approach. The
plane proceeded above the runway for a distance
at about 60 feet of altitude and then was seen to
nose over to a 40° downward inclination and dive
straight into the runway with no apparent effort
on the part of the pilot to recover.

The post mortem examination revealed an
“extremely narrow” left descending coronary
artery, with the lumen “pinpoint in size for its
entire length.” The right circumflex coronary
artery was reported “also narrow, with the wall
thick and yellow.”

The investigators felt that the pilot became
physically incapacitated while attempting to land.

Case History Number Two

A 48-year-old male private pilot with 134
hours known flight time was flying alone in a
Cessna 150 in the Southwest on April 8, 1969.
The aircraft had departed the airport and was
witnessed to suddenly enter a left bank from a
low altitude and then to dive straight into the
ground. No evidence of any attempt to pull out
was seen.

The post mortem report states that “the in-
terior descending branch of the left coronary
artery 1 centimeter from the site of origin shows
recent hemorrhage into the atherosclerotic
plaque.” It also states “this effectively occludes
the narrowed lumen.”

The investigators concluded that the pilot be-
came totally incapacitated in flight, resulting in
the fatal accident.

The above cases illustrate the discovery that
coronary insufficiency at a given moment or
coronary occlusion may yield a transient ischemia
over a small part of the myocardium followed by
a lethal arrhythmia with or without myocardial
necrosis.*, Improvements in electrocardiography

have made possible the premortem detection of
compromised coronary arteries and, or, myocar-
dial necrosis. Continuing information developed
by pathologists is desired to augment these
clinical techniques.

The post mortem examinations accomplished
to date, together with the analyses of the cireum-
stances related to general aviation accidents,
lead us to the conclusion that approximately six
inflight cardiovascular incapacitations per year
occur to pilots flying light planes.

The diversity of terminology currently used
by pathologists reflects the lack of general appli-
cation of a standardized format for autopsy
accomplishments. If the valuable data being
collected by aeromedical investigators in these
accidents is to be analyzed on a broad scale, and
if it is to be treated by computer-assisted tech-
niques, some type of quantitative approach to
post mortem data recording must now take place.
We must know in each case the extent of athero-
sclerosis throughout the coronary artery bed.
We must know the degree to which the lumen
of the coronary artery is compromised. Also,
this information must be expressed by patholo-
gists as closely as possible in generally agreed
upon mathematical terms. In addition, data
must be recorded concerning whether or not a
particular pathologic change was or was not
present. It is observed that sometimes the
cranial vault is not examined during the post
mortem examination. This portion of the exam-
ination is considered to be quite significant.

It is noted that a number of pathologists in
various parts of the country have developed
their own standard format and have had forms
printed. These forms serve as a guide during
the conduct of the post mortem and comprise
valuable systematic collection of data. Figure 1
illustrates a page from one example and Figure
2 illustrates another. Particularly clever, it
seems to us, is the approach used in Figure 1
whereby the major coronary arteries are dia-
grammed on the form and atherosclerotic plaques
sketched as found. Also, any deviation in coro-
nary artery distribution can be shown.

We re-emphasize the need for pathological in-
formation which transcends the earlier predomi-
nantly verbal descriptive approach and takes on
a computer-age quantitative character. Notable
progress in obtaining post mortems has occurred,




THE SAFETY SIGNIFICANCE OF ATRCRAFT ACCIDENT
POST MORTEM FINDINGS

I. Introduction.

We are all aware that in the early days of civil
aviation, pathologists played an extremely minor
role in aircraft accident investigation. This, of
course, reflected, in part, the relatively limited
role of civilian physicians in aviation activities
prior to World War II. Subsequent to World
War II, the pioneering achievements in aviation
pathology carried out by military pathologists
(in the United States, especially at the Armed
Forces Institute of Pathology) have been docu-
mented. Post mortem examinations of crew
member victims of civil air transport aircraft
accidents have achieved a level of virtually 100
percent. This achievement has resulted from the
recognition by transport aircraft accident inves-
tigators that the findings of pathologists provide
definitive information concerning the circum-
stances underlying aircraft accidents. This in-
formation covers causative factors as. well as
crash-injury and survival factors.

Unfortunately, a general recognition by various
individuals involved in the investigation of light
aircraft accidents of the contributions to be made
by pathologists has not been realized to the full-
est extent possible. We know of some recent
fatal light plane accidents in which the investi-
gators did not request post mortem examinations.
This oversight, however, is being seen less fre-
quently as a result of the recognition by accident
investigators of the value of either positive or
negative pathology findings. This paper will
present some information on the current status
of aircraft accident post mortem findings as these
relate to air safety and will give special emphasis
to such findings in those accidents which occur
in the general aviation segment of civil flight
activities.

II. Findings and Discussion.

The accident folders for the year 1968 con-
tained in the Accident Investigation Branch of

the Office of Aviation Medicine were reviewed.
It was found that there were records of 706 fatal
general aviation accidents. Within this fatal
accident population were 687 pilots. In 19 of
the 706 fatal accidents, only passengers suc-
sumbed, thus the lesser number of fatal pilots
in relationship to the number of fatal accidents.
It was found that of these 687 pilot fatalities,
365 post mortem examinations were accomplished.
It is seen, then, that in 1968, a 51 percent post
mortem examination level was achieved in U.S.
general aviation accidents.

Table 1 includes a sequential listing of pathol-
ogists’ comments included in the autopsy records
for the first 60 days of 1968. These comments
come from pathologists in all sections of the
U.S., and are representative of the terminology
used by pathologists throughout the entire year.
Special attention was given to extracting com-
ments bearing specifically upon atherosclerosis,
especially with respect to the coronary arteries.
Since atherosclerotic changes in the coronary
arteries ultimately can lead to sudden incapacita-
tion, aeromedical personnel are particularly con-
cerned about the extent to which this condition
exists throughout the pilot population. It is
noted that some pathologists utilize descriptive
terminology such as “minimal atherosclerosis”
(presumably on a scale of minimal, moderate, or
severe). Others describe the atherosclerosis as
having stenosed the lumen to 75 percent of
normal. Some pathologists made no mention at
all of the interior of the coronary arteries, either
on their gross or microscopic examinations.

Because of the findings by the pathologist,
many accidents each year are better understood.
When the circumstances of the accident are con-
sidered together with the findings of a fresh
occlusion of a coronary artery or severe coronary
disease compatible with sudden heart failure, the
investigators conclusions are essentially made.
The following relatively recent case histories



Prepared for the Seventh Scientific Session of the Joint Committee on
Aviation Pathology, Halton, England, October 15, 1969. Dr. Siegel is Fed-
eral Air Surgeon, Federal Aviation Administration; Dr. Mohler is Chief,
Aeromedical Applications Division, Office of Aviation Medicine, Federal
Aviation Administration; and Dr. Cierebiej is Chief, Accident Investigation
Branch, Office of Aviation Medicine, Federal Aviation Administration,
Washington, D.C. 20590.

Qualified requesters may obtain Aviation Medical Reports from Defense Documentation
Center. The general public may purchase from Clearinghouse for Federal Scientific and
‘Technical Information, U.S. Dept. of Commerce, Springfield, Va. 22151.


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