Fatal Aviation Accidents: 

Fiscal Years 2009-2013

Christy R. Hileman

Cheryl A. McNeil

Paul Rogers

Civil Aerospace Medical Institute

Federal Aviation Administration

Oklahoma City, OK 73125

November 2015

Final Report

DOT/FAA/AM-15/19

Office of Aerospace Medicine

Washington, DC 20591
NOTICE

This document is disseminated under the sponsorship 

of the U.S. Department of Transportation in the interest 

of information exchange. The United States Government 

assumes no liability for the contents thereof.

___________

This publication and all Office of Aerospace Medicine 

technical reports are available in full-text from the 

Federal Aviation Administration website.
i

Technical Report Documentation Page

1. Report No. 2. Government Accession No. 3. Recipient's Catalog No.

DOT/FAA/AM-15/19

4. Title and Subtitle 5. Report Date

Fatal Aviation Accidents: Fiscal Years 2009-2013 November 2015

6. Performing Organization Code

7. Author(s) 8. Performing Organization Report No.

Hileman CR, McNeil CA, Rogers P

9. Performing Organization Name and Address 10. Work Unit No. (TRAIS)

FAA Civil Aerospace Medical Institute

P.O. Box 25082 11. Contract or Grant No.

Oklahoma City, OK 73125

12. Sponsoring Agency name and Address 13. Type of Report and Period Covered

Office of Aerospace Medicine

Federal Aviation Administration

800 Independence Ave., S.W.

Washington, DC 20591 14. Sponsoring Agency Code

15. Supplemental Notes

16. Abstract

Introduction. This report describes the FAA’s Autopsy Program Team’s efforts to support accident 

investigation and research conducted within the Civil Aerospace Medical Institute, including descriptive 

characteristics for fatal aviation accidents and incidents investigated by the Federal Aviation Administration 

and the National Transportation Safety Board for fiscal years 2009 through 2013.

Methods. Autopsy data utilizing the Medical Analysis Tracking Registry database was ordered into the 

following categories: date of autopsy acquisition, date of accident, region and state of residence, accident 

type, age, gender, pilot flight hours, aircraft type, and governing operation. Incidental medical findings 

described in the autopsy reports were classified according to the International Classification of Diseases, 

Tenth Edition – Clinical Modification (ICD-10-CM) and International Classification of Disease, Procedure 

Coding System.

Results. The Team reviewed 1,330 fatal accidents/incidents from fiscal years 2009 through 2013 and 

assisted with requests. Additionally, the Team obtained over 95% of autopsy reports for individuals 

involved in fatal aviation accidents, averaging 266 fatal accidents/incidents per year. The average age of a 

fatally injured pilot was 55 years, compared to the average age of 45 for the U.S. Civil pilot population.

Accidents involving float planes were 2.63% of all fatal accidents. An analysis of 22 Medical Transport 

fatal accidents revealed 46% occurred during the repositiong phase of the flight. During the time frame of 

the study, 37 (31.35%) of pilots let their FAA medical certificate laspse in 118 Light Sport aircraft fatal 

accidents. Summaries of information collected from of fatal accident/incidents are included in the report.

17. Key Words 18. Distribution Statement

Autopsy, Fatal Aircraft Accident, Accident Investigation, 

NTSB, Death Statistics, Coroner, Medical Examiner

Document is available to the public 

through the Internet:

www.faa.gov/go/oamtechreports

19. Security Classif. (of this report) 20. Security Classif. (of this page) 21. No. of Pages 22. Price

Unclassified Unclassified 20

Form DOT F 1700.7 (8-72) Reproduction of completed page authorized

iii

PREFACE

This report is an initial five-year program review for the Autopsy Program Team, encompassing fiscal years 2009-

2013. A fiscal year is from October 1 through September 30 of the following year. The scope of the program applies 

to all fatal and high-profile aviation accidents and incidents, beginning October 1, 2008. The content of this report 

highlights our functions and accomplishments, as well as information about the Autopsy Program. 

v

ACKNOWLEDGMENTS

The Autopsy Program Team acknowledges the work of medical examiners, coroners, and pathologists throughout 

the United States and Territories. These individuals provide pathological examinations for all fatal aviation accidents. 

Furthermore, we acknowledge the Federal Aviation Administration (FAA) and National Transportation Safety Board 

Investigators, FAA Regional Operations Center, as well as the Medical Research Team, and the Management Staff 

at the Civil Aerospace Medical Institute. We extend our sincere thanks to these individuals because without their 

contributions this report would not be possible.

The Team gratefully recognizes all the work and insight of Mitchell Selensky, R.N., Supervisory Legal Instrument 

Examiner, FAA Aerospace Medical Certification Division. His efforts helped to launch the Autopsy Program in 2008 

and supported the creation of the autopsy database. We extend special thanks to Nicholas Webster, M.D., for his support 

and guidance of the Autopsy Program Team. Additionally, we thank CAMI Librarian Roni Anderson, CAMI Research 

Engineer David Moorcroft, CAMI Health Physicist Kyle Copeland, and FAA Accident Investigator Matt Rigsby for 

their help and support. We also appreciate the CAMI’s i-Zone Team, Rick Butler and Jason Nigh, for graphics creation. 

Finally, many thanks to Mike Wayda, CAMI Editor, for oversight of this report. 

vii

Contents

Fatal Aviation Accidents: Fiscal Years 2009-2013

1.0 Background and History. 

2.0 Methods. 

2.1 Aviation Operations Classified by Federal Aviation Regulations  

3.0 Results. 

3.1 Autopsy Report - Acquisition and Distribution. 

3.2 Abstraction Days. 

3.3 Autopsy Medical Findings. 

3.4 Fatal Accidents by Fiscal Year and Quarter. 

3.5 Number of Fatal Accidents by Age Groups. 

3.6 Fatal Aviation Accidents by Gender and Age. 

3.7 Average Self-Reported Flight Hours, by Region. 

3.8 Percentage of Accidents in Airman’s Home State and Region. 

3.9 Float Planes. 

3.10 Medical Transport. 

3.11 Aerobatics and Airshows. 

3.12 Light Sport Aircraft. 

3.13 Mid-Air Accidents by Region. .

3.14 Agricultural Accidents by FAA Region and Airman’s Home State. .

4.0 Summary. .

4.1 General Accident Statistics. .

4.2 Float Planes. .

4.3 Medical Transport. .

4.4 Aerobatic and Airshow. .

4.5 Light Sport. .

4.6 Mid-Air  .

4.7 Agricultural. .

5.0 References. .

6.0 Appendix A. Autopsy Program Case Selection Workflow Diagram. 

ix

GLOSSARY BY CATEGORY

General Definitions

Acquisition – The number of autopsy reports requested for 

pilots or other crewmembers.

Distribution – The number of requests for support from the 

FAA or NTSB accident investigators.

Fatal Accident - An occurrence to an aircraft or its surroundings 

in which a person is fatally injured.

Fatal Incident - An occurrence where an occupant of the aircraft or an individual in close proximity dies from injuries or a 

medical condition unrelated to a crash.

Float Plane – An aircraft that is built with floats or modified 

to land and takeoff on water.

Incident - An occurrence, other than an accident, associated 

with the operation of an aircraft that affects or could affect the 

safety of operation.

Aerobatics and Airshows

Aerobatic Practice – Practicing aerobatic maneuvers at a location other than an airshow.

Airshow – An aviation event defined as an aerial demonstration 

by one or more aircraft before an invited assembly of people. 

Airshow Practice – The practicing of aerobatic maneuvers at 

an airshow prior to the event.

Organized Fly-In/Fly-By – A fly-in or fly-by not sanctioned 

by the FAA.

Federal Aviation Administration Regions

Alaskan (AAL) – Alaska.

Western Pacific (AWP) – California, Nevada, Arizona, and 

Hawaii.

Northwest Mountain (ANM) – Oregon, Washington, Idaho, 

Utah, Colorado, Wyoming, and Montana.

Southwest (ASW) – Texas, Oklahoma, New Mexico, Arkansas, 

and Louisiana.

Central (ACE) – Kansas, Missouri, Iowa, and Nebraska.

Great Lakes (AGL) – South Dakota, North Dakota, Illinois, 

Minnesota, Michigan, Ohio, Wisconsin, and Indiana.

Southern (ASO) – Kentucky, Tennessee, Mississippi, Georgia, 

Alabama, Florida, as well as North Carolina and South Carolina.

Eastern (AEA) – Virginia, West Virginia, Maryland, Delaware, 

Pennsylvania, New York, New Jersey, and Washington, D.C.

New England (ANE) – Connecticut, Rhode Island, Massachusetts, New Hampshire, Vermont, and Maine.

Light Sport Aircraft

Denied Medical Certificate – Flying in an Aircraft That Meets 

the Definition of Light Sport With a Pilot Who Met Light 

Sport Medical: The airman has been denied a valid medical 

certificate and is usually a passenger when flying with a pilot 

who has a valid medical certificate.

Denied Medical Certificate – Flying With a Pilot Holding 

a Current Medical Certificate: The airman has been denied a 

medical certificate (has medical issues preventing issuance of 

the certificate) and is flying with a pilot who has a valid medical certificate. The airman is not actually piloting the aircraft.

No Medical Certificate: Operating an aircraft that meets the 

definition of Light Sport – requires valid driver’s license: This 

classification meets the definition of the new Light Sport rules 

(14 CFR § 61.23/53/303). The Light Sport category does not 

require a medical certificate issued by the FAA, but if an airman 

has been denied a medical certificate for any class, he or she may 

not operate an aircraft designated as a Light Sport.

No Medical Certificate – Operating LSA – Requires Valid 

Driver’s License: The airman is legally operating an aircraft that 

originally met certification as a Light Sport. No valid medical is 

necessary for this category.

No Medical Certificate – Student Pilot Operating an Aircraft 

With an Instructor Pilot: This airman may be attending a 

flight school or may be receiving personal instruction from an 

instructor pilot.

Out of Date – Flying as a Passenger: The airman allowed 

the medical certificate expire and is flying as a passenger (no 

certificate required).

Out of Date – Flying With a Pilot with Current Medical 

Certificate: The airman has held a valid medical certificate in 

the past but has allowed the certificate to lapse.

Out of Date – Operating an Aircraft That Meets the Definition 

of Light Sport: The airman is operating an aircraft that meets 

the definition of light sport but does not have a valid medical 

certificate. The certificate has expired, and the airman has chosen 

not to reapply for a new medical certificate.

Out of Date – Operating a LSA: The medical certificate is out 

of date (airman has chosen not to reapply) and is operating an 

aircraft that originally met certification requirements as a Light 

Sport aircraft.

Out of Date – Operating an Ultralight: The medical certificate 

is out of date (expired), and the airman is operating an aircraft 

that qualifies as an Ultralight.

Medical Transport

Angel Flight – A flight that provides free transportation for 

medical treatment or care.

Doctors Without Borders – A flight that is associated with the 

non-profit organization to provide medical aid.

Other – Medical Transports that do not meet the definition of 

repositioning or a flight with a patient on board. 

Organ Transport – A flight that has medical personnel on board 

for the procurement of organs for transplantation.

Patient on Board - A medical transport flight with a medical 

crew and patient on board.

Post Maintenance – A test flight without the medical crew that 

is for a post- maintenance inspection.

Repositioning – A flight with the medical crew that is changing 

positions but does not have a patient on board.

1

Fatal Aviation Accidents: Fiscal Years 2009-20

1.0 BACKGROUND AND HISTORY

The purpose of this report is to summarize statistics and trends 

in fatal aviation accidents and incidents.

In 2008, the Federal Avi ation Administration’s (FAA’s) Federal 

Air Surgeon directed that the Autopsy Program be relocated to 

Oklahoma City, Oklahoma, to centralize the coordination and 

acquisition of autopsy records for all U.S.-registered civil aircraft 

accidents involving pilot fatalities. Prior to 2008, this task was 

performed separately in each of the nine FAA Regions within 

the United States. Centralization of the program allowed for 

the medical components of aviation accident investigation to be 

consolidated at the Civil Aerospace Medical Institute (CAMI). 

The Autopsy Program Team is currently established within the 

Office of Aerospace Medicine’s Aeromedical Research Division, 

Bioaeronautical Sciences Research Lab.

The Autopsy Program Team’s primary functions are:

•	 To obtain the final autopsy reports for airmen involved in 

fatal aviation accidents. 

•	 Assist more than 980 investigators coordinate autopsy services, 

which includes dissemination of the FAA toxicology box to 

about 580 medical examiners/coroners. 

•	 Obtain demographic information regarding individuals involved in fatal aviation accidents and incidents. 

•	 Support research activities within the realm of aviation safety.

The Team coordinates data dissemination among FAA and 

National Transportation Safety Board (NTSB) accident investigators and records findings into a database and requests the 

final autopsy report. The team utilizes a multi-faceted database 

called the Medical Analysis Tracking Registry (MANTRA). 

MANTRA serves the operational function of tracking, trending, and distributing autopsy reports. See appendix A for a flow 

chart describing the process for determining case eligibility for 

inclusion into the MANTRA system. Additionally, it supports 

accident investigation by providing information to FAA/NTSB 

investigators to aid in determining the probable cause of the 

accident/incident. The collected data are available for research 

within the FAA. Autopsy reports are not released to the public by 

the Autopsy Team. Requests for autopsy or death investigation 

reports are referred to the Custodian of Records at the medical 

examiner’s or coroner’s office. 

After receipt of the final autopsy report, a summary of the 

autopsy and/or the report is distributed to the FAA/NTSB investigators as well as the Medical Case Review Officer. This is an 

important aspect to accident investigation, since this information 

provides valuable clues to the medical state of the airman prior 

to or at the time of the accident.

In 2014, there were 202,865 general aviation aircraft in operation, with an expected growth of an average of 0.5% a year, 

reaching 225,700 aircraft by 2034. Regional carriers have flown 

834.1 billion passenger miles, and this is expected to increase to 

1.47 trillion passenger miles by 2034 (FAA, 2014).The ability to 

catalogue and classify different factors in fatal aviation accidents 

only serves to make these events understandable, as well as make 

the industry safer.

2.0 METHODS

The Autopsy Program Team collects information about individuals involved in fatal aviation accidents/incidents. A fatal 

aviation accident or incident is defined by the International Civil 

Aviation Organization (ICAO) as an occurrence to an aircraft 

or its surroundings in which a person is fatally injured (ICAO, 

2006). Additionally, ICAO defines an aircraft accident as 

An occurrence associated with the operation of an aircraft 

which, in the case of a manned aircraft, takes place between the 

time any person boards the aircraft with the intention of flight 

until such time as all such persons have disembarked, or in the case 

of an unmanned aircraft, takes place between the time the aircraft 

is ready to move with the purpose of flight until such time as it 

comes to rest at the end of the flight and the primary propulsion 

system is shut down, in which: (a) a person is fatally or seriously 

injured; (b) the aircraft sustains damage or structural failure, or 

(c) the aircraft is missing or is completely inaccessible. 

ICAO also defines an incident as “an occurrence, other than 

an accident, associated with the operation of an aircraft which 

affects or could affect the safety of operation.”

The Autopsy Team defines a fatal incident as an occurrence 

where an occupant of the aircraft or an individual in close proximity dies from injuries or a medical condition unrelated to a 

crash. An example of a fatal incident could be a crewmember 

who has a fatal heart attack in flight, but the flight is able to 

land safely. 

Contents of the MANTRA database were reviewed for fiscal 

years 2009 through 2013. The information was classified and 

categorized by Autopsy Acquisition Date, Autopsy Performed, 

Date of Accident, FAA Region of Residence, Mid-Air Accident, 

Age of Pilot, Gender, Flight Hours at last FAA Physical Form 

8500-8, Airman Home State, Float Plane, Medical Transport, 

Airshow Event, Light Sport Medical Certificate Review, and 14 

CFR Part 137 Agriculture. Descriptive statistics are presented 

for each of these categories. Incidental medical findings described in the autopsy reports were classified according to the 

International Classification of Diseases, 10th Edition – Clinical 

Modification (ICD-10-CM) and International Classification of 

Disease, Procedure Coding System. 
2

2.1 Aviation Operations Classified by Federal Aviation 

Regulations 

Fatal aviation accident data have been classified in MANTRA 

according to the Code of Federal Regulations (CFR) that governs 

aviation operations in the United States. These regulations are 

categorized into Federal Aviation Regulations (FAR) as follows:

•	 14 CFR §125 Aircraft operating with 20+ passengers and 

weighing more than 6,000 pounds 

•	 Part 121 Domestic, Flag, and Supplemental Operations 

•	 Part 129 Foreign Air Carrier 

•	 Part 133 Rotorcraft External Load 

•	 Part 135 Air Taxi 

•	 Part 137 Agricultural Aircraft 

•	 Part 141 Pilot School 

•	 Part 91 General Aviation 

Note: Ultralights operating under 14 CFR§103 or Parachute 

Operations Part 105 are not a part of the MANTRA dataset 

unless the aircraft meets the definition of a Light Sport. 

3.0 RESULTS

3.1 Autopsy Report - Acquisition and Distribution

For this report, the term acquisition is defined as the number 

of autopsy reports requested for pilots or other crewmembers that 

may have been in control of the aircraft. The term distribution

is defined as the number of requests for support from the FAA 

or NTSB accident investigators. For the period investigated, 

the Autopsy Program Team averaged 1,175 requests for autopsy 

reports or assistance from both FAA and NTSB accident investigators every fiscal year. Annual data are shown in Figure 1.

The United States has a mixed medicolegal system that is 

comprised of both medical examiners and coroners. Local 

medical examiners and/or coroners who have jurisdiction over 

the accident/incident site perform autopsy services on behalf 

of the NTSB. Although infrequent, the Autopsy Team will, on 

occasion, receive autopsy reports on passengers and ground crew 

involved in an aviation accident. Thus, there are sometimes more 

autopsies than requested.

The NTSB investigator-in-charge has the authority to obtain 

autopsies and other necessary information pertinent to an accident investigation. Occasionally, an autopsy is not performed 

for a number of reasons (Figure 2). For example, some autopsies 

are not performed due to provisions of local law in observing 

religious beliefs. It is interesting to note that in the five years of 

data collection, there have been only two cases where autopsies 

have not been performed due to religious beliefs. Other reasons 

include unrecovered remains. The Autopsy Program Team does 

not usually handle autopsy reports for accidents outside the U.S. 

or its territories unless requested by the NTSB.

Prior to the centralization of the program in 2008, CAMI 

received around 54% of pilot autopsy reports (Ricaurte & 

Gallimore, 2006). CAMI now obtains around 95% of autopsy 

Figure 1. Acquisition and distribution statistics by year

267

312

293

271

265

227

317

313

272

297

370

1367

1505

1232

1402

FY 2009

FY 2010

FY 2011

FY 2012

FY 2013

0 200 400 600 800 1000 1200 1400 1600

Acquistion and Distribution Statistics 

Total Requests Distributed

Total Autopsies Received

Total Autopsies Requested

Figure 1. Acquisition and distribution statistics by year
3

reports involving pilot fatalities. The reasons that an autopsy 

may not be performed are described in Figure 2.

The average time to receive a completed autopsy report from 

a Medical Examiner or Coroner is categorized by FAA Region 

and year in Figure 3. The total average completion time for all 

Regions is given, stratified by year. OFS is the designation for 

fatal accidents occurring outside the U.S. 

3.2 Abstraction Days

Abstraction of data is the collecting and aggregating of the 

airman’s medical records and other relevant information. This 

information is collected and stored in the Medical Analysis 

Tracking Registry (MANTRA). The collection of data starts immediately after notification of a fatal accident. This information 

includes logistical data, aircraft details, demographic information 

about the airman, as well as medical examiner/coroner contact 

information. Additional medical findings, autopsy results, and 

toxicology data discovered during the course of the accident 

investigation are also recorded in MANTRA. MANTRA also 

utilizes records from the Emergency Operations Network (EON), 

Safety Performance Analysis System (SPAS), Document Imaging 

Workflow System (DIWS), NTSB, and Toxicology databases. 

The MANTRA system did not become operational until 2010, 

creating a backlog of cases reflected in the year 2009. 

 

8

11

8

2

9

2

11

5

0 2 4 6 8 10 12

Body Not Recovered/Lost at Sea

Coroner/Medical Examiner Decision

No/Limited Remains Left

Expired 30 Days After Accident

Expired Within 30 Days of Accident in hospital

Religious Beliefs

Foreign

Other

Categories for Autopsy Services Not Performed

FY 2009 - FY 2013

N = 56

 

0

50

100

150

200

250

300

350

AAL ACE AEA AGL OFS ANE ANM ASO ASW AWP Total

Autopsies

Total

Average

Regions Days

Time For Autopsy Report Completion 

by Region & Year

FY 2009

FY 2010

FY 2011

FY 2012

FY 2013

Figure 2. Categories for unperformed autopsies

Figure 3. Time in days until autopsy completion, by FAA region Days
4

Figure 4 and Table 1 show the delaying effects of the 2009 

backlog, as well as the four-week government furlough in 2013. 

3.3 Autopsy Medical Findings

Data from autopsy reports are classified and coded according 

to the International Classification of Diseases, Tenth Edition – 

Clinical Modification (ICD-10-CM). The top five most frequent 

incidental medical findings discovered during autopsy are listed 

in Table 2. These findings are based on a medical review of 965 

fatally injured airmen. 

Note that there were 401 cases not medically coded in the 

early part of the program and subsequently excluded in this 

review. Also, the numbers in Table 2 are not exclusive to any 

one category. That is, the medical findings at autopsy of a fatally 

injured airman can contribute to multiple categories. The most 

common finding was atherosclerotic heart disease of the native 

coronary artery.

831

4 5 3 4

0

100

200

300

400

500

600

700

800

900

FY-2009 FY-2010 FY-2011 FY-2012 FY-2013

Days

Fiscal Year

MANTRA Average Abstraction Time, in Days

Average Days

Table 1. Average number of days for abstraction

Fiscal 

Year Total Days Mean

95% Confidence 

Interval Std. Dev. Min. Max.

2009 290,917.11 831.19 (794.14, 868.24) 353.62 56.48 1,810.38

2010 1,680.78 4.39 (2.62, 6.16) 17.72 0 96.60

2011 1,709.93 4.77 (3.40, 6.15) 13.26 0 41.55

2012 1,159.63 3.44 (3.42, 3.45) 0.13 0 74.48

2013 1,358.09 4.07 (3.19, 4.93) 8.11 0 79.36

Figure 4. Case abstraction time in days

Table 2. Incidental medical findings discovered during autopsy

Number Autopsy Finding

ICD-10-CM 

Code

341 Atherosclerotic heart disease of native coronary artery I 25.1

146 Cardiomegaly I 51.7

104 Atherosclerosis of aorta I 70.0

48 Fatty (change of) liver, not elsewhere classified K 76.0

43

Hypertensive chronic kidney disease with stage 1 

through stage 4 chronic kidney disease, or unspecified 

chronic kidney disease

I 12.9
5

1st Qtr

Oct- Dec

2nd Qtr

Jan - March

3rd Qtr

April - June

4th Qtr

July - Sept

FY 2009 54 53 77 83

FY 2010 60 57 65 93

FY 2011 61 47 71 95

FY 2012 65 52 62 81

FY 2013 81 50 61 62

0

10

20

30

40

50

60

70

80

90

100

N

u

m

b

e

r

o

f

A

c

c

i

d

n

e

t

s

Accidents By Fiscal Year Quarter

FY 2009

FY 2010

FY 2011

FY 2012

FY 2013

Figure 5. Fatal accidents by quarter and year

3.4 Fatal Accidents by Fiscal Year and Quarter

As previously stated, the government fiscal year begins 

on October 1, ends September 31 and is comprised of 

four quarters. 1st Quarter: October 1 – December 31, 

2nd Quarter: January 1 – March 31, 3rd Quarter: April 

1 – June 30, and 4th Quarter: July 1 – September 30. 

Figures 5 and 6 reveal that the summer months of July, 

August, and September (4th Quarter) occurred during the 

greatest number of fatal accidents/incidents. In contrast, 

the winter months of January, February, and March (2nd

Quarter) had the lowest number. Table 3 categorizes the 

numbers of fatal accidents by FAA Region. FAA Regions 

are further explained in the glossary. Together, Figures 

5, 6, and 7 give different visuals of the distribution of 

fatal accidents by region, year, and quarter. 

54

60 61

65

81

53

57

47

52 50

77

65

71

62 61

83

93 95

81

62

0

10

20

30

40

50

60

70

80

90

100

FY 2009 FY 2010 FY 2011 FY 2012 FY 2013

N

u

m

b

e

r

o

f

A

c

c

i

d

e

n

t

s

Fiscal Quarters

Accident Distribution Quarters

1st Qtr

2nd Qtr

3rd Qtr

4th Qtr

Figure 6. Number of fatal accidents by year and quarter

Table 3. Number of fatal accidents by region

Region Accidents

Southern (ASO) 276

Western Pacific (AWP) 217

Northwest Mountain (ANM) 190

Southwest (ASW) 186

Great Lakes (AGL) 170

Eastern (AEA) 111

Central (ACE) 69

Alaska (AAL) 52

New England (ANE) 38

International (OFS) (Not shown) 21

Figure 5. Fatal accidents by quarter and year

Figure 6. Number of fatal accidents by year and quarter

Figure 7. Number of fatal accidents, with percentages by region

Figure 7. Number of fatal accidents, with percentages by region
6

3.5 Number of Fatal Accidents by Age Groups

Figure 8 and Table 4 show the total number of pilots involved 

in a fatal aviation accident by age group. The age groups from 

45-54, 55-64, and 65-74 had the highest number of deaths. The 

average age for a fatal aviation accident pilot is 54.75 years. The 

average age of the U.S. civil aviation pilot is 44.8 years (FAA, 2013). 

3.6 Fatal Aviation Accidents by Gender and Age

During this study period the U.S. civil pilot population 

consisted of 6.61% females to 93.3% males (FAA, 2013). This 

distribution helps to explain the difference in fatal aviation 

accident numbers by gender in Figure 9. Stratifying the age 

categories in Section 3.6 by gender further reveals that of fatal 

accidents,1.6% were females, compared to 98.4% of males. 

6

30

90

154

306

335

254

89

10

0

50

100

150

200

250

300

350

400

15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

T

o

t

a

l

P

i

l

o

t

s

Pilot Age

Number of Deaths Per Pilot/Pilot-Instructor

 by Age Group 

# of Pilot Deaths

N =1,274

Figure 8. Number of Accident Pilots and Deaths by Age Group

Table 4. Accidents in airman’s home state: the number of accidents in the home state and the 

regional totals

Region AAL AWP ASW ACE AGL ASO AEA ANE ANM OFS

(#/Total) 44/

52

163/21

7

122/18

6

35/6

9

115/17

0

174/27

6

67/11

1

19/3

8

105/19

0

3/2

1

Figure 8. Number of accident pilots and deaths by age group

6

33

98

169

321

352

265

91

10 0 3 4 3 3 3 4 1 0

0

50

100

150

200

250

300

350

400

15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Total Pilots

Pilot Age

Fatal Aviation Accident Males and Females 

by Age

Males

Females

Figure 9. Figure 9. Fatal aviation accident Fatal aviation accidents by age and gender s by age and gender
7

3.7 Average Self-Reported Flight Hours, by Region

The total self-reported flight hours are obtained from the 

pilot’s last medical application, as reported on Form 8500-8 to 

the Civil Aerospace Medical Institute. Figure 10 gives the average 

of these self-reported hours by region. Alaska is different from 

the lower 48 states in that air taxis are the only way to reach 

many destinations, which explains the high number of average 

flight times (Detwiler et al., 2006). Therefore, it is reasonable 

to assume that this region would have the most self-reported 

flight hours for airmen involved in a fatal aviation accident. In 

contrast, the Great Lakes Region had the lowest self-reported 

number of flight hours by accident airmen.

3.8 Percentage of Accidents in Airman’s Home State and 

Region

We examined the geographical locations of fatal aviation accidents by home state and region as a measure of fatal accident 

locale. Note that the numbers of fatal accidents by the airman’s 

home state are a subset of the numbers by region. Home state 

was identified using data from the last medical application of the 

airman as reported to CAMI. The home state was obtained by 

collecting the home address reported by airmen on Form 8500-8 

and compared to the accident location. Data were examined to 

determine the number of fatal accidents that occurred only in 

the airman’s home state, as reported at the time of his/her latest 

medical exam. The results are displayed as a percentage in Figure 

11, with the actual values given in Table 4. 

Figure 10. Figure 10. Average self Average self-reported flight hours by region for -reported flight hours by region for fatally injured pilots

fatally injured pilots

Figure 11. Figure 11. Accidents in airman’s home state Accidents in airman’s home state and region and region

This analysis is expanded to also include the airman’s home 

region in Figure 11. The home region corresponds to the group 

of states according the FAA’s Regional graph (Figure 7). The actual data values are given in Table 5. For example, if an airman’s 

home address is in Texas, then the home region is the Southwest 

Region (ASW), which includes the states of Texas, New Mexico, 

Oklahoma, Arkansas, and Louisiana. Note that Alaska (AAL) is 

both a state and a region.

Table 5. Accidents in airman’s home region: Ratios of the number of accidents in the home region to

the regional totals

Region AAL AWP ASW ACE AGL ASO AEA ANE ANM OFS

(#/

Total)

44/

52

180/

217

139/

186

38/

69

136/

170

225/

276

87/

111

25/

38

134/

190

3/

21
8

3.9 Float Planes

A float plane/seaplane is defined as an aircraft that is originally 

built with floats or one that has been modified to take off and 

land on water (FAA, 2004). Many float planes can make landings on both water and a traditional runways. The data revealed 

that 54% (19 out of 35) of float plane accidents occurred during 

takeoff or landing on water. Many float plane accidents occurred 

on water due to failure to retract landing gear.

3.10 Medical Transport

We reviewed the data for any possible trends related 

to fatal medical transport accidents. Medical transport 

flights operate under 14 CFR Part 91 (general operating flight rules) or 14 CFR Part 135 (Commuter and 

on Demand Operations and Rules Governing Persons 

on Board Such Aircraft). Currently, the NTSB does 

not classify Angel Flights, Organ Transports, or Doctors 

Without Borders as Medical Transport flights. For the 

purposes of this study, we will treat Angel Flights, Organ 

Transports, and Doctors Without Borders as medical 

transport flights, since they frequently carry patients. 

Information and data to support this collection were 

obtained from the FAA Flight Standards District 

Office or FAA Office of Accident Investigation and 

Prevention – investigator-in-charge. Note that the 

aircraft involved in the medical transport accidents 

in (Figure 12) consisted of 17 rotorcraft and five fixed 

wing multi-engine aircraft. Definitions of the terms 

and categories are provided in the glossary.

3.11 Aerobatics and Airshows

There were 31 fatal accidents in the 2009 - 2013 

time frame involving aerobatic or airshow performance 

or practice. According to FAA regulations (FAA Order 8900.1), a civil aircraft pilot must show evidence 

of performing or practicing within the previous 15 

days before the actual performance. Figure 13 shows 

the number of fatal aerobatic and airshow accidents 

categorized by type of operation. There was a single 

airshow accident in which the pilot died after surviving for more than 30 days. According to the NTSB, 

accidents in which any fatality occurs within 30 days 

after the accident are considered fatal accidents. Technically, in this situation, the pilot survived longer than 

30 days, so it was not classified as a fatal accident. An 

explanation of the terms and labels used in Figure 13 

can be found in the glossary.

3.12 Light Sport Aircraft

Within the MANTRA database, Light Sport aircraft (LSA) are 

classified according to the class and currency of the pilot’s medical certificate. This categorization was performed by either the 

reviewing Medical Officer or by the Autopsy Team. Many pilots 

flying Light Sport aircraft are exempt from holding a medical 

certificate. Therefore, fatal accidents involving Light Sport aircraft 

0 2 4 6 8 10 12

Angel Flight

Doctors Without Borders

Organ Transport

Other

Patient on Board

Post Maintenance

Repositioning

Angel Flight

Doctors

Without

Borders

Organ

Transport Other Patient onBoard

Post

Maintenance Repositioning

Accidents 1 0 1 4 5 1 10

Medical Transport Accidents

N = 22

Figure 12. Medical transport accidents

14

3

4

9

1

0 2 4 6 8 10 12 14 16

Aerobatic Practice

Airshow Practice

Organized Fly-In

/ Fly-By

Airshow

Airshow - Non-Fatal

Aerobatic Practice Airshow Practice Organized Fly-In

/ Fly-By Airshow Airshow - NonFatal

Accidents 14 3 4 9 1

Fatal Accidents Involved With Aerobatic 

Maneuvers or Airshow Events

N = 31

Figure 13. Fatal accidents involving airshows or aerobatics

Figure 12. Medical transport accidents

Figure 13. Fatal accidents involving airshows or aerobatics
9

consist of aviators with a variety of medical certification levels, 

ranging from none to that of a first-class medical certificate. An 

aircraft can be registered as a Light Sport aircraft or simply meet 

the FAA’s definition of the Light Sport classification. For the 

purposes of this study, aircraft in either one of these categories 

are classified as Light Sport aircraft. In Figure 14, the Light Sport 

population is divided into 11 groups that describe the airman’s 

medical certification status. The medical certification status is 

further explained and described in the glossary.

21

37

22

25

4 3 1 2 1 1 1

0

5

10

15

20

25

30

35

40

A B C D E F G H I J K

F

a

t

a

l

A

c

c

i

d

e

n

t

s

Light Sport Medical Certificate Review

A

B

C

D

E

F

G

H

No medical certificate – operating aircraft that meets the definition of Light Sport requires valid driver’s license

Out of date – operating aircraft that meets the definition of Light Sport

Out of date – operating aircraft that is registered as a Light Sport

No medical certificate – Operating aircraft that is registered as a Light Sport

Out of date – operating an ultralight

Out of date – flying as a passenger

Denied medical certificate – flying with a pilot with a current medical certificate

Denied medical certificate – flying in an aircraft that meets the definition of Light Sport with a pilot who met Light Sport medical

Denied medical certificate – operating an aircraft that meets the definition of Light Sport

Out of date – flying with a pilot with a current medical certificate

No medical certificate – student pilot operating an aircraft with an instructor pilot

Figure 14. Light Sport fatal accident medical certificate review for reporting period

Figure 14. Light Sport fatal accident medical certificate review for reporting period
10

9

7

2

3

2

2

1

5

3

4

10

3

0 2 4 6 8 10 12

ACE

AGL

ANM

ASO

ASW

AWP F

A

A

R

e

g

i

o

n

s

Fatal Agricultural Accidents by 

Region and Airman's Home State

Airman's Home State

Accident Region

Figure 16. Figure 16. Fatal Fatal agricultural accidents by FAA Region and home agricultural accidents by FAA Region and home state of airman

state of airman

2

5

4

2

1

3

5

0

4

0

0 1 2 3 4 5 6

AAL

AWP

ASW

ACE

AGL

ASO

AEA

ANE

ANM

OFS

Frequency of Accidents

N = 26 

F

A

A

R

e

g

i

o

n

s

Fatal Mid-Air Accidents by FAA Region

AAL

AWP

ASW

ACE

AGL

ASO

AEA

ANE

ANM

OFS

Figure 15. Fatal mid-air accidents by region

3.13 Mid-Air Accidents by Region

An aviation accident is classified as a mid-air accident when 

two or more aircraft collide during flight. The number of mid-air 

collisions is low, which is reflected in the number of fatal accidents in Figure 15. The values range from 0 to 5 fatal accidents 

due to mid-air collisions.

3.14 Agricultural Accidents by FAA Region and Airman’s 

Home State

Agricultural operations are conducted under 14 CFR Part 

137. Part 137 agricultural operations are a commercial service 

that has the additional hazards of handling highly concentrated 

insecticides. Agricultural pilots are required to have special skills 

and knowledge for handling these chemicals. Part 137 operators, 

working commercially, are required to hold at least a second-class 

medical certificate. Numbers of fatal agricultural accidents were 

classified by FAA Regions in Figure 16. A total of 25 accidents 

involved 26 airmen (one accident was a mid-air). The majority of 

Part 137 agricultural accidents happened in the Central Region.

Figure 16 also displays the fatal Part 137 accidents by the 

home region of the accident airman, as reported at the time of 

his/her medical examination on FAA Form 8500-8. Figure 16 

revealed that the Southwest Region (ASW) had only two Part 137 

accidents. When we classified the accidents by the airman’s home 

region, we see that 10 airmen were from the Southwest Region 

but had their fatal accident outside of this area. This is due to 

the migratory and seasonal nature of air agricultural operations. 
11

4.0 SUMMARY

4.1 General Accident Statistics

The United States had 1,330 fatal aviation accidents/incidents 

in fiscal years 2009-2013. Most of the fatal accidents occurred 

in the fourth quarter (July 1-September 30) of the fiscal year. 

The data indicated that the FAA Southern Region (Florida, 

Georgia, Alabama, Mississippi, South Carolina, North Carolina, Tennessee, and Kentucky) sustained the greatest number 

of fatal accidents and incidents (Figure 7). The New England 

geographical region had the least number of fatal accidents over 

this five-year period.

The most common incidental medical finding found on the 

autopsy reports is atherosclerotic heart disease of the coronary 

artery (Table 2). Of the 1,274 total pilots, the 55-64 age group 

had the most deaths (Figure 8.). These two findings are most 

likely highly correlated. 

A gender difference was also observed (Figure 9). The overall 

U.S. civil pilot population during the reporting period was 

comprised of 93.3% males and 6.61% females, but the fatal 

accident population consisted of 98.5% males and 1.5% 

females.

The greatest self-reported average flight time by Region for 

fatally injured was 6,000 hours in the Alaskan Region (Figure 

10). This is not surprising, as Alaskans depend upon aviation for 

transport to otherwise inaccessible parts of the state. 

The reported statistics by home Region and state are intended 

to be proximity measures of fatal aircraft accidents. They are intended to explore whether most fatally injured airmen had their 

accident fairly close or away from their home of record. Alaska 

is both a state and a Region and had the greatest percentage of 

fatal accidents, as compared to the other Regions (Figure 11). 

Alaska is a large state that depends on aviation more so than 

any other region. 

The greatest number of fatal accidents occurred during the 

summer months of July through September. However, this was 

not the case in 2013, when the months of October through 

December had the most fatal accidents. 

The average age of a fatally injured pilot was 55 years, compared to the average of 45 for the U.S. civil pilot population. 

There could be many possibilities for this difference in the age 

distribution. According to the U.S. Census Bureau, in 2011 

(Vornovitsky, Gottschalck, & Smith, N.D), the average median 

household net worth by age was: 

•	 $6,676 for age 35 and under

•	 $35,000 for age 35-44

•	 $84,542 for age 45-54

•	 $143,964 for age 55-64

•	 $170,516 for age 65 years and over. 

It is plausible to consider that individuals in the older age 

groups may have more disposable income with which to purchase 

or rent aircraft. Another factor to consider for a spike in fatal 

aviation accidents at 45-64 is that perceptual-motor and spatial 

tasks start to decline after age 40 (Braune & Wickens, 1984). 

The third factor to consider is that high exposure to flight time is 

associated with a higher risk of a fatal aviation accident (Booze, 

1977). Older pilots, generally speaking, have greater cumulative 

flight times than younger pilots.

4.2 Float Planes

Float plane pilots had 2.63% of all fatal accidents. There were 

35 float plane accidents within the study timeframe with 54% 

of the accidents occurring during a water takeoff or landing. A 

common cause of float plane accidents is the airman’s failure to 

retract the landing gear which may explain the slight disparity 

in accident occurrences on water runways.

4.3 Medical Transport

There were 22 Medical Transport fatal accidents with 46% 

occurring during a repositioning phase of the flight. Repositioning is defined as a flight with a medical crew, without a patient 

on board, which is changing its operating location (Figure 12). 

Repositioning was the most common phase of flight for medical transport accidents. This is similar to a research finding that 

“slightly more accidents were occurring during the reposition 

phase” (Boquet, Holcomb, Detwiler, & Hackworth, 2006). 

Furthermore, Frazer (1999) indicated that the accident crew 

may have experienced “get home itis” (Frazer, 1999). After long 

shifts on duty, the focus of these crews was to return to their 

home or duty station. The aircraft involved in medical transport 

accidents consisted of 17 rotorcraft and five fixed wing, multiengine aircraft.

4.4 Aerobatic and Airshow

There were 31 fatal accidents involving aerobatic maneuvers 

or airshow events. Fourteen (45%) occurred during aerobatic 

practice, while nine (29%) occurred at an FAA-sanctioned 

aviation event (Figure 13). De Voogt and Van Doorn (2009) 

analyzed aerobatic maneuver accidents from 1982-2006 and 

found that most of them were attributed to stalls, spins, and 

improper altitudes (De Voogt & Van Doorn, 2009). Additionally, they stated that over the last 25 years, fatal aerobatic 

accidents have decreased. 

4.5 Light Sport

A pilot does not necessarily have to hold a valid medical 

certificate to fly aircraft in the Light Sport category. Therefore, 

the Team performed a medical certificate review of Light Sport 

plane accidents to determine the number of aviators with and 

without a medical certificate who died in these Light Sport 

accidents. There were 118 Light Sport aircraft accidents; 37 

(31.35%) occurred to pilots with a lapsed FAA medical certificate. 

There were 25 (21.18%) fatal accidents in aircraft registered as 

a Light Sport where the pilot utilized a driver’s license in lieu of 

a medical certificate (Figure 14).
12

4.6 Mid-Air 

Twenty-six fatal mid-air accidents occurred within the reporting period, with the Western Pacific and Eastern Regions tied 

for the most mid-air accidents, having five each (Figure 15). The 

New England Region did not have any mid-air fatal accidents 

during the study period. The national average for mid-air accidents during the study period was around 2%. Overall, the 

number of fatal mid-air accidents was low and considered to be 

a rare occurrence.

4.7 Agricultural

Part 137 agricultural operations are migratory in nature. 

Our data confirmed this, finding as roughly 50% of the fatal 

accidents occurred outside of the airman’s home region. Of the 

25 fatal accidents involving agricultural operations, 22 aircraft 

had some form of chemical such as herbicide, fungicide, and/

or insecticide on board. It is possible that the hazardous nature 

of these chemicals may have contributed to impairment or 

incapacitation of the operator. 

5.0 REFERENCES

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occupation, age, and exposure in general aviation 

accidents. Aviation, Space, and Environmental 

Medicine, 48(11), 1081 -1091.

Boquet, A., Holcomb, K., Detwiler, C., Hackworth, C., 

Wiegmann, D., and Shappell, S. (2006). Human error 

associated with air medical transport accidents in the United 

States. Presented at the 77th Annual Meeting of the 

Aerospace Medical Association, Orlando, FL.

Braune, R., and Wickens, C.D. (1984). Individual differences 

and age-related performance assessment in aviators: Part 2: 

Initial battery validation (Final Technical Report EPL83-7/NAMRL-83-2). Urbana-Champaign, IL: University 

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Detwiler, C., Hackworth, C., Holcomb, K., Pfleiderer, E., 

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Washington, DC: Federal Aviation Administration 

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AM-06/7).

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associated with aerobatic maneuvers in U.S. aviation. 

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forecast - fiscal years 2014-34. Retrieved April 28, 2015 

from: http://www.faa.gov/news/fact_sheets/news_story.

cfm?newsid=15934

Federal Aviation Adminstration. (2013). US Civil Airmen 

Statistics. Retrieved April 28, 2015 from: http://www.faa.

gov/data_research/aviation_data_statistics/civil_airmen_

statistics/2013/

Frazer, R. (1999). Air medical accidents: A 20 year search for 

information. AirMed Journal, September/October, 

34-39., 5 USC 552 (1966).

ICAO (2006). Convention on International Civil Aviation. 

Montreal, Canada: International Civil Aviation 

Organization (Doc No.7300/9).

Ricaurte, E. M., and Gallimore, J. J., (2006). FAA Civil 

Aerospace Medical Institute Aerospace Accident- Injury and 

Autopsy Database System AA-IADS. Retrieved April 28, 

2015 from: http://www.tc.faa.gov/logistics/grants/

pdf/2004/04-G-034.pdf/Final Project Report FAA 04-G034 Gallimore 9-19-06.pdf

Vornovitsky, M., Gottschalck, A., and Smith, A., Distribution 

of household wealth in the U.S.: 2000 to 2011. 

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28, 2015 from: http://www.census.gov/people/wealth/

files/Wealth distribution 2000 to 2011.pdf
A1

Appendix A

Autopsy Program Case Selection Workflow Diagram

APPENDIX A

Autopsy Program Case Selection Workflow Diagram