Ted Stevens plane crash: Did pilot's health issues contribute to accident?

Jill Burke,Craig MedredAlaska Dispatch News
Map of the accident site and the surrounding area.
National Transportation Safety Board map
The accident site is located in the upper left corner of this photograph.
National Transportation Safety Board photo
Close-up of the wing and fuselage at the accident site near Aleknagik, Alaska that took the lives of 5 of the 9 persons aboard, including former U.S. Senator Ted Stevens.
National Transportation Safety Board photo
The accident site near Aleknagik, Alaska that took the lives of 5 of the 9 persons aboard, including former U.S. Senator Ted Stevens.
National Transportation Safety Board photo
Aerial view of the aircraft accident site near Aleknagik, Alaska that took the lives of 5 of the 9 persons aboard, including former U.S. Senator Ted Stevens.
Alaska State Troopers photo
Preaccident view of the N455A airplane.
National Transportation Safety Board photo
View of the instrument panel as initially found.
National Transportation Safety Board photo
Cockpit before recovery.
National Transportation Safety Board photo
Cockpit before recovery (labels provided by the NTSB).
National Transportation Safety Board photo
Photographed from behind the airplane, the small red arrow indicates where the first part of the airplane (ventral fin) was found. The white arrows point to the imprints of the floats. The dashed line is a cut in the alders with the span of the left wing.
National Transportation Safety Board photo
Aft view of the airplane, showing tail control surfaces.
National Transportation Safety Board photo

Pilot Terry Smith loved to fly. Skilled and highly experienced, the lifelong Alaskan -- son of a legendary Alaska pilot -- flew everything from Super Cubs to Boeing 737s. Over the years, he spent more than 25,000 hours at the controls of airplanes. His career reached its pinnacle when he was named chief pilot for Alaska Airlines, and then he suffered a stroke.

That was in 2006, and what happened after is the subject of an 18-page report by medical examiners for a National Transportation Safety Board team trying to determine what caused the crash of a GCI-owned aircraft that killed former U.S. Sen. Ted Stevens and four others on Aug. 9.

Smith was at the controls of that plane when it slammed into the Muklung Hills north of Dillingham in Southwest Alaska. Whether he was ailing when the plane went down is not known, but the report suggests he was alert enough to maneuver the plane in the seconds prior to the crash.

On Thursday, the NTSB released this report and hundreds of pages of other documents related to the investigation, probing Smith's health history and raising questions of whether he was fit to fly.

PLANE CRASH: More on the accident and Ted Stevens

Federal investigators draw no conclusions about what caused the crash. An official ruling on whether Smith suffered a new health attack while in flight or suffered from a lingering impairment, if any, that might have affected his piloting skills and judgment is something that will be left to a five-member NTSB board to decide next month.

The accident claimed the lives of Smith, Stevens, lobbyist Bill Phillips, General Communication Inc. executive Dana Tindall, and Tindall’s 16-year-old daughter, Corey. Four people survived, including former NASA administrator Sean O’Keefe and his 19-year-old son, Kevin; Washington, D.C., lobbyist Jim Morhard, and Phillips’s 13-year-old son, Willy.

The mountainside crash in Southwest Alaska, 20 miles north of the coastal fishing community of Dillingham, thrust the plane and its passengers into steep, remote terrain as poor weather began to settle in. The GCI-owned plane -- a 1957 DeHavilland DHC-3 Otter -- was ferrying its high profile guests from a lodge, also owned by the Anchorage-based telecommunications company, to the Nushagak River for silver salmon fishing.

When the 53-year-old airplane went down, it became a matter of national concern. Stevens had been the longest-serving Republican in Senate history. He lost re-election in 2008, but remained among the most powerful and influential figures in Alaska history. He retained many friends in the nation's capital despite losing his Senate seat in a close election after being convicted of failing to properly report campaign contributions. The conviction was later overturned, and Stevens was working hard toward clearing his name when he died.

The responsibility for piecing together what happened to the plane on which he was a passenger became a responsibility at the highest levels of the NTSB after the crash.

The NTSB must figure out whether it is man, machine or weather that brought the plane down. Combing through all of the variables requires investigators to consider a wide range of possibilities. Did the plane's owner or operator fail in some way? Did equipment malfunction? Did federal regulations or guidelines miss something they could have or should have had control over?

None of the survivors, all of whom were interviewed throughout the course of the investigation, reported being aware there was a problem until the plane crashed. There do not appear to have been mechanical problems with the plane. The weather in the area at the time of the crash was rainy and overcast, with scattered clouds.

There is "solid indication that the airplane was not cruising at impact, but was climbing and maneuvering," according to NTSB reports, indicating that Smith may have been trying to avoid the mountains.

But the location in which the downed aircraft was found does not fit with a pilot's efforts to avoid bad weather.

"There was no reason for Terry to be flying near the accident site hills," pilot Virgil Peachey, who was not on the plane that day, told NTSB investigators. "With weather, he would be flying through the lowest area."

Pilot in high demand

A pilot at the GCI-owned lodge on Nerka Lake, Peachey regularly flew the single-engine deHavilland Otter that crashed with Smith at the controls. Peachey's wife, GCI senior vice president Dana Tindall, was among those who died in the crash, along with her 16-year-old daughter Corey. Tindall, 48, was a rising star in the highly competitive Alaska telecommunications business in which GCI had built its fortune. Her husband told NTSB investigators he was aware of the 62-year-old Smith's 2006 stroke and watched for signs of any lingering problems when the older man showed up at the lodge at River Bay to work part-time as a pilot for GCI.

"Mr. Peachey," according to an interview with NTSB investigators, "had no concerns with Terry's performance," but noted that at one point he observed "Terry did not have as much energy as he had shown at previous times."

Whether Smith had lingering medical problems is something yet to be determined by the NTSB panel that will make the official ruling on the cause of the accident, but the NTSB documents hint at problems and indicate that Smith -- because he so loved to fly -- might have tried to hide them. "It was frustrating for him not to have his license," his widow, Terri, told NTSB investigators.

"Even without an FAA license,'' she told investigators, "Terry was flying almost continuously. People called to have Terry fly with them. They owned a PA-18 in New Zealand, where they tried to visit every year and where Terry also flew. Terry maintained a pilot medical license in New Zealand and took his physicals down there. He may not have advised New Zealand authorities about his stroke.''

The NTSB summary of "Medial Records Information" confirms the latter suggestion. "The pilot's most recent New Zealand Civil Aviation Authority Application for a Medical Certificate dated 3/20/2009 did not note the pilot's personal or family history of intracerebral hemorrhage, and specifically denied any history of stroke in the pilot,'' it says.

Intracerebral hemorrhage is bleeding into the brain. The bleeding creates pressure on the brain that can lead to dizziness, vertigo, unconsciousness, even death.

The NTSB medical report explores in detail the medial history of Terry Smith, who lost his U.S. pilot's license after the March 2006 stroke and tried to get it back only a year later even though the FAA requires a mandatory, two-year wait. The FAA at that time, according to records, sent Smith a letter saying, "we regret that due to your neurological condition (cerebral vascular accident) we have no alternative other than to deny your application for airman medical certification. ... The recommended recovery period is two years (March 2008)."

Smith resubmitted the paperwork for his medical certificate almost exactly two years after the date of his stroke. In the paperwork, he noted the stroke as required, reporting he "had a tiny CVA (cerebrovascual accident) 2 years ago (3-21-06) He has fully recovered. Recent neurological evaluation by (local neurologist) was completely normal."

The "tiny CVA," as Smith called it, put him in the hospital for almost a week and diminished his motor skills for months after.

"One month after the stroke," Smith's widow told investigators, "he was pulled over by a police officer who thought incorrectly that he was inebriated ... She thought he should have waited a few more weeks before driving but said that after two to three months, he stopped scaring her."

The NTSB records summary raises questions about whether the FAA should have reissued Mr. Smith's medical certificate. Smith underwent some medical tests, the report says, "but no conventional angiography, no neuropsychiatric evaluation, no cognitive testing, and no cardiovascular evaluation prior to being an unrestricted Class 1 airman medical certificate by the Alaska FAA. ...There was no documentation of any internal FAA neurology consultation and no additional follow up was required, though the pilot was cautioned that 'operation of aircraft is prohibited at any time new symptoms or adverse changes occur.'"

Did pilot's medical history contribute to crash?

Possible new symptoms or adverse changes are certain to be a subject of discussion when the NTSB board meets to consider an official ruling on factors that might have contributed to or caused the crash near Dillingham.

The neuropsychiatric evaluation suggested by the report would have looked for cognitive problems on Smith's part after his stroke, along with probing to see if he might be predisposed to dismiss or overlook problems that might threaten to prevent his continued flying.

Smith's widow told NTSB investigators that she wondered if her husband might suffer from sleep apnea. "Asked whether Terry ever stopped breathing during his sleep, (Mrs.) Smith indicated that she did not know, but she did recall wondering if he ever did. She had heard sounds like he had temporarily stopped breathing, although not nightly."

The National Institutes of Health a year ago warned that "sleep apnea more than doubles the risk of stroke in men. Obstructive sleep apnea is a common disorder in which the upper airway is intermittently narrowed or blocked, disrupting sleep and breathing during sleep."

Strokes have been linked to past air crashes, and only weeks ago, the NTSB took the FAA to task for not paying close enough attention to the after-effects of stroke and the likelihood for recurrences. In a report on a late 2010 helicopter crash in North Carolina, the NTSB cited as the cause "the pilot's impairment during cruise flight due to a recurrent stroke. Contributing to the accident was the Federal Aviation Administration's inadequate oversight of the pilot's known medical condition."

The pilot had a known stroke history and suffered an attack while at the controls of a flight ambulance. No patients were on board, but as the pilot began to take the helicopter down for a landing, he lost control of his right arm, suffered slurred speech and was unable to recognize the main runway, even though a nurse on board pointed it out for him. While the helicopter was substantially damaged during the hard emergency landing in December, no one died.

The NTSB investigation into the helicopter's emergency landing found that although FAA medical records revealed the pilot had experienced a stroke four years earlier, "there was no evidence in the FAA records of any formal evaluation of the risk of a recurrent stroke for the pilot or of any formal neurology evaluation."

The NTSB report in the case of Smith would appear to question the thoroughness of the FAA.

"Personal medical reports that were not provided to the FAA ... (include) an outpatient neurology follow-up in which the pilot 'was instructed to try and investigate into his family history more.'"

Had that follow-up been done, it would have shown that Smith's father and his father's siblings -- a brother and a sister -- had all suffered strokes, one of which was fatal for Smith’s uncle, who died at the age of 36.

A 2006 neurological exam of Smith done in Seattle concluded that "it is unclear if these (strokes) were caused by aneurysms vs. other structural abnormalities, or whether there is a genetic component to this," according to the NTSB report. "Some sort of cavernous abnormality may be present, which could have a genetic component and may explain (Mr. Smith's) intracerebral hemorrhage in the setting of no risk factors."

Smith was instructed to obtain "whatever records he can for further evaluation into the pathology of his family history," according to medical files released by the NTSB.

There is no indication Smith ever did that. The NTSB report says his next medical consultation was with a primary care physician in Anchorage, who talked by phone to a neurologist in Seattle and concluded everything was OK. "There are no subsequent primary care physicians' notes in the records reviewed," the NTBS report says.

"Local neurologist's records (for 2008) consisted entirely of the evaluation noted" by the primary care physician. Smith's widow, meanwhile, had a different recollection of what transpired in Seattle.

She said the doctors there "assured her that there was nothing hereditary about Terry's condition. ... She was adamant that she had the key to the stroke through the family history, but the physicians said no," the NTSB report reads. "No physician ever reviewed the family records."

Smith, the NTSB report indicates, also appeared to have pushed all these issues into the past by the start of 2009. His application for a medical certificate that year noted his only visits to a "Health Professional Within Last 3 Years" as a "June 2009 visit to an orthopedic surgeon to 'repair torn Achilles tendon.'" As to comments on medical history, his application said, "3+ years status post minor stroke. Fully recovered. No further problems."

There was no mention of a September 2008 visit to a naturopath whose notes indicated Smith's "wife sent him to be looked at ... (for) facial twitches, left check, probably started before hemorrhage ... Worse with stress, tired, loss of focus.'' Such twitches are not necessarily tied to stroke, but this one, according to the naturopath's report, appeared to be at times causing Smith some problems with his vision. The twitches, the notes indicate, "will make eye close." The report also noted that Mr. Smith had "poor balance, eyes open/eyes closed, left foot." Mr. Smith's meetings with the naturopath continued through the month of September. The naturopath recommended some homeopathic remedies to help with the twitches. There is no indication of why Smith stopped visiting.

It will be up to the NTSB board to try to determine whether all this medical information points to health issues as a contribution to the cause of the crash or not. The Armed Forces pathology report, the last of three autopsies, recognizes the evidence of past stroke in Mr. Smith's brain, but finds no definitive evidence of a new stroke prior to the crash.

"The findings of acute hemorrhage and hypoxic/ischemic neuronal injury were most likely related to traumatic head injury" from the crash of the plane, the report says. "Although investigative information reported suspected recent behavioral changes, no specific anatomic derangement was identified as a potential contributing factor to this mishap."

In fact, Smith, Stevens and the other deceased passengers all died from the force of the crash, according to the autopsies. None could have survived.

A last-second warning

Passengers who survived the 10- to 15-minute flight reported nothing unusual until the moment of impact. The most detailed account in the NTSB reported comes from one described only as "Passenger #4," who told investigators that:

...the weather was not remarkable or notable in any way. The pilot remained below the cloud ceiling flying along the tree line, following streams, and executing several turns to avoid terrain; it was "characteristic" Alaska flying. The pilot made a left turn, going up a hill, and immediately impacted terrain. The turn was not unusual in bank angle, and Passenger #4 did not hear any change in the engine sound before impact. Also, he did not perceive any change in pitch attitude of the airplane or any unusual maneuvering prior to impact.

One of the NTSB files says there is "solid indication that the airplane was not cruising at impact, but was climbing and maneuvering," indicating that Smith was somehow manipulating the controls of the aircraft at the time of the crash.

The NTSB report says that 4 to 6 seconds before the crash, an altitude alert warning went off in the plane. At about the same time, according to the report, the plane began to climb and turn toward the left.

The "altitude alerter," according to the report, was set to go off at 275 feet. As the plane flew toward the mountain, though, the ground was rising.

Thus, the report says, there was "about 305 elevation change from the point of altitude alert to impact. Several samples from Google Earth (mapping) show that an elevation change of 305 feet could occur in about 700 feet (forward flight). That distance would be traveled in about 4 seconds at 100-knot ground speed," the cruising speed of the airplane.

Understanding how the plane, with an exceptionally experienced pilot at the controls, ended up off course and on a fatal trajectory is no small task to unravel. Knowing how much Smith comprehended the situation as the plane headed for trouble may never be known. 

Contact Jill Burke at jill(at)alaskadispatch.com and Craig Medred at craig(at)alaskadispatch.com. Reporter Ben Anderson contributed to this story.