Federal investigators aren't sure why Gene Damschroder lost control of the airplane he was piloting on June 8, 2008, but they say the 86-year-old should not have been flying given his vision and heart problems.
And the physician who signed off on his airman medical certificate a year earlier - Ottawa County Coroner Jerome McTague - also contributed to the crash that killed Mr. Damschroder and his five passengers, the National Transportation Safety Board said in a report issued late Thursday.
Investigators concluded the probable cause of the crash was "the pilot's failure to maintain airplane control for an undetermined reason, which resulted in an inadvertent stall."
"Contributing to the accident was the pilot's poor judgment in continuing to fly with his severe visual deficiency," the NTSB stated. "Also contributing to the accident was the aviation medical examiner's failure to accurately assess and report the pilot's visual deficiency."
Killed in the crash were Bill Ansted, 62, and his daughter, Allison, 23, both of Lindsey, Ohio; Matt Clearman, 25, of Maumee, who was Ms. Ansted's fiance, and Danielle Gerwin, 31, and her daughter, Emily, 4, both of Gibsonburg. All had paid for an airplane ride with Mr. Damschroder at the airport he owned and operated during a "Drive-In/Fly-In Breakfast" sponsored by the Fremont Lions Club.
Federal Aviation Administration records show that just a month before the fatal crash, Dr. McTague was barred by the FAA from performing medical exams for pilots after officials found he had issued numerous improper airman medical certificates.
In Mr. Damschroder's case, Dr. McTague recorded 20/20 uncorrected vision in Mr. Damschroder's eyes, reported "normal" eye test results, and issued him a certificate.
According to the NTSB, Mr. Damschroder actually had been treated for age-related macular degeneration in both eyes for more than two years and had a distant visual acuity without correction of 20/200 for each eye just three weeks before the crash.
Depending on the class of certificate issued, pilots must have vision measured between 20/20 and 20/40.
The NTSB report states that Mr. Damschroder provided false information to Dr. McTague at the time of his May 4, 2007, examination, but Mr. Damschroder's vision problems "should have been detectable during the vision examinations required before issuance of such an Airman Medical Certificate."
The same medical examiner had conducted Mr. Damschroder's exams since 1998, the NTSB said.
The agency also said in its report that Mr. Damschroder's autopsy revealed he had severe coronary artery disease, which "could have increased the likelihood of a heart attack or abnormal heart rhythm, resulting in impairment or incapacitation. There was no evidence of such an event, but no such evidence would necessarily be expected if death occurred within a few minutes to an hour of the impairment or incapacitation."
The NTSB ruled out possible mechanical problems with the airplane saying that witness statements as well as ground scarring and wreckage distribution were consistent with an "aerodynamic stall."
"When a car stalls, the engine dies. That is not the case here. In fact, testing on the engine post-accident showed no mechanical anomalies," said NTSB Spokesman Peter Knudson. "In aviation, a stall is when the airplane is not flying through the air fast enough to stay aloft."
The report points heavily to Mr. Damschroder's medical history.
Dr. McTague, 45, of Oak Harbor did not return multiple phone messages seeking comment yesterday.
In addition to the elected office he holds in Ottawa County, Dr. McTague is also a deputy coroner in Sandusky County, co-founder of Physicians Choice Hospital in Fremont - which opened last July - and a partner at Skiver & Associates law firm in Perrysburg Township.
Dr. Stephen Skiver, who heads the Perrysburg Township firm, used to practice medicine at Toledo Hospital and was previously certified to issue medical certificates to pilots. He said Dr. McTague is "very conscientious in everything that he does."
"It's my understanding the pilot in this instance falsified his medical history," Dr. Skiver said. "When you do these types of exams, much of [the exam] is based on what the pilot tells you. If he says he has no vision problems, you take him at his word."
Family members of the victims have filed a lawsuit in Lucas County Common Pleas Court seeking in excess of $15 million from David Damschroder, executor of the Gene Damschroder estate, as well as International Association of Lions Clubs, Fremont Noon Lions Club, and six club members.
Although Dr. McTague has not been named in the suit, Toledo attorney Dale Emch said he and other lawyers representing the Ansted family are "going to explore all our legal remedies against the responsible parties.
"As far as Dr. McTague's role goes, I would say it's clear by the findings of this report that the doctor never should have signed off on Gene Damschroder's airman medical certificate," Mr. Emch said. "If Mr. Damschroder would have been deemed medically unfit to fly, he wouldn't have been piloting a plane that day."
The NTSB's Mr. Knudson said it's impossible to say if the crash would have been prevented had the medical examiner refused to certify Mr. Damschroder.
"It's very difficult to keep pilots from flying," Mr. Knudson said. "We have investigated any number of accidents where pilots without proper certificates have continued to fly."
Joe Albrechta, an attorney for the Damschroder defendants, welcomed the release of the final report nearly two years after the crash, but he said he could not comment until he'd reviewed it thoroughly.
"This case is going to take some time to unwrap and unwind," he said. "We're looking forward to studying this more carefully, and I'm certain there's more that's going to come out."
A review of Dr. McTague's personnel file at the FAA, obtained through the Freedom of Information Act, shows a medical doctor with a once-sparkling record as a pilot medical examiner who began to make mistakes.
In May, 2008, the FAA wrote a letter to Dr. McTague ordering him to cease exercising his pilot medical examiner privileges immediately because of "significant aerospace medical certification errors on airmen examined in your office."
Once commended by the FAA in 2003 for achieving an error rate "among the lowest of all [medical examiners] within the Great Lakes Region," Dr. McTague was warned by the FAA on May 17, 2007, for erroneously issuing a certificate to a pilot with a history of diabetes requiring oral hypoglycemic medication for control.
By the end of April, 2008, the FAA had been made aware of Dr. McTague's "many errors in which certificates were issued to airmen who are hypertensive." The FAA continued to review Dr. McTague's previous work while he was suspended and found numerous mistakes as menial as filling out certificates in ink instead of typing them, and as serious as not asking for further information from applicants who declared to have thyroid cancer.
The packet of information provided by the FAA to The Blade did not include any information regarding Mr. Damschroder, and FAA officials declined to say if Dr. McTague's issuance of a certificate to Mr. Damschroder was among the "egregious errors" found in the administration's investigation.
In December, 2008, the FAA told Dr. McTague, who had been a medical examiner since 1997, that he could be reinstated if he completed a series of training seminars. On Jan. 28, 2009, the FAA officially terminated Dr. McTague's designation, saying he had not responded to the agency's requirements.
Projects Editor Joe Vardon contributed to this report.
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