ERA13FA309

The pilot's failure to terminate the intentional aerobatic spin at an altitude adequate to prevent impacting the water. Contributing to the accident was the pilot's loss of situational awareness due to target fixation during the prolonged aerobatic maneuver.

Witness accounts and on-board video recordings of the accident flight revealed that the pilot initiated and performed a series of aerobatic maneuvers with the airplane before initiating a stall, rolling the airplane inverted, and entering a steady-state spin to water contact. The airplane completed 22 revolutions in the spin, with the engine running smoothly, and the stick held fully aft. Examination of the wreckage revealed no evidence of any preimpact mechanical anomaly. Review of the pilot's flight records revealed no evidence of formal aerobatic training. However, the records indicated that he had conducted aerobatic maneuvers, including, on at least one occasion, a flat spin. The on-board video recordings showed no signs of pilot distress or incapacitation and indicated that the pilot was actively engaged in controlling the airplane and was providing control inputs to maintain the spin to impact. There was no indication of any distracting event or of the pilot attempting to diagnose, troubleshoot, or respond to a perceived in-flight control, system, or engine anomaly. There were multiple cues available to the pilot that the maneuver should be terminated, including an increasing ground presence/perspective from the out-the-window view and the rapidly decreasing altitude indicated on the altimeter in the panel. However, the pilot failed to terminate the maneuver at an altitude adequate to prevent impacting the water. Therefore, it is most likely that the pilot lost situational awareness during the aerobatic maneuver/prolonged spin and did not recover from the spin before impact. Given the fact that this was a sustained aerobatic maneuver, it is possible that the pilot lost situational awareness due to target fixation, a phenomenon that can occur at varying levels ranging from a breakdown in an instrument scan to failing to pull out of an aerial application run. In these cases, the pilot has cues that a response is required and has the knowledge and skills necessary to successfully perform the response. However, because of the narrowing of attention resulting from the goal-directed activity associated with this phenomenon, a loss of overall situational awareness occurs and the appropriate response is not commanded/input. The circumstances of this accident are consistent with the loss of situational awareness due to target fixation. The pilot appears to have focused on the performance/sustainment of the spin maneuver and therefore misjudged or lost awareness of his exit altitude.

On July 8, 2014, two GoPro Hero self-contained video recorders and one Garmin Aera hand-held global positioning system (GPS) receiver were examined in the NTSB Recorders Laboratory in Washington, D.C. The GPS receiver was damaged by impact and salt water immersion. Removal and download of the data chip revealed that no track data was recorded on the day of the accident. The GoPro Hero video recorder was a high quality self-contained battery powered video and audio recorder. One camera was damaged and the flash memory card was wet from salt water immersion. The memory card was dried and data was recovered using the laboratory's file recovery software. The second camera was undamaged, and the memory card was downloaded normally. The video recovered from the first memory card consisted of the entire accident flight from taxi, takeoff, enroute maneuvering and the start of the accident spin sequence. The portions of the accident flight captured by the second memory card consisted of the events that occurred just prior to the accident spin sequence through water impact. The angle of each video suggested that the first camera was mounted on the aft glareshield facing aft, and the second camera was hand-held by the passenger in the aft seat. A Recorder Laboratory Specialist reviewed the video and prepared a transcript of the events from each camera. Video from the first camera revealed that after takeoff the airplane climbed to about 5,000 feet and performed a series of maneuvers that included barrel rolls, banks of 60 degrees, as well as positive and negative pitch angles of 80 degrees or more. The passenger was seen holding a GoPro camera facing forward, and rudder movement was evident throughout the flight. Beginning about 1604:00, video from the second camera showed the airplane pitched up through 70 degrees, roll through 120 degrees of bank and eventually rolled inverted, before it entered a steady-state, nose-down spin. The video showed the airplane stabilized in a 30-degree nose down attitude, wings level, the inclinometer (trim ball) displaced 1-2 ball widths to the right, and a 600 feet-per-minute rate of descent. As the airplane descended in the spin, the nosed-down pitch attitude decreased to about 20 degrees. The pilot's head was upright and faced forward, the control stick was fully aft, and the pedals moved somewhat, but remained generally neutral. The pilot and the airplane maintained this attitude through 22 complete revolutions before water contact at 1605:00. The pilot never released aft pressure on the control stick, and no evidence of remedial action was observed. The propeller was rotating and the engine sound was smooth and continuous without interruption all the way to water contact. A friend of the pilot provided a written statement as well as video footage of flights he had taken with the accident pilot. The witness was not a pilot, but interested in taking lessons at some point in the future. He said that the accident pilot was not his instructor, but offered him advice with regards to study guides, practice tests, and map reading. During flights, he was given the flight controls, and allowed to practice navigation and steep turns. The pilot would assist him in donning a parachute, and go over "bail-out" procedures prior to each flight. The flights would depart to the east over the water, and then turn north and travel between 5 and 30 miles to perform aerobatic flight "as a safety precaution to any one on the ground should something go wrong." He said that during the flights, the pilot would perform loops, rolls, and on one occasion, "went vertical and put the plane into a stall." A review of the video footage provided by the witness revealed views from a wingtip-mounted camera pointed back towards the fuselage, as well as a rear-facing view from a camera mounted on the aft-cockpit glareshield. The footage showed the airplane operating at low altitude over the ocean, as well as climbs that penetrated clouds. The airplane would be surrounded, and the ground would be completely obscured by clouds, for several seconds. The aerobatic maneuvers were also as the witness described them. The vertical climb, stall, and spin entry captured in the video provided by the witness was consistent with the accident spin entry. The airframe and powerplant mechanic who maintained the accident airplane was interviewed by telephone and provided a written statement. He held an airline transport pilot certificate, flight instructor certificate, and had approximately 14,000 hours of flight experience, with 1,300 hours in the accident airplane make and model. He provided instruction and a "check-out" in the accident airplane to the pilot/owner after it was purchased. The instructor did not provide any aerobatic instruction to the pilot/owner, and said he did not think any formal aerobatic training had been provided to him. When it was explained that there was video evidence of the pilot/owner performing aerobatics in the accident airplane during several flights previous to the accident flight he said, "If I had known that, I would have put a stop to it." When asked about the stall/spin characteristics of the accident airplane, the instructor said that the airplane had very predictable handling characteristics. The instructor stated, "You have to hold the airplane in a spin. The airplane will recover from a spin by itself. The second you release the stick, it will come out of the spin. The airplane will recover by itself from a fully developed spin in less than one turn. Once it is in the stall and spinning, you must hold the stick fully aft to maintain the spin." The instructor volunteered and stressed that "aerobatics over water is dangerous. It's disorienting." Among the Federal Aviation Regulations that address aerobatic flight, "…no person may operate an aircraft in aerobatic flight— (b) Over an open air assembly of persons; (e) Below an altitude of 1,500 feet above the surface." According to U.S. Army Field Manual 3-04.301 (1-301) Aeromedical Training for Flight Personnel: 9-31. Fascination, or fixation, flying can be separated into two categories: task saturation and target fixation. Task saturation may occur during the accomplishment of simple tasks within the cockpit. Crew members may become so engrossed with a problem or task within the cockpit that they fail to properly scan outside the aircraft. Target fixation, commonly referred to as target hypnosis, occurs when an aircrew member ignores orientation cues and focuses his attention on his object or goal; for example, an attack pilot on a gunnery range becomes so intent on hitting the target that he forgets to fly the aircraft, resulting in the aircraft striking the ground, the target, or the shrapnel created by hitting the target. The Office of the Chief Medical Examiner, State of Maryland, performed the autopsy on the pilot. The autopsy report indicated that each died as a result of "multiple injuries." The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of the pilot. The testing was negative for drugs, alcohol, and carbon monoxide. At 1621, the weather reported at OXB included few clouds at 600 feet, and the winds were from 200 degrees at 7 knots gusting to 17 knots. Video footage as well as still photography revealed that the airplane appeared intact all the way to water contact. Sonar mapping and salvage divers revealed that the entire airplane rested together on the ocean floor, but was fractured in several places due to impact. The majority of the airplane was recovered on July 4, 2013. All major components were recovered with the exception of the left wing, and the vertical stabilizer. Examination of the airplane revealed that the engine was still attached to the firewall, but the upper two engine mounts were fractured due to impact. The firewall-mounted oil tank was crushed. The u