WPR15FA021

The pilots' failure to recover from a spin for reasons that could not be determined based on available information. Contributing to the student's fatal injury was his delayed egress from the airplane below the specified egression altitude.

The flight instructor and student, who was receiving instruction as part of a Flight Test Engineer program, departed with the intent of completing a flight card that called for 10 maneuvers, 4 of which included spins for a certain amount of rotations. The program allowed students to fly the airplane if they felt comfortable; however, it did not require that the student fly the airplane. A camera mounted inside the airplane provided a view of the right wing. Review of the recorded video revealed that the flight performed two left spins and one right spin with uneventful recoveries before the accident sequence. The video showed that, during the accident sequence, the airplane entered a right spin, consistent with a maneuver on the flight card, which called for a six-rotation right spin with aileron inputs before recovery. Throughout the spin sequence, little-to-no aileron input was observed. As the airplane completed about 21 revolutions, the student made an altitude call of "6,000 ft," which was the specified bailout altitude. Shortly after, a callout of "5,500 ft" was made during revolution 22, and the canopy was opened between revolutions 24 and 25. Reflections within the canopy showed the student standing while grabbing the upper canopy rail between revolutions 29 and 30 and subsequently jumping from the right wing between revolutions 33 and 34. At the time of ground impact, the airplane had completed about 34 revolutions. The delayed egress from the airplane below the specified egression altitude and just before impact likely contributed to the student's fatal injuries. Little-to-no movement of the flight instructor was observed on the video; thus it is likely he did not attempt to bailout of the airplane. Postaccident examination of the airframe and engine revealed no evidence of any preexisting mechanical malfunctions that would have precluded normal operation. In addition, the airplane was found to be within weight-and-balance and center-of-gravity limits. Further, a recent inspection of the airplane's rigging revealed that it was within limits prior to the accident flight. The accident circumstances are consistent with the pilots' failure to recover from a spin; however, the reason for this could not be determined. Although the flight instructor's toxicology testing detected ethanol in the kidney, the absence of ethanol in the muscle suggests the identified ethanol was likely from postmortem production rather than ingestion. Although the autopsy of the flight instructor identified left ventricular hypertrophy, which is most often associated with hypertension, age, or regular, vigorous exercise and may be associated with an increased risk for acute cardiovascular events, only mild coronary artery disease and no significant atherosclerosis were noted. However, if a cardiovascular event or loss of consciousness from any other cause (such as a seizure or neurogenic syncope) occurred in the few minutes before the flight instructor's death, it would have left no evidence on autopsy.

Flight Test Procedures Review of the BFAP F9 flight card for the accident flight revealed that 10 maneuvers were to be conducted. The first four maneuvers involved unusual attitudes and a stall series that included straight ahead, left, and right turn 1-g stalls with delayed subsequent recoveries from 1 to 3 seconds. Maneuvers 5 through 8, which included spins, stated the following: Maneuver 5: Right spin, three turns, flight manual recovery Maneuver 6: Left spin, three turns, flight manual recovery Maneuver 7: Right spin, six turns, two turns ailerons neutral, additional two turns left aileron, additional two turns right aileron, flight manual recovery Maneuver 8: Left spin, six turns, two turns ailerons neutral, additional two turns right aileron, additional two turns left aileron, Flight manual recovery Maneuvers 9 and 10 included a loop and roll before returning to the airport. The flight card stated that the stall series and three-turn spin series were to be executed at an altitude of 9,000 ft msl and that the six-turn spin series was to be executed at 10,000 ft msl. In addition, the card noted that all recoveries should be initiated by 7,500 ft msl and that the bailout altitude was 6,000 ft msl. Video Examination A GoPro Hero 3 camera, enclosed in a watertight case, was located in the wreckage and subsequently sent to the NTSB Vehicle Recorders Laboratory for review. Examination of the camera revealed that the memory card contained various recordings and had captured video showing the airplane located on the ramp at the departure airport through the time the accident occurred. The camera appeared to have been mounted on the right side of the airplane's canopy and provided a view of the right wing, including the right flap and aileron. Additionally, reflections on the canopy were observed throughout various portions of the recording. The reflections included those of the passenger, who was seated in the right seat and was wearing a green flight suit, and the flight instructor, who was seated in the left seat and was wearing a blue flight suit. Throughout the recordings, some muffled vocal comments, cockpit noises, and muffled engine noises were heard. The video showed that, about 11 minutes after takeoff, the flight instructor and student conducted a stall, consistent with maneuver 2 on the flight card, and that maneuvers 1 and 3 were not flown. Upon completion of maneuver 2, the airplane entered maneuver 4, and a left 2-revolution spin was performed. About 4 minutes later, the airplane performed maneuver 5, which incorporated a 4-revolution right spin with a normal recovery. About 5 minutes later, the airplane performed a left 4.5-revolution spin, consistent with maneuver 6. The airplane then entered a right spin, consistent with maneuver 7. As the airplane completed about 21 revolutions, the student reported an altitude of "6,000 ft" followed by another announcement of an altitude of "5,500 [ft]" 1 revolution later. It could not be determined whether the word "bailout" was said after "5,500" was announced. The canopy was opened between revolutions 24 and 25. Reflections within the canopy showed the instructors right arm grabbing the canopy between revolutions 27 and 28, while the student was observed standing while grabbing the upper canopy rail between revolutions 29 and 30. The student subsequently jumped from the right wing between revolutions 33 and 34; little-to-no movement of the flight instructor was observed. At the time of ground impact, the airplane had completed about 34 revolutions. For further information regarding the captured video, see the Onboard Image Recorder Factual Report in the public docket for this accident. Spin Procedures Review of the Pilot's Operating Handbook for the accident make/model airplane, Section 4, "Normal Procedures, Spin Recovery," stated that the following steps were to be taken to recover from a spin: 1. Throttle- IDLE 2. Flaps – Raise (If lowered) 3. Hold control stick back with ailerons neutral 4. Check direction of rotation of spin by external visual reference and the turn indicator needle 5. Apply and maintain full rudder to oppose the direction of spin 6. Pause – One Second 7. Move control stick, with the ailerons neutral, progressively forward until the spin stops 8. Immediately [when] the spin stops, centralize the rudder and fly the aircraft in a straight line, out of the dive with a 3-g pullout. Warning – A high rotation rate spin may occur if the correct recovery procedure is not followed; particularly if the control column is moved forward, partially, or fully before the application of full anti-spin rudder. Such out of sequence control actions will delay recovery and increase the height loss. If the aircraft has not recovered within 2 (two) complete rotations after application of full anti-spin rudder and fully forward control column, the following procedure may be used to expedite recovery. 1. Check that full ant-spin rudder is applied. 2. Move the control column FULLY AFT – then slowly forward until the spin stops. 3. Centralize the controls and recover to level flight (observing the 'g' limits). Flight Instructor According to the Kern County Coroner's autopsy report, the flight instructor's cause of death was "multiple blunt force trauma," and the manner of death was "accident." Examination of the body identified left ventricular hypertrophy, which is most often associated with hypertension, age, or regular, vigorous exercise. When identifiable by electrocardiogram, LVH may be associated with an increased risk for acute cardiovascular events, such as sudden cardiac death, stroke, and heart attacks. Mild focal areas of coronary artery disease were noted (not further described in the autopsy report), no significant atherosclerosis was noted, and the remainder of the heart evaluation was unremarkable. No other significant natural disease was identified. The FAA's Bioaeronautical Research Laboratory conducted toxicology testing of specimens from the flight instructor. The testing identified 0.013 gm/dl of ethanol in the kidney, but no ethanol was identified in the muscle tissue. After absorption, ethanol is quickly distributed throughout the body's tissues and fluids fairly uniformly. The distribution pattern parallels the water content and blood supply of each organ. Ethanol may also be produced by postmortem microbial activity in the body. Student According to the Kern County Coroner's autopsy report, the student's cause of death was "multiple blunt force trauma," and the manner of death was "accident." The FAA's Bioaeronautical Research Laboratory conducted toxicology tests on specimens from the student. The results were negative for carbon monoxide and volatiles and positive for salicylate in the urine. Representatives of the FAA and NTSB conducted an on-scene examination of the accident site on October 24 and 25, 2014. Examination of the accident site revealed that the airplane impacted open desert terrain about 12 miles south of Ridgecrest. The airplane came to rest upright oriented on a magnetic heading of about 027° at a GPS elevation of 2,345 ft msl. Wreckage debris, which included plexiglass, rudder, and portions of the engine cowling, remained within about 10 ft of the main wreckage. Vegetation, about 12 to 18 inches high and located immediately to the left and right of the aft area of the fuselage, appeared to be undamaged. The left wing remained attached to the fuselage. The left aileron remained attached to its respective mounts. The outboard portion of the left flap was separated and located about 1 ft aft of the left wing. The inboard portion of the flap remained attached via the inboard attachment point. The right wing remained attached to the fuselage. The right aileron remained attached to its respective mounts. The outboard portion of the right flap was separated at the outboard attac