WPR16LA071

The pilot's improper decision to operate the high-performance aircraft despite warnings from a flight instructor that he did not have the experience to operate the aircraft that had different and more sensitive handling characteristics than the low-performance weight-shift-control aircraft that he was used to flying, which led to his improper control inputs and resulted in his loss of aircraft control and ground impact immediately after takeoff.

The commercial pilot, who had a total flight experience of about 4,500 hours in conventional airplanes, was learning to fly weight-shift-control (WSC) aircraft with the expressed intent of purchasing a high-performance WSC aircraft. The pilot obtained all of his 13.5 hours of WSC experience, including his WSC pilot and instructor certificates, in the 2 weeks before the accident in a docile, low performance WSC aircraft with dual seating. Despite being explicitly warned by his instructor that he was not "not qualified" to fly the specific model high performance WSC aircraft involved in the accident, the pilot convinced an owner of a high-performance WSC aircraft to allow him to fly it solo. The owner reported that the engine start, taxi out, and run-up appeared normal. The wind was light. Witnesses reported that, on takeoff, the aircraft climbed rapidly and entered a steep right bank/roll from which it did not recover. The flight lasted about 16 seconds, and the aircraft reached a maximum altitude of about 80 ft above the runway. Detailed examination of the wreckage did not reveal any mechanical deficiencies or failures that would have precluded normal operation, and data from an electronic engine control indicated that the engine operated normally throughout the flight. The pilot's autopsy did not reveal the presence of any debilitating physical conditions or impairing drugs. The pilot inputs for pitch and bank/roll control on a WSC aircraft are opposite those of conventional airplanes, and the pilot's experience differential between the two aircraft types was substantial. In addition, the high performance WSC aircraft was a much more powerful and challenging aircraft due to its control sensitivity than the one flown by the pilot during his limited WSC training, which was all done with an instructor. The witnesses' description of the sequence of events and the rapidity with which they occurred is consistent with excessive and contrary control inputs. Given the handling characteristics of the accident aircraft relative to the pilot's flight experience, it is likely that the pilot over-controlled it during the initial rotation, which led to what witnesses reported to be a very steep takeoff attitude. The lack of familiarity with the aircraft, combined with potential threat of a stall or other loss of control, and possible reversion to habit patterns appropriate to his conventional airplane experience may then have led to the pilot's reflexive and incorrect control inputs. Those inputs exacerbated the situation and ultimately resulted in a loss of aircraft control. The aircraft was equipped with a rocket-powered parachute, but the first responders worked on and around the wreckage for about 1 hour before they were advised by a Federal Aviation Administration inspector of the presence of the rocket and its potential hazard. Existing industry consensus standards only specify warning placards near the rocket egress point, which in this case, was on the aircraft's left side. Because the aircraft came to rest on its left side, neither the rocket nor any placards would have been visible. ASTM International standards do not require that warning placards be placed on all sides of the aircraft.

Revo Flight Characteristics The manufacturer of the aircraft agreed with the two CFI assessments that the Revo and Navajo had dramatically different flight characteristics, and that the Revo performance characteristics were not well suited for beginner level WSC pilots. The pilot's primary CFI noted that the Revo is a very high performance aircraft, and that a first flight in that aircraft, particularly a solo flight, would be very different from the pilot's prior dual experience in the lower-performance Navajo. Learning Primacy According to the Aviation Instructor Handbook (AIH, FAA-8083-9), the first information or behavior learned by a person "often creates a strong, almost unshakable, impression." This phenomenon is called "primacy," and the AIH states that such primacy of learning and behaviors "lay the foundation for all that is to follow." The AIH further stated that unlearning those first-learned behaviors is significantly more difficult than learning them in the first place. Persons will frequently revert to the first-learned behaviors in time of stress, distraction, or inattention. The AIH also discussed how the "element of threat...adversely affects perception by narrowing the perceptual field," which reduces the pilot's ability to adequately or accurately sense or process the inputs available. The imposition of a threat can result in an individual becoming overly task-focused on countering the threat, while concurrently ignoring relevant or critical information. Rocket and Parachute System Information According to the FAA inspector, until he arrived at the site about one and a half hours after the accident, the first responders who were working on the wreckage and pilot were unaware of the presence of the rocket, or the hazard that it posed. Review of the body camera footage and audio from one of the responding police officers revealed that one of the firefighters did raise the possibility of the presence of a rocket early in the emergency response, but the question did not receive a considered response, and the matter was apparently not discussed again by any of the first responders. When the FAA inspector arrived on scene, it was he who advised them of the rocket's presence. Once the personnel became aware of the system, they ceased all activity, and the NTSB was contacted for guidance to disarm the rocket. That was accomplished, and the recovery of the pilot and aircraft were completed without incident. FAA regulations and ASTM standards required proper completion of certain FAA forms, and proper placarding of the aircraft with regard to the parachute recovery system. In this case, ASTM standard F2316 (Airframe Emergency Parachutes) is the applicable standard. In part, the standard required that the "airframe manufacturer shall supply conspicuous placards or labels for placement in unobstructed view to anyone near the egress point (exterior). These placards are to be displayed such that they provide a visual warning to rescue or other personnel at the scene of an accident or incident." The standard also specified that the "airframe manufacturer shall permanently install the warning placards or labels in a manner defined by this specification and documented in the PIM [parachute installation manual]". The standard presented sample labels in an appendix. Based on the installation configuration of the rocket and parachute inside the carriage/fuselage, the standard required that a placard be mounted adjacent to the fuselage exit point, which in the case of this aircraft, was on the left aft side. However, the aircraft came to rest on its left side, which obscured the rocket and parachute from view of the first responders. Any co-located, left-side placards would have been similarly obscured from view. NTSB investigators coordinated with the FAA Light-Sport Aircraft Program Manager in an attempt to modify the ASTM standard, and require that warning placards be affixed to all sides of the aircraft, in order to minimize the potential for injury to first responders. On May 11, 2016, the proposal to alter the F2316 placarding standard was presented to and considered by the responsible ASTM committee; the committee rejected that proposed change. The formal substantiating rationale was that the existing standard is sufficient, and does not need to be revised, and that first responder training ensures adequate protections. Although the ballistic airframe parachute recovery system was installed by the factory prior to delivery of the aircraft to the owner, the as-found condition of the aircraft revealed that none of the required rocket-related placards were present on the fuselage. Additional investigation revealed that the owner had the required, unused placards in his documentation package from the aircraft manufacturer. According to the aircraft manufacturer president, the required placards had been installed when the aircraft was originally constructed, but then subsequently removed for an unspecified "photo shoot." The aircraft was then delivered to the owner without the placards installed, but provided to him in a separate package. According to the owner, he was unaware that he was supposed to affix the placards to the aircraft, and they remained stored with his aircraft documentation files. The timing of the completion of aircraft construction, the photo shoot, and the delivery of the aircraft to the customer/owner was not determined. Insufficient time between the manufacture date of the aircraft and the accident date precluded the need for an annual condition inspection, which would have provided an opportunity to detect and rectify the absence of the proper placards. Review of the FAA form 8130-15 for the accident aircraft, which was part of the airworthiness application that was completed by the airframe manufacture, revealed that, although required, the form did not cite ASTM F2316 as one of the "Consensus Standards" that the aircraft had been manufactured to. The reasons for this discrepancy could not be determined. The pilot's most recent valid FAA medical certificate was obtained in 2004, and was expired by the time of the accident flight. In February 2005, the pilot was seriously injured in an accident where he was piloting a Cessna 177. That accident was attributed to a complete loss of power due to oil starvation/exhaustion. The pilot's girlfriend reported that the initial injuries and resulting debilitation had delayed the pilot's decision to apply for another FAA medical certificate and resume flying certificated airplanes, and that the pilot continued to suffer pain from some of those injuries. Therefore, at the time of his weight shift training and the accident, the pilot was operating in accordance the light sport rules, which do not require a valid FAA medical certificate. The Maricopa County (Arizona) Office of the Medical Examiner autopsy report indicated that the cause of death was "multiple blunt force trauma," and that alcohol and drug test results were all negative. Review of the pilot's previous medical history by an FAA Civil Aeromedical Institute (CAMI) physician indicated that the pilot reported no significant medical concerns, and that his FAA medical examiner did not identify any significant conditions during the pilot's 2004 physical examination. The CAMI physician's review also noted that the autopsy "revealed some moderately severe cardiovascular disease but no evidence of thromboemboli or a recent or previous heart attack," and that "there were no significant natural disease findings that could point towards a sudden incapacitating event." CAMI conducted forensic toxicology examinations on specimens from the pilot, and reported that no carbon monoxide, cyanide, ethanol, or any screened drugs were detected. The BXK 1455 automated weather observation included winds from 130 degrees at 8 knots, visibility 10 miles, clear skies, temperature 27 degrees C, dew point