WPR18FA013

Collision with terrain after the pilot was unable to regain airplane control during an aerobatic maneuver. Contributing to the accident was the operator's failure to provide effective internal oversight to identify and prohibit exceedance of the airplanes' performance parameters, and the lack of regulatory framework available to oversee and regulate such flight operations.

The commercial pilot and passenger departed in the aerobatic airplane to an area established by the operator for accomplishing aerobatic maneuvers. Although operating as a flight training company, the operator described itself as an "extreme aviation attraction," providing a series of aviation-related experiences that included aerobatics, simulated air combat, and flight training, during which passengers had the opportunity to fly the airplane. The accident flight was a 25-minute-long "Top Gun" experience, which incorporated aerobatics, high-g maneuvers, and a low-level bombing run simulation. Radar data revealed that the airplane flew to the standard practice area while performing the maneuvers. About that time, witnesses observed the airplane performing aerobatic maneuvers, then watched the airplane descend to the ground. One witness stated that he could see the airplane spiraling down behind a ridge. Another, who was closer to the accident site, stated that the airplane appeared to be descending at a rapid rate. He then heard popping sounds as the airplane passed behind a ridge and impacted the ground. Another witness, who was familiar with the aerobatic operations in the area, stated that the airplane appeared to be flying more aggressively than usual. An accurate analysis of the final stages of the flight could not be derived due to the sample rate of the radar data relative to the airplane's rapid aerobatic movements. An aft-facing onboard camera, mounted in front of the passenger was recording throughout the entire flight. The video revealed that the airplane was performing aerobatic maneuvers for about 7 minutes with both the pilot and passenger manipulating the controls. After the pilot completed a tumble maneuver, the airplane began to regain altitude. The passenger then moved his hands away from the flight controls and appeared to be bracing his arms against the sides of the airframe in anticipation for an aerobatic maneuver. The airplane then pitched up and rolled right, and then rolled left while the pilot made a "whooping" sound, as the airplane transitioned into an inverted spin. The passenger experienced negative g forces and reached up with his right arm up to secure the headphones that were pulling away from his head. The maneuver progressed, and its direction of rotation then reversed, until the airplane transitioned into an attitude such that only the sky was visible in the canopy. The wind noise began to increase, and a gap began to appear at the interface between the canopy frame and fuselage, indicating that the airplane was approaching its never exceed speed. The passenger then began to aggressively be rocked from side to side; however, the sun could be seen gradually transitioning across the canopy, indicating the airplane was no longer tumbling and its attitude had stabilized. Up until this point, the passenger appeared to be enjoying the flight, but his facial expression changed, and he looked down and reached forward with his right hand. At that moment, the pilot activated the canopy release handle and the canopy opened. The camera was ejected, and continued to record as it descended to the ground, capturing the airplane collide with terrain 6 seconds later. The violent rocking movement experienced by the passenger in the final seconds did not correspond to the gradual movement of the sun in the canopy, and was likely a result of the pilot applying rapid control inputs, possibly to the rudder, in an attempt to regain airplane control. The pilot released the canopy very shortly after the rocking movements began, so it is likely that he quickly deduced that recovery was not possible and that a bailout was necessary. The collision with terrain happened so fast after canopy release that a successful bailout was unlikely. Both occupants' seat belts were found in the latched and locked positions, further indicating that they did not have enough time to egress the airplane. Likewise, both occupants were wearing parachutes, neither of which had been deployed. The video did not reveal any evidence of bird strike, fire, canopy failure, or flight control separation, and the passenger appeared to be conscious throughout the entire recording. Sound spectrum analysis revealed that the engine was operating within its normal operating speed range prior to the canopy opening. The passenger's seatbelt harness was loose throughout the flight, and he could be seen moving up, down, and forward throughout the maneuvers, with particularly accentuated movement during the maneuver leading up to the accident. The position of his feet during the final maneuver could not be determined, however, inadvertent flight control interference could not be ruled out as he braced himself against the effects of the negative g-forces while secured with a loose seatbelt. The debris field and wreckage distribution indicated that the airplane impacted the ground in a near-vertical attitude at high speed. The airplane was heavily fragmented during the impact, but remnants of all flight control surfaces were found within the immediate vicinity of the accident site. The airplane had recently been purchased by the operator, and although it was about 8 years old, it had very low total flight time. Post impact examination did not reveal any anomalies with the airframe or engine that would have precluded normal operation; however, due to the extensive damage sustained during impact, such anomalies could not be ruled out. The airplane was subject to two service bulletins (SB) pertaining to the flight controls, neither of which had been performed. The first required replacement of the rudder cable to prevent premature failure, however the airplane's rudder cable did not display evidence of failure in the area documented by the SB. The other SB required the addition of a safety clamp to the transponder after a report that a transponder had slid out of its rack and jammed against the pilot control stick during aerobatic maneuvers. It could not be determined if the transponder had moved during the accident flight and inhibited the control stick. Federal Aviation Regulations do not require compliance with SB's for aircraft operating under 14 Code of Federal Regulations (CFR) Part 91. Due to the physical trauma to the occupants, it was not possible to confirm or eliminate preexisting natural diseases that may have occurred before the accident. No samples definitively attributed to the pilot were available for toxicological testing, and only limited samples were available from the passenger. Federal Aviation Regulations require commuter and on-demand operators to be appropriately certificated under 14 CFR Part 135; as such, their operations, pilots, and aircraft are subject to Federal Aviation Administration (FAA) regulations and oversight that exceed that of Part 91 operations. Part 135 also prohibits passengers from manipulating the flight controls, and FAA guidance generally does not allow anyone operating under Part 91 to advertise their services, however, exceptions exist for flight training. The operator presented itself as a 14 CFR Part 61 flight school, and although they did provide upset recovery and tailwheel endorsement flight training and all the company pilots held flight instructor certificates, the vast majority of customers (including the accident passenger) did not hold any type of pilot certificate, and purchased flights for the aerobatic and air combat experience. Further, the operator's facilities were outfitted with equipment to host parties, including a bar, dart boards, pool tables, and basketball hoops. The company's website and sales literature was clearly directed toward the adventure and experience side of the business and contained numerous references to sightseeing. The operator employed a marketing director and actively advertised its services, often to groups, for corporate events and birthday, retirement,

An autopsy was performed on both occupants by the San Diego County Medical Examiners Department. The cause of death for both was reported as multiple blunt force injuries. The reports indicated extensive fragmentation and charring. Due to the condition of the remains, all of which were located in and around the crater in the primary debris field, it was not possible to confirm or eliminate preexisting natural diseases or injuries that occurred prior to the accident. Additionally, no samples definitively attributed to the pilot were available for toxicological testing, and only limited samples were available from the passenger. Toxicology testing performed at the FAA Forensic Sciences Laboratory on specimens from the passenger. The results were negative for all screened drug substances with the following results for volatiles: -66 (mg/dL, mg/hg) Ethanol detected in Muscle -N-Butanol detected in Muscle -Propanol (N-) detected in Muscle Ethanol is the intoxicant in beer, wine, and liquor, but it can also be produced in postmortem tissues by bacterial action. How much, if any, of the identified ethanol had been ingested could not be determined. A weather sounding released at 1600 from Miramar MCAS Airport, San Diego, California, 2 miles west of the accident site, indicated 7 to 12 knot wind speeds generally out of the northwest at altitudes from 2,000 ft to 8,500 ft. Flight Instructor The pilot was hired by SCA in May 2017, and according to the president of SCA, quickly came to be considered one of the company's most dependable and reliable pilots. The president stated that he was a good mentor, was conservative in nature, and provided supervision for some of the younger pilots. He further stated that the pilot was well-suited to work unsupervised at SCA's smaller SEE location. The pilot's resume included experience in manufacturing and engineering until 2002, when he began to work as both a flight instructor and a commercial air tour pilot in the Southern California area. His experience included aerobatic, tailwheel, and emergency maneuver training in both the Pitts and Extra 200 series of aerobatic airplanes. The pilot held a commercial pilot certificate with ratings for airplane single- and multiengine land and instrument airplane. He also held a flight instructor certificate with ratings for airplane single- and multiengine, instrument airplane, and ground instructor (advanced). His most recent FAA medical examination was conducted on December 12, 2016, following which he was issued a second-class medical certificate with the limitation that he must wear corrective lenses. The last entry in the pilot's flight logbook was dated October 15, 2017. At that time, he had documented 4,289.3 total hours of flight experience, with 2,246.2 as a flight instructor. The logbooks revealed that he had accrued about 113 hours of total flight experience in the Extra 300 series, all since he first flew the type as part of his SCA initial hire training in May 2017. There were no entries indicating that he had flown the accident airplane; review of SCA records indicated that the accident flight was likely the third time he had flown it. The Extra 300 airplane that he usually flew was being used in Florida as part of an event. It was used because it was more suited for the cross-country trip, because it had a heater and autopilot, unlike the accident airplane. SCA's base of operations was located near Las Vegas at Henderson Executive Airport (HND), Henderson, Nevada. The pilot was based in San Diego, and the day before the accident, he flew from there to Las Vegas by commercial airline and had dinner with SCA employees that night. SCA had sleeping quarters in Henderson. According to a company employee, all rooms were taken the night before the accident, so the pilot slept on a couch (which he had done before). He was observed to retire about 2200. No witnesses observed what time the pilot woke up, but one stated that it was not unusual for him to rise at 0600 and go for a run. All individuals who were with him stated that he was in good spirits, and none observed anything out of the ordinary. About 1000 on the morning of the accident, the pilot flew a customer on a group combat mission from HND in an Extra 300 airplane. He then flew back to the SEE facility in the accident airplane with the company's director of marketing. The accident flight was his third flight of the day. Passenger The passenger did not hold any FAA pilot or medical certificates. He had had flown with SCA on a similar flight in December 2015 out of SCA's HND location. The accident site was located within a valley on a hillside slope at an elevation about 775 ft msl, about 1,000 ft east of the last radar target. The primary wreckage consisted of a 4-ft-deep by 6-ft-wide crater, which contained fragmented engine and airframe components. (See figure 1.) The outboard left wingtip rib, along with shards of the red position light, were located about 14 ft west, with the corresponding right wingtip rib and green position light shards about the same distance to the east. The debris field continued about 75 ft downhill to the north, and contained the engine crankcase, instrument panel components, fragmented tubular airframe material, the crumpled steel remains of the tail section, and burnt composite structure. Most of the airplane's composite structure was consumed by fire, except for about a dozen composite skin fragments, which were scattered in the surrounding trees and in the immediate vicinity of the impact site. The impact ignited a brush fire, which burned about 45 acres of land northeast of the accident site along the flank of the adjacent hillside. A secondary debris field was located in a dry riverbed about 400 ft north of the crater. The debris was oriented east-west, about 800 ft long, and contained the left (lock side) and rear arch sections of the canopy frame, multiple pieces of canopy plexiglass material, and parts from the passenger's headset. No items in the secondary debris field, including the canopy components, displayed any indications of fire or bird strike. Figure 1. Accident Site Viewed to the South Airframe and Engine Examination The wreckage was recovered from the accident site and examined by the NTSB and technical representatives from Extra Flugzeugproduktions-Und and Lycoming Engines. A complete report is included in the public docket; the following is a summary of findings. The identifiable components were separated and organized into their respective subsystems for examination. Except for the tail, all steel airframe tubing members were fragmented and deformed into sizes varying from 3 to 24 inches. Additionally, all composite components that had not been ejected from the impact site (skin sections, cockpit instruments, tailwheel assembly) were consumed by fire. Remnants of all flight control surfaces and their corresponding primary aerodynamic load structures were located, and no bird remnants or feathers were found. The left and right rudder cables were continuous from the aft rudder pedal assembly to the base of the rudder. Forward of the aft rudder pedals, the cables had separated into multiple pieces with the fragmented airframe structure. The left cable remained attached to the control arm at the base of the rudder; the right cable had detached from the right arm, which had melted at the cable attach point. There were no indications of cable degradation or separation in the locations referenced in SAIB CE-12-01. The primary components of the elevator and aileron control system sustained extensive fragmentation throughout. All located bellcranks, control tube fittings, hinges, and wing spades sustained varying degrees of bending damage consistent with impact overload. Most of the wing primary structure and fuel tanks were consumed by fire. The left and right main spar attachment flanges remain