Four Corners, CA, USA
N414MT
Flugzeugproduktions-und Vertri EA 300/L
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, and wedding celebrations. Very little of the advertising was related to traditional flight training. The operator's president stated that he had conferred with the FAA and made attempts to identify the appropriate operations category, and it was on that basis that he had chosen to establish the company as a Part 61 flight school operation. Limited FAA oversight exists for Part 61 operations, and there are essentially no regulations specifically tailored for the certification and comprehensive oversight of the "adventure flight" category that the company was essentially operating under. Therefore, by operating as a Part 61 flight training provider, the company was able to advertise its services, expose fee-paying passengers to high-risk flight profiles, while circumventing the regulations and oversight for operators who provide transportation for compensation or hire. The operator was involved in four other accidents in the previous 3 years, one of which resulted in two fatalities, and one of which was never reported to the NTSB, although it was required to be based upon the damage sustained to the airplane. Additionally, the operator was involved in two FAA enforcement actions during the same period, all involving incidents with passengers on board. In one case, a pilot's certificate was suspended for careless and reckless flying. In another, the FAA concluded that the pilot was likely acting carelessly and sanctioned him with safety awareness counselling. Review of onboard video footage from the accident pilot's previous flights revealed that, although considered to be a mentor and conservative in nature by his colleagues, the pilot routinely flew airplanes beyond their operating limitations (specifically their vertical acceleration, or g limitations) and at speeds very close to the never-exceed speed, all with passengers on board. Review of footage taken with other pilots revealed a company-wide pattern of disregard for the airplane's published operating limitations and the company's own policies regarding airspeed and g limitations. Because both the accident airplane and other airplanes in the company fleet had been flown beyond their rated g limits, they would have been required to undergo additional maintenance checks. There was no evidence that such checks had ever been performed on the accident airplane; as such, the airplane was likely unairworthy at the time of the accident. Both the company's ineffective internal controls and their ability to operate in an environment where limited FAA oversight existed allowed these behaviors and violations to continue.
HISTORY OF FLIGHTOn October 21, 2017, at 1612 Pacific daylight time, an EXTRA Flugzeugproduktions-und Vertriebs-GmbH, EA 300/L, N414MT, collided with terrain within the watershed of the El Capitan Reservoir, near Four Corners, California. The flight instructor and passenger sustained fatal injuries and the airplane was destroyed. The airplane was registered to KD Leasing, LLC, and was being operated by California Extreme Adventures, LLC, doing business as Sky Combat Ace (SCA), as a Title 14 Code of Federal Regulations (CFR) Part 91 instructional flight. Visual meteorological conditions prevailed, and no flight plan was filed for the local flight, which departed Gillespie Field Airport (SEE), San Diego/El Cajon, California, at 1557. SCA's website described itself as an "extreme aviation attraction," providing a series of aviation-related experiences, which it described as including aerobatics, air combat, and flight training. The accident flight was a 25-minute "Top Gun" experience which, according to sales literature, included "Advanced Aerobatics," "Basic Aerobatics," a "Low Level Bombing Run," "You Fly Maneuvers," and "You Fly Departure." Ground-based radar tracking data provided by the Federal Aviation Administration (FAA) indicated that the airplane departed from runway 17 at SEE and initiated a climbing left turn, reaching a transponder-reported altitude about 4,700 ft mean sea level (msl) about 5 nautical miles (nm) northeast of the airport. For the next 10 minutes, the airplane followed a track northeast along the general path of the San Diego River, then east of the El Capitan Reservoir and north toward the town of Four Corners. The track depicted a meandering path at varying airspeeds and altitudes between 4,300 and 6,300 ft msl in a manner consistent with aerobatic maneuvers. Multiple witnesses along the route reported seeing an airplane performing aerobatic maneuvers about the time indicated by the radar data. At 1610, the airplane was about 15 nm from SEE and just north of the reservoir. It then began to track back to the southwest, climbing from 5,000 ft msl to 6,900 ft msl over the next 90 seconds. About 15 seconds later, the last radar return was recorded at the northern edge of the reservoir at an altitude of 3,800 ft msl (about 3,000 ft above ground level). One witness, who was piloting a motorglider, was flying southwest and was inbound for SEE at 4,500 ft msl when she observed an airplane trailing white smoke and performing aerobatic maneuvers. The airplane was ahead of her and appeared to be at an altitude of about 3,500 ft msl at the northern end of the reservoir. As the witness's glider got closer to the airplane, the airplane was leveling out at the bottom of a loop when the smoke stopped. The witness was concerned that the other pilot would not see her, so she banked the glider to the left in order to present the glider's long wing profile to the other airplane for increased conspicuity. She then passed the airplane and did not see it again. The witness stated that the aerobatic maneuvers appeared standard and that the airplane did not appear to be in distress. A witness who was in her residence about 3 miles north of the accident site stated that she was very familiar with the aerobatic operations in the area and had seen airplanes perform maneuvers in the same general location many times before. She stated that she was often drawn to look at the airplanes because she found the sound annoying. On this occasion, she noticed that the airplane was being flown either faster, more "recklessly," or more "intense" than usual, with sharper turns than she was used to seeing. She saw white smoke, but it was thicker than usual and lasted much longer. A short time later, the noise had stopped, and she saw a plume of smoke rising from the ground below. Another witness was also about 3 miles north of the accident site. He saw the airplane perform two "giant" loops, after which it began to climb and then started to "corkscrew" toward the ground. It then disappeared behind a ridge. Initially, he did not think anything was unusual because he had previously seen airplanes perform similar maneuvers over the same area; however, a few minutes later, he saw smoke rising from behind the ridge. Another witness, located at a camping area about 1 mile northeast of the accident site, stated that he could hear an airplane performing maneuvers. He said that he heard a "dive" sound like the sound airplanes typically make in movies. The engine noise then stopped, and he heard a "pop pop" sound, followed a few seconds later by the sound of an impact. He looked toward the direction of the impact sound and saw a rising plume of black smoke. PERSONNEL INFORMATIONFlight 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. AIRCRAFT INFORMATIONThe tandem-seat normal and aerobatic category airplane was manufactured in 2009, imported into the US in 2013, and purchased by KD leasing on May 10, 2017. The airplane was equipped with dual flight controls, a Lycoming six-cylinder AEIO-580-B1A engine, and a three-blade hydraulic constant-speed propeller manufactured by MT Propellers. FAA and maintenance records did not reveal any modifications to the airplane beyond the installation of a remote oil filter kit. According to the maintenance records, at the time of the last 100-hour inspection on October 1, 2017, the airframe and engine had accrued a total of 186.57 flight hours. The airplane had a basic empty weight of 1,513 lbs and a maximum takeoff weight (MTOW) of 2,095 lbs. The maneuvering speed limitation (Va) in the aerobatic category was 158 knots indicated (KIAS). The never-exceed (Vne) speed was 220 KIAS. The airplane was placarded with the following: CAUTION: Particular caution must be exercised when performing maneuvers at speeds above Va (158 KIAS). Large or abrupt control inputs above this speed may impose unacceptably high loads which exceed the structural capability of the aircraft. The airplane had g limitations in the aerobatic category of +/-10 g. This limit was only allowed with one person onboard, at a MTOW of 1,808 lbs. In a two-person configuration, the limits were +/-8 g at 1,918 lbs MTOW and +/-6 g at 2,095 lbs MTOW. The pilot was seated in the rear seat for the accident flight. With a pilot weight of 173 lbs, passenger weight of 195 lbs, 30 lbs of parachute equipment and 25 gallons of fuel, the airplane's weight on the accident flight would have been about 2,061 lbs. The airplane was equipped with a mechanical accelerometer (g-meter) which had a sweep range of -6 g to +10 g. The unit had maximum and minimum g needles that recorded the highest and lowest sensed g values, respectively. Both needles could be reset to zero using a button on the front of the instrument bezel. The airplane was equipped with a one-piece plexiglass and composite canopy, which was fixed by three hinges on the right side and was opened by the pilot lifting it to the right. It had forward and aft interior locking handles, which were painted bright red and located on the left side of the canopy frame and within reach and view of both seats. The canopy was unlocked by squeezing the handles together, whereby three locking pins on the left side of the canopy would slide forward and out of locking sleeves mounted to the airframe. According to the airplane's information manual, if unlatched during normal flight, the canopy will open automatically due to low pressure over its surface. The canopy can be jettisoned by pushing it forward while opening. The airplane manufacturer issued two service bulletins (SBs) applicable to the accident airplane's model. SB 300-1-15 was issued on May 5, 2015, following reports of throttle cable failures; it recommended the inspection and replacement of the throttle cable. SB 300-1-11 was issued July 18, 2011, after a report that a transponder had slid out of its rack and jammed against the control stick during aerobatic maneuvers; it recommended the installation of a safety clamp. The FAA issued Special Information Airworthiness Bulletin (SAIB) CE-12-01, applicable to the accident airplane's model, on October 24, 2011, after receiving a report of a severely frayed stainless steel rudder cable. The SAIB recommended careful inspection of the rudder cable and its eventual replacement with a galvanized version, when available. The maintenance records for the airplane contained no record of compliance with SB 300-1-15, SB 300-1-11, or SAIB CE-12-01. Federal Aviation Regulations do not require compliance with SBs or SAIBs for aircraft operating under 14 CFR Part 91. During the investigation, multiple parties contacted the NTSB regarding a rudder pedal inspection airworthiness directive (AD 98-24-07) that had been issued for the airplane type. Subsequent research indicated that this AD was not applicable to the accident airplane based on airplane serial number. According to the airplane's service manual, in the event of exceedances of limitations such as load factor and never exceed speed, the manufacturer should be contacted for appropriate unscheduled maintenance check procedures. There were no entries in the airplane's logbooks documenting that such exceedances had occurred or that unscheduled maintenance inspections were performed. METEOROLOGICAL INFORMATIONA 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. AIRPORT INFORMATIONThe tandem-seat normal and aerobatic category airplane was manufactured in 2009, imported into the US in 2013, and purchased by KD leasing on May 10, 2017. The airplane was equipped with dual flight controls, a Lycoming six-cylinder AEIO-580-B1A engine, and a three-blade hydraulic constant-speed propeller manufactured by MT Propellers. FAA and maintenance records did not reveal any modifications to the airplane beyond the installation of a remote oil filter kit. According to the maintenance records, at the time of the last 100-hour inspection on October 1, 2017, the airframe and engine had accrued a total of 186.57 flight hours. The airplane had a basic empty weight of 1,513 lbs and a maximum takeoff weight (MTOW) of 2,095 lbs. The maneuvering speed limitation (Va) in the aerobatic category was 158 knots indicated (KIAS). The never-exceed (Vne) speed was 220 KIAS. The airplane was placarded with the following: CAUTION: Particular caution must be exercised when performing maneuvers at speeds above Va (158 KIAS). Large or abrupt control inputs above this speed may impose unacceptably high loads which exceed the structural capability of the aircraft. The airplane had g limitations in the aerobatic category of +/-10 g. This limit was only allowed with one person onboard, at a MTOW of 1,808 lbs. In a two-person configuration, the limits were +/-8 g at 1,918 lbs MTOW and +/-6 g at 2,095 lbs MTOW. The pilot was seated in the rear seat for the accident flight. With a pilot weight of 173 lbs, passenger weight of 195 lbs, 30 lbs of parachute equipment and 25 gallons of fuel, the airplane's weight on the accident flight would have been about 2,061 lbs. The airplane was equipped with a mechanical accelerometer (g-meter) which had a sweep range of -6 g to +10 g. The unit had maximum and minimum g needles that recorded the highest and lowest sensed g values, respectively. Both needles could be reset to zero using a button on the front of the instrument bezel. The airplane was equipped with a one-piece plexiglass and composite canopy, which was fixed by three hinges on the right side and was opened by the pilot lifting it to the right. It had forward and aft interior locking handles, which were painted bright red and located on the left side of the canopy frame and within reach and view of both seats. The canopy was unlocked by squeezing the handles together, whereby three locking pins on the left side of the canopy would slide forward and out of locking sleeves mounted to the airframe. According to the airplane's information manual, if unlatched during normal flight, the canopy will open automatically due to low pressure over its surface. The canopy can be jettisoned by pushing it forward while opening. The airplane manufacturer issued two service bulletins (SBs) applicable to the accident airplane's model. SB 300-1-15 was issued on May 5, 2015, following reports of throttle cable failures; it recommended the inspection and replacement of the throttle cable. SB 300-1-11 was issued July 18, 2011, after a report that a transponder had slid out of its rack and jammed against the control stick during aerobatic maneuvers; it recommended the installation of a safety clamp. The FAA issued Special Information Airworthiness Bulletin (SAIB) CE-12-01, applicable to the accident airplane's model, on October 24, 2011, after receiving a report of a severely frayed stainless steel rudder cable. The SAIB recommended careful inspection of the rudder cable and its eventual replacement with a galvanized version, w
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.
Source: NTSB Aviation Accident Database
Aviation Accidents App
In-Depth Access to Aviation Accident Reports
