LAX08FA134
LAX08FA134

HISTORY OF FLIGHT

On May 9, 2008, at 1317 Mountain standard time, an Extra Flugzeugproduktions-und Vertriebs-GmBH EA-300/L, N133EE, collided with desert terrain near Queen Creek, Arizona. The airplane was operated by Aviation Performance Solutions (APS) under Title 14 of the Code of Federal Regulations (CFR) Part 91. The commercial pilot, serving as an instructor, and the airline transport pilot were killed, and the airplane was substantially damaged. Visual meteorological conditions prevailed, and a company flight plan was filed. The flight originated at Phoenix-Mesa Gateway Airport, Phoenix, Arizona, about 1243.

The operator noted that the airplane was overdue from a practice upset recovery training flight. About 1430 the operator and the Mesa Police Air Support located the wreckage in flat desert terrain about 10 miles east of the airport. The two occupants were located approximately 50 feet to the north of the airplane wreckage and were wearing parachutes. The instructor pilot’s parachute was found to have been activated and partially deployed. The pilot under instruction's (PUI) parachute had not been activated. No radio distress call by the aircrew was heard by any agency.

Radar data revealed that at 1313:56 the airplane was on a northeasterly track at 5,600 feet msl. A radar return at 1314:04 placed the airplane at 5,300 feet, in a slight descent. At 1314:15, the radar data showed that the airplane was operating in an area approximately 800 feet across, and the altitude increased to 6,100 feet, then decreased to 2,300 feet. The last radar return was at 1314:46 at an altitude of 2,300 feet. The wreckage was located within a few hundred feet of the last radar return.

The airplane was equipped with video and audio recording equipment; the recordings were recovered by investigators. The end of the video showed the airplane entering a vertical loop, performing a roll at the top of the loop that progressed into a left turning spin. The aircrew then stated that there was something wrong with the rudder control, the canopy opens, and the aircrew proceeded to egress. A full description of the video and audio is included in the Test and Research section of this report.

According to the operator, the purpose of the instructional flight was to practice airplane upset recovery which involved aerobatic maneuvers.

PERSONNEL INFORMATION

Instructor (Commercial Pilot, Rear Cockpit)

The pilot, age 57, held a commercial pilot certificate with airplane single-engine, multi-engine, and instrument ratings, issued on July 13, 2004. He held a flight instructor certificate issued on November 14, 1984, with ratings for airplane single-engine land and instrument. He also held an airframe and powerplant mechanic certificate, issued on July 13, 2004. The pilot held a second class medical certificate issued on December 12, 2007, with the restrictions that he wear corrective lenses. An examination of the pilot’s logbook revealed that as of May 8, 2007, he had 2,208.6 total hours, 269.2 hours in the Extra 300L, and his biennial flight review was dated 25 April, 2008. The pilot served 6 years in the US Air Force flying F-105's and F-4's, 2 years in the Kansas Air National Guard flying F-4's, had 20 years of experience flying competitive aerobatics, and was the 1995 Arizona State Advance Aerobatics Champion. He had been employed by APS since May 2007, and his primary duties were aerobatic upset recovery and spin instruction.

Pilot Under Instruction (Airline Transport Pilot, Front Cockpit)

The second pilot, age 35, held an Airline Transport Pilot certificate issued on October 12, 2004, with airplane single-engine and multi-engine land ratings, airplane single-engine and multi-engine sea ratings, and held private pilot privileges for rotorcraft-helicopter. The pilot held type ratings for the Bombardier CL604 and the Hawker HS-125. A flight instructor certificate, was issued on February 21, 2007, for single and multi-engine airplane, and instrument airplane. An airframe and powerplant mechanic certificate, was issued on April 16, 1996. The pilot held a first class medical certificate, issued on February 25, 2008, with the limitation that he must wear corrective lenses. On his medical application he indicated that he had 6,100 hours of flight time, and had accumulated 100 hours within the last 6 months. The pilot was employed as a professional pilot, and the training with APS was contracted by his company.

AIRCRAFT INFORMATION

The tandem seat, low wing, fixed-gear, single-engine, aerobatic airplane, serial number 09, was manufactured in 1995. It was powered by a Lycoming AEIO-540-L1B5, 6-cylinder, fuel injected engine, and equipped with an MT-Propeller 3-bladed constant speed propeller, model MTV-9-B-C/C 200-15. An examination of the maintenance logbooks showed that the most recent 100-hour airframe inspection was completed on April 17, 2008, at 1,734.13 hours total time. A 25-hour inspection was performed on May 1, 2008, at 1763.1 hours total time. A 100-hour inspection on the engine was completed on April 17, 2008; total time on the engine was 2,512.86 hours, time since major overhaul (TSMOH) was 582.3 hours. A 25-hour inspection on the engine was completed on May 1, 2008, TSMOH was 701.33 hours. The most recent inspection on the propeller was an 100-hour inspection on April 17, 2008.

WRECKAGE AND IMPACT

The wreckage was located approximately 10 miles east of the Phoenix-Mesa Gateway Airport, Phoenix, Arizona, in flat desert terrain. The terrain elevation was measured using a GPS receiver as 1,633 feet mean sea level (msl). The terrain was sparsely populated with desert scrub bushes. The airplane was orientated from tail to nose, on a bearing of 112 degrees magnetic. The entire airplane was embedded into the desert floor such that the fuselage was protruding into the air at an approximately 45-degree angle. The wings were attached to the fuselage and in their generally normal position relative to the fuselage. The tail had separated from the empennage and laid approximately 3 feet directly in front of the fuselage. Canopy glass was shattered and was scattered immediately around the wreckage. The canopy frame had come off the fuselage hinge and was in three pieces in the vicinity of the tail section. Both wings exhibited leading edge delamination and paint chipping/pealing along their entire length. The nose and engine of the airplane was removed from a 4 foot by 4 foot, by 22 inch deep indentation in the ground. Aileron spades, elevator, and rudder balance weights were attached to their respective control surface. Four to five larger pieces of canopy glass were located approximately 300 feet to the northwest of the wreckage. Examination of the engine and propeller revealed no evidence of preimpact mechanical malfunction.

Detailed examination of the airplane control system revealed that the right wing aileron control tubes were attached to the bell cranks from the wing root out to the aileron; the control tube at the wing root was buckled and separated. The left aileron control tubes were continuous to the cockpit. The elevator control tube was separated at the bell crank rod end bearing behind the rear cockpit in a fashion consistent with overload. The opposite end of the elevator control tube was separated and bent at the elevator bell crank rod end bearing, consistent with overload. Rudder cable ends were attached to the rudder horn. The rudder cables ran forward from the rudder horn 30.25 inches (right side) and 30.0 inches (left side), both ending in broomstrawed ends at the approximate location where the entire tail separated from the fuselage. The remaining rudder cables were traced forward and found to run through the appropriate guides and pulleys, with the ends attached to airframe structure forward of the rear cockpit pedals. The forward cockpit rudder pedal cables were traced from their attach points on the pedals to cable interconnect fittings on both left and right sides. Rudder pedal springs were present on all four pedals. All four pedals remained attached to the airframe structure.

MEDICAL AND PATHOLOGICIAL INFORMATION

An autopsy was performed on the commercial pilot May 11, 2008, by the Forensic Science Center in Tucson, Arizona. The autopsy concluded that the pilot died of "multiple injuries due to blunt force trauma." Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The results of the analysis were negative for ethanol, cyanide, carbon monoxide, and listed drugs. A positive result for ibuprofen was detected in urine.

An autopsy was performed on the airline transport pilot on May 11, 2008, by the Forensic Science Center in Tucson, Arizona. The autopsy concluded that the pilot died of "multiple injuries due to blunt force trauma." Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The results of the analysis were negative for ethanol, cyanide, carbon monoxide, and listed drugs. A positive result for ibuprofen was detected in blood.

TESTS AND RESEARCH

Video and Audio Recording System Installed on the Airplane

The airplane was equipped with an on-board audio/video recording system, Neuros MPEG4 Recorder, which recorded audio from the airplane’s intercom, as well as video from either one of four installed video cameras. The recording is stored digitally on a removable memory card located inside the recorder. The recorder was undamaged, however, the recording could not be accessed on the memory card using normal procedures. Testing showed that when electrical power is suddenly removed from the recorder, the resulting file(s) in the memory card are “corrupted.” Most of the recording was ultimately recovered in segments. Partial transcripts (one of the last two minutes of recorded audio, and a written description of video segment for the last flight maneuver; approximately the last one minute of recorded video) were created. The audio was recovered as a single audio file, which was separate from the recorded video segments. The audio file was not entirely continuous; several locations were noted where the audio seemed to briefly ‘skip.’ As a result, the audio and video could not be accurately synchronized to one another in time. Separate transcripts were produced - one for video and one for audio.

The entire video recording after takeoff is taken from the camera located on the vertical stabilizer. The camera is mounted in the upper portion of the vertical stabilizer, facing forward. The airplane can be seen in the lower half of the view. The view is a ‘wide angle’ view, both wingtips can be seen, (view extends slightly beyond the end of each wingtip) as well as the back of the front seat pilot’s head. The pilot in the front seat was the pilot under instruction. The instructor pilot in the rear seat cannot be seen when in the seated position, which is below the top of the fuselage. The top half of the propeller arc can be seen. Due to the video image frame rate and the speed of the propeller, a ‘beating effect’ can cause the propeller to appear to be stationary, or rotating slowly (in either direction), depending on the propeller RPM. None of the tail surfaces can be seen.

Throughout the video, the sky condition appears scattered to thinly scattered, there does not appear to be a ceiling. Visibility appears unrestricted, on the order of 50-miles, and the horizon is visible. The airplane remains below and clear of clouds throughout the flight.

Once airborne the view from the tail camera is recorded without interruption. About 6 minutes after takeoff the airplane enters the area where the upset recovery training will occur. Thereafter the maneuvers follow the training syllabus as planned and in order. The final maneuver recorded (accident maneuver) appeared to be the first half of a climbing loop followed by a roll along the longitudinal axis at the top of the loop, that introduced a pronounced left yaw, which developed into an erect spin to the left. A change in the propeller 'beating effect' occurred, consistent with a change in propeller rpm. Aileron movement and deflections were noted throughout the entire final portion of the video. Just after the completion of the third turn of the spin, the pilot in the rear cockpit released the canopy. The canopy opened fully to the right, the canopy restraint strap broke, and the canopy top impacted the top of the right wing, breaking portions of the canopy glass out. After the fifth turn of the spin, the shoulders of the pilot in the front cockpit was seen moving, and at the end of the seventh turn, the pilot began to stand up. As the front pilot attempted to stand up, the rear pilot could be seen beginning to move. At the completion of the tenth turn, the front pilot still had his headset on, was sitting on the left canopy rail, and was reaching down toward the right side of the cockpit. The rear pilot removed his headset and discarded it to the right. At the completion of the eleventh turn the front pilot was sitting on the left canopy rail and removed his hand from the right canopy rail. The rear pilot began to stand up. The video recording ended at the beginning of the thirteenth turn, both pilots were sitting on the left canopy rail, leaning outboard, falling backwards with their arms moving upwards. Terrain and ground vegetation were clearly identifiable in the final frames of the video.

The time for the crew to egress the cockpit is broken down as follows. The time from canopy release to the moment the pilot in the rear cockpit removed his head set was 14-seconds. From that point to the end of the video was an additional 9-seconds. A total elapsed time from canopy release to the end of the video (crew departure) was 23 seconds. The total elapsed time from the moment the airplanes nose passes below the horizon at the top of the loop to the end of the video was 36 seconds.

The last 1 minute and 49 seconds of audio were transcribed. Just before the accident maneuver, the pilots discussed what maneuver the pilot in the front seat would like to do next. He stated that he would like to do an ‘avalanche.’ The pilot in the rear described the ‘avalanche’ as a loop with a snap roll at the top. The pilot in the front cockpit then said that he was assuming control of the airplane. The pilot in the rear cockpit said that he should enter the loop at 160 (knots), and verbally indicated that the entry looked ok. Then the front cockpit pilot said that he broke something. The other pilot verbally stated the recovery procedures of push (the nose over), power, and rudder; he then verbally indicated that there was something wrong with the rudder. Immediately, a sound similar to air noise began and continued to the end of the recording. The rear pilot told the front pilot to get out. The audio recording ends 17 seconds later, and no other verbal communication was recorded.

Airplane Performance Calculations

The Data Analysis Numerical Toolbox & Editor (DANTE) software computer program was used to calculate the performance of the Extra 300/L using radar data during the airplanes final maneuver. The average rate of descent during the final 36-seconds of radar data was calculated to be 7,034 feet per minute (fpm).

Actual Bailout Altitude

Utilizing the radar data, the calculated rate of descent, time of descent, and the terrain elevation, an estimated altitude can be identified for the moment the aircrew left the airplane. Using 6,100 feet msl as the altitude the descent started at, a descent rate of 7,034 fpm, for the duration of 36-seconds, then subtract the terrain elevation of 1,633 feet msl, gives the estimated bailout altitude as 246 feet agl.

Flight Simulating the Accident Maneuver

On July 1, 2008, the President and the Director of Operations of APS test flew the accident maneuver in one of their Extra 300L’s. They reported that in a left turning spin, power on and power off, if the controls were released the airplane would fly its self out of the spin in about 3-rotations. They then simulated the accident flight by entering a loop, performing a roll at the top, and at that point held the rudder in all the way to the left to simulate a jammed rudder. They reported that the airplane acted just like the airplane in the accident video.

Additional Wreckage Examinations

A second aircraft wreckage examination was conducted on July 16, 2008, which included a representative from Extra Aircraft, and an FAA Inspector, under the supervision of the Safety Board Investigator-in-Charge (IIC). The purpose of the examination was to reexamine the flight control system, with a focus on the rudder system. All rudder control cable ends were attached to their appropriate rudder pedal or the rudder bell crank. Cables were traced and found to be routed through the appropriate cable guides and pulleys. The rudder cable interconnection fittings that connect the front cockpit rudder cables to the primary rudder cables were present with no indication of slippage.

The Safety Board IIC conducted a third aircraft wreckage examination on January 12, 2009, with similar findings as the two previous exams.

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