# NTSB LAX05LA007: DeRosier DR-107, N31SH, San Diego, CA, October 15, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: October 15, 2004, 10:15 local (17:15 UTC) - Place: San Diego, CA - Coordinates: 32.868331, -117.142501 - Nearby events: https://openairdocs.org/map.md?lat=32.8683&lon=-117.1425&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report March 28, 2006 - Report: Approved by Office Director - Parties: Federal Aviation Administration - NTSB case key (mKey): 60344 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX05LA007 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60344/pdf - Page: https://openairdocs.org/ntsb/LAX05LA007 ## Probable cause the pilot's failure to maintain adequate clearance from terrain while performing low-level aerobatic maneuvers. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, maneuvering - aerobatics - initiated, pilot in command - terrain condition - ground - clearance - not maintained, pilot in command (cause) ## Analysis The airplane impacted terrain while the pilot was performing low-level aerobatic maneuvers at an airshow. Review of videotaped footage of the pilot's performance showed that about 15 minutes into the flight, the pilot began a rolling maneuver that the airplane was to pull out of and continue parallel to the ground. The airplane never pulled out of the downward flight path and impacted terrain. This particular airshow was a milestone for the pilot and there may have been self-induced pressure to perform well. ## Factual narrative HISTORY OF FLIGHT On October 15, 2004, about 1015 Pacific daylight time, a DeRosier DR-107 experimental airplane, N31SH, impacted terrain during an airshow at the Miramar Marine Corps Air Station, San Diego, California. The pilot/owner was operating the airplane under the provisions of 14 CFR Part 91. The commercial pilot, the sole occupant, sustained fatal injuries; the airplane sustained substantial damage. The local aerobatic flight departed from Miramar about 1000. Visual meteorological conditions prevailed, and a flight plan had not been filed. In a telephone conversation with a National Transporation Safety Board investigator, a Federal Aviation Administration (FAA) inspector stated that the pilot was scheduled to perform aerobatic maneuvers for an airshow. About 15 minutes into the flight, the pilot began a rolling maneuver that the airplane was to pull out of and continue parallel to the ground. The airplane never pulled out of the downward flight path and impacted terrain. During a telephone conversation with a Safety Board investigator, a renowned airshow performer and aerobatic expert briefly described a performer's initial entry into the airshow industry. He stated that an aspiring airshow pilot must make an inquiry with the International Council of Airshows (ICAS), at which time he/she will be appointed an Airshow Certification Evaluator (ACE). The ACE is an experienced airshow performer that has the authority to endorse pilots to receive their aerobatic competency card. The ACE is then to meet with the pilot and conduct both an oral and practical test standards evaluation, which includes testing the pilot's understanding of aerodynamics, airman physiology, weather, and reviewing the proposed routines and sequences. The expert was the pilot's appointed ACE and conducted his evaluation about 1 month prior to the accident, which was completed in a Panzl S-330, rather than the pilot's own airplane, the One Design. He estimated that the pilot had flown the One Design for about 3 years, and performed the same routine done at the airshow at least 50 times (in several different airplanes, but mainly the One Design). On all occasions that he had seen the pilot perform that routine, the lowest flight level the airplane reached was the pilot's prescribed minimum of 250 feet. The expert further stated that he recognized the maneuver, which resulted in the accident, as the "Dink." He stated that the Dink consists of the airplane's tail tumbling over the nose, which is accomplished by the pilot stalling the horizontal stabilizer. This is done by the pilot maneuvering the airplane in a slightly nose-high attitude, followed by inputting left rudder authority to obtain a full right yaw configuration. As the horizontal stabilizer reaches the critical angle of attack, a stall will occur, and the airplane's nose falls in a nose-lose attitude. The pilot responds to this attitude change by maintaining the rudder input and manipulating the airplane's elevator control (a stick) to the full forward position. The airplane continues to tumble, and about 270 degrees through the rotation, the pilot makes a quick "stab" input to the right rudder control, in an effort to stop rotation. The pilot continues by easing the elevator control stick in the aft position and inputting pressure on the left rudder control. This results in the airplane recovering from the stall about 360 degrees back to the origination of the maneuver, and in a level to slightly nose-low attitude. After watching video coverage of the accident maneuver, the expert opined that possibly the pilot did not add the right rudder "stab" input, rather he only used the elevator stick control, which would not allow him to recover from the maneuver in sufficient time. He noted that the airplane's wings were engineered in such a way that the airfoil's leading edge is almost completely round, which makes it very difficult for a pilot to recover from stalled conditions within narrow time constraints. He stated that if the airspeed became too slow, the pilot would not have had the altitude to recover, which he thought was consistent to the airplane's maneuver after the pilot completed a half snap-roll about 600 feet above ground level (agl). By examining the airplane's track and wing tip smoke contrails, he ascertained that just prior to impact the pilot was manipulating the elevator stick all the way aft, attempting to maneuver the airplane up, to clear the terrain. He added that prior to performing the Dink, the pilot executed a maneuver where the airplane reached slightly below the 250-foot level. The pilot began the Dink at 1,000 feet agl, which he thought was enough altitude if everything went accordingly, but did not allow for any error. After the accident he inspected the Kollsman setting on the altimeter and reported that is was set appropriately, reading negative 250 feet while at the ground level; the pilot normally would set the altimeter to indicate the bottom of their minimum flight level, and orient themselves referencing the altimeter in "above flight level" altitudes. The expert further stated that this particular airshow was a milestone for the pilot, and that he might have been undergoing a great deal of pressure to perform well. He stated that on numerous occasions he and the pilot discussed the appropriate action to take if the airplane does not have enough speed or energy when reaching the starting point of a maneuver: complete a climbing 270-degree turn. PERSONNEL INFORMATION A review of FAA airman records revealed that the pilot held a commercial pilot certificate with an airplane single engine land rating, which contained limitations prohibiting the pilot from carrying passengers for hire at night and cross-country flights of more than 50 nautical miles (nm). In addition, the pilot held an Airframe and Powerplant (A&P) mechanic's certificate with an Inspection Authorization (IA). On October 13, 2003, when the pilot was issued a second-class medical certificate, his self-reported total civilian flight time was 2,400 hours. The pilot was issued a Statement of Aerobatic Competency (FAA Form 8710-7) on September 09, 2004, which held a level 2 (250 feet) altitude limitation. Although he performed the evaluation in the Panzl S-330, the card also listed both the accident airplane and a Giles 202. The pilot's completed 8710-7 forms are appended to this report. AIRCRAFT INFORMATION The airplane was a single engine amateur-built experimental One Design DR-107, serial number 273. A review of the airplane's logbooks revealed a total airframe time of 325 hours at the last inspection on May 20, 2004. The pilot completed an inspection in accordance with the scope and detail of Appendix "D" of 14 CFR Part 43. The engine was a Textron Lycoming IO-360 engine, serial number L-12340-96. The airplane's last Special Airworthiness Certificate was issued on July 14, 2003. ADDITIONAL INFORMATION Most pilots performing aerial demonstrations for the purpose of an airshow, begin their careers performing in aerobatic competitions. According to industry sources, there are about 5,000 pilots currently involved in the numerous aerobatic circuits; those pilots that hold FAA qualifications to perform in airshows make up about 360 pilots. In 1990, together the airshow industry and FAA implemented an Airshow Certification Evaluator (ACE) program, where under the auspice of the International Council of Air Shows (ICAS), designated pilots have the authority to recommend a pilot to receive his/her aerobatic competency certificate. Currently, ICAS has granted ACE authority to about 60 pilots, all of which are experienced airshow performers. The function of the ACE is twofold: assess a pilot's aerobatic competency and determine altitude limitations. The aerobatic competency evaluation is required annually for every pilot planning to perform i ## Aircraft - Registration: [N31SH](https://openairdocs.org/deregistered/N31SH-2008-12-09), registration cancelled 2008-12-09, S/N 273, built 1999 (OpenAirDocs) - Reported make and model: DeRosier DR-107 - Registry model: [Derosier Sean DR-107](https://openairdocs.org/model/derosier-sean-dr-107) (registry code 056068K) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 273 - Engines: Lycoming IO-360 SER 210 horsepower reciprocating - Damage: Substantial damage - Flight: Air race/show, Part 91 - Registered owner: Sean DeRosier - Airworthiness certificate: Special, Experimental (Special) - Departed: KNKX, Miramar, CA - Airport: KNKX, Miramar Marine Corps Air Sta ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 31; injuries: fatal; commercial; airplane ratings: single-engine land; medical: class 2; last flight review August 1, 2003; seat: front; toxicology performed; flight hours: 1,130 total, 375 in this make and model, 75 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 3 knots - Visibility: 5 statute miles - Lowest ceiling: none - Temperature: 66 °F, dew point 57 °F - Altimeter: 29.94 inHg - Observed at: KNKX ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20041015033759A](https://openairdocs.org/incident/20041015033759A), Oct 15, 2004: Amtr DR107, San Diego, CA, Destroyed, 1 fatal. (-23) While performing a low level aerobatics air show at Miramar marine corps air station, San Diego California, the pilot [privacy data omitted] flying an… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.