# NTSB CEN22FA016: AutoGyro Cavalon, N419LB, Stroud, OK, October 18, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: October 18, 2021, 15:34 local (20:34 UTC) - Place: Stroud, OK · Private property/farm - Coordinates: 35.881312, -96.657354 - Nearby events: https://openairdocs.org/map.md?lat=35.8813&lon=-96.6574&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 104119 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN22FA016 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104119/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104119 - Page: https://openairdocs.org/ntsb/CEN22FA016 ## Probable cause The pilot’s lack of experience in the gyroplane and his decision to takeoff with a tailwind. As a result, the gyroplane did not generate enough lift to takeoff before it struck a barbed wire fence. Contributing to the accident was the pilot’s failure to wear a seatbelt, which would have reduced his level of injury. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Wind: tailwind](https://openairdocs.org/ntsb-findings/03034015): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [All aircraft, 594 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md) - [Runway/land/takeoff/taxi surface](https://openairdocs.org/ntsb-findings/03023000): Environmental issues › Physical environment · Effect on operation; cases with it: [All aircraft, 253 cases](https://openairdocs.org/ntsb-findings/03023000/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot; cases with it: [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Physical workspace](https://openairdocs.org/ntsb-findings/03041000): Environmental issues › Task environment · Effect on personnel; cases with it: [All aircraft, 5 cases](https://openairdocs.org/ntsb-findings/03041000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## Analysis A witness reported that the pilot purchased the gyroplane in January 2020 and has been undergoing flight lessons. Two days before the accident was the pilot’s first solo flight. On the day of the accident, the witness observed the gyroplane positioned heading to the north on a 300-yard, private, field. The wind was gusting from the south, which was a tailwind. The pilot added full engine power and the gyroplane started its takeoff roll toward the north. The gyroplane never lifted off the ground and impacted a barbed wire fence at the end of the field. The witness proceeded toward the accident site, and he observed that the pilot was ejected from the gyroplane. The gyroplane came to rest upright with the engine still running. After calling for help, he turned the engine off via cockpit controls. The pilot’s flight instructor reported that the pilot had about 20 total hours of flight training over the course of about a year. He would fly a few hours at a time with large gaps in-between. The pilot traveled a long distance to obtain the instruction and about 3 months prior to the accident, he elected to move the gyroplane closer to his home despite the instructor informing him he was not ready for solo flight. It is unknown if the pilot obtained additional flight instruction as advised. On scene examination of the airframe did not reveal any anomalies that would have precluded normal operations. A large hole was noted in the forward windscreen; the seatbelts remained secured to the airframe, and they were not clasped. Since the pilot was ejected, it is likely he was not wearing a seatbelt. The nearest weather reporting station was about 7 nautical miles northwest of the accident site. At the time of the accident, wind was from 160° at 8 knots, gusting to 17 knots, which would have been a tailwind. The AutoGyro Cavalon Pilot Operating Handbook states under Environmental Limitations “Maximum tailwind component for take-off and landing…5 knots.” The pilot’s toxicology results showed that he had used methamphetamine. His high methamphetamine blood level was consistent with methamphetamine abuse although the level does not indicate if he was experiencing early drug effects (possibly feeling alert, euphoric, and invulnerable, with a tendency to make high-risk decisions) or later effects (possibly feeling restless, disorganized, uncoordinated, and craving more drug). Toxicology results also showed that the pilot had used THC, although it is impossible to infer specific impairing effects from the measured levels of THC and its metabolites, or to predict how THC and methamphetamine effects may have interacted. Given the pilot’s overall lack of experience, along with his decision to take off with a tailwind, it is likely he did not possess the necessary skill or experience to safely conduct solo flight. Therefore, it was impossible to determine whether impairment of his handling of the aircraft from drug effects contributed to the accident. ## Factual narrative On October 18, 2021, about 1534 central daylight time, an AutoGyro Cavalon gyroplane, N419LB, was substantially damaged when it was involved in an accident near Stroud, Oklahoma. The pilot was fatally injured. The gyroplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A witness reported that the pilot purchased the gyroplane in January 2020 and has been undergoing flight lessons. Two days before the accident was the pilot’s first solo flight. On the day of the accident, the witness observed the gyroplane positioned heading north on a 300-yard long, field. The witness stated the wind was gusting from the south, which was a tailwind. The pilot added full engine power and the gyroplane started its takeoff roll toward the north. However, the gyroplane never lifted off the ground and impacted a barbed wire fence at the end of the field. The witness proceeded toward the accident site, and he observed that the pilot was ejected from the gyroplane. The gyroplane came to rest upright with the engine still running. After calling for help, he turned the engine off via cockpit controls. The pilot did not have a Federal Aviation Administration (FAA) medical certificate. The Oklahoma Office of the Chief Medical Examiner performed his autopsy. According to the autopsy report, the cause of death was blunt force trauma, and the manner of death was accident. The autopsy identified mild atherosclerotic disease of the coronary arteries and cerebral vasculature. Concentric heart muscle thickening was present, with a normal heart weight. The autopsy did not identify other significant natural disease. The Office of the Chief Medical Examiner detected methamphetamine and the methamphetamine metabolite amphetamine in heart blood. The FAA Forensic Sciences Laboratory also performed toxicological testing of postmortem specimens from the pilot. Methamphetamine was identified in urine and at 979 ng/mL in femoral blood. Amphetamine was identified in urine and at 75 ng/mL in femoral blood. Phenylpropanolamine and pseudoephedrine were detected in urine but not in femoral blood. Delta-9-THC (commonly known as THC) was identified in urine and at 2.6 ng/mL in femoral blood. The THC metabolite 11-hydroxy-delta-9-THC was identified in urine but not in femoral blood. The THC metabolite carboxy-delta-9-THC was identified in urine and at 6.1 ng/mL in femoral blood. Tamsulosin was detected in urine and femoral blood. Methamphetamine is a central nervous system stimulant drug. Amphetamine is a metabolite of methamphetamine and is also a central nervous system stimulant. Both methamphetamine and amphetamine are available as prescription medications used to treat attention deficit hyperactivity disorder, narcolepsy, and occasionally obesity; each may also be a metabolite of certain other medications. Methamphetamine and amphetamine are Drug Enforcement Administration (DEA) Schedule II controlled substances, with a high potential for abuse and dependence.At low doses used as part of appropriate medical treatment, the drugs may improve reaction time, cognitive function, and fatigue, but may cause people to make higher-risk choices. At higher doses, the drugs may have a variety of impairing effects on psychomotor function, cognition, and perception. The drugs typically carry warnings that they may impair the ability to engage in potentially hazardous activities such as driving a motor vehicle. Such impairment can result from drug or withdrawal effects. Both methamphetamine and amphetamine are considered “do not issue/do not fly” medications by the FAA. Delta-9-THC, commonly known as THC, is the primary psychoactive chemical in cannabis and hashish, derived from the cannabis plant. THC is commonly smoked or ingested recreationally by users seeking mind-altering effects. It may also be used medicinally to treat illness-associated nausea and appetite loss. It is present as an undeclared contaminant in some commercial cannabidiol (CBD) extracts and oils that may be used by a variety of routes for a variety of reasons. In the body, THC is metabolized mainly to the psychoactive chemical 11-hydroxy-delta-9-THC, which is then further metabolized to the non-psychoactive chemical carboxy-delta-9-THC. Psychoactive effects of THC vary depending on the user, dose, and route of administration, and may impair motor coordination, reaction time, decision making, problem solving, and vigilance. THC is a DEA controlled substance, and the FAA considers it unsuitable for flying, regardless of state cannabis laws. The nearest weather reporting station was about 7 nautical miles northwest of the accident site. At the time of the accident, wind was from 160° at 8 knots, gusting to 17 knots. The pilot’s flight instructor reported that the pilot underwent about 20 total hours of flight training in about a year. The pilot did not live locally to the training facility so he would fly a few hours at a time with large gaps in between. The pilot’s last flight lesson occurred about 3 months prior to the accident. According to the flight instructor, the pilot insisted on moving the gyroplane home so he could fly it more. The flight instructor informed the pilot that he was not ready for solo flight and encouraged the pilot to find another instructor for continued training. The pilot said he had an instructor “lined up,” but did not mention who it was. The first identified point of impact was a barbed wire fence on the upslope side of an open field. About 100 ft beyond the fence were striations in the dirt consistent with rotor blade strikes. About 25 ft beyond the striations, the gyroplane came to rest upright, and parallel to the fence line. All major components remained attached to the gyroplane. A large hole was observed in the front windscreen, otherwise, the cabin area remained mostly intact. The seatbelts remained secured to the airframe, and they were not clasped. Flight control continuity was established from the cockpitcontrols to their respective flight control surfaces. The rotor head was bent aft about 45°, and both rotor blades remained attached at the hub. One blade was bent down at the root, and the second blade was fractured and separated about midspan. The propeller blades on the engine remained attached at the hub. One blade was fractured at the root and the other two were fractured about midspan. The propeller blade fragments were scattered throughout the debris field. Striations consistent with barbed wire fencing were noted along the left and right landing gear struts. A portion of wire was wedged at the top of the gear struts where they connect to the fuselage. The AutoGryo Cavalon Pilot Operating Handbook states under Environmental Limitations “Maximum tailwind component for take-off and landing…5 knots”. ## Aircraft - Registration: N419LB (not matched to a registry record) - Reported make and model: AutoGyro Cavalon - Category: Gyroplane, amateur-built - Serial number: V00313 - Year built: 2018 - Airframe hours: 187.3 - Engines: Rotax 914 115 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Continuous airworthiness, August 16, 2021 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 66; injuries: fatal; restraint: none; toxicology performed; flight hours: 20 total, 20 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 160° at 8 knots, gusting 17 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 41 °F - Altimeter: 30.01 inHg - Observed at: KCUH, 7 nm away ## 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 20211018017589A](https://openairdocs.org/incident/20211018017589A), Oct 18, 2021: Timothy Knapp CAVALON, Cushing, OK, Substantial damage, 1 fatal. On October 18, 2021 at approximately 1534 local time, a Cavalon gyrocopter attempted to takeoff from a private residence approximately 7 miles north of the… ## Docket (7 files) The files NTSB released with the investigation on September 2, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104119. 8.8 MB in all. - Witness statement (item 1, PDF, 1 page, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12920932&FileExtension=pdf&FileName=Witness%20Statement_Redacted-Rel.pdf - On scene observations (item 2, PDF, 10 pages, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14159758&FileExtension=pdf&FileName=On%20Scene%20Notes%202%20-Rel.pdf - Record of conversation - flight instructor (item 3, PDF, 1 page, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14159690&FileExtension=pdf&FileName=roc%20flight%20instructor-Rel.pdf - Excerpt from autogyro cavalon pilot operating handbook (item 4, PDF, 2 pages, 522 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12920200&FileExtension=pdf&FileName=POH%20excerpt-Rel.pdf - Toxicological report (item 5, PDF, 2 pages, 813 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13061797&FileExtension=pdf&FileName=TOX%20printed_Redacted-Rel.pdf - Record of memorandum - autopsy (item 6, PDF, 1 page, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13808043&FileExtension=pdf&FileName=ROM%20Autopsy-Rel.pdf - Medical factual report (item 7, PDF, 5 pages, 245 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14154764&FileExtension=pdf&FileName=CEN22FA016_MedicalFactualReport-Rel.pdf 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.