DEN02LA103

NTSB accident investigation · Adler SA-1 · Mead, CO · September 8, 2002

Accident · FatalLimited investigationFinal report
Date
September 8, 2002, 09:30 local (15:30 UTC)
Place
Mead, CO
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N551SAAdler SA-1
Weather
Visual (VMC) · Day
Status
Completed · report April 1, 2003
Report
Approved by Office Director
Parties
FAA Flight Standards District Office
FAA report
20020908024449A
Case key
55668

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

the pilot's failure to maintain main rotor rpm, resulting in blade flapping, subsequent blade contact with the airframe, and loss of control.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - in flightManeuvering
Use of inappropriate medication/drugPilot in command
Rotor rpm - not maintainedPilot in commandCause
Rotor system,main rotor - oscillationCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - grass
Terrain condition - open field

Analysis

Witnesses observed "a rotor or a wing" separate from the gyroplane, and the gyroplane then descended and impacted terrain.

According to the deputy's report, a rotor blade was found about 150 feet north of the point of impact, and other debris was strewn to the southwest. The co-builder of the accident gyroplane, who was also a close friend of the pilot, contacted three gyroplane experts: the designer of the SA-1 Dominator and President of Rotor Flight Dynamics; a gyroplane aerodynamist; and the designer of another gyroplane. They examined the wreckage and compiled both a factual and analytical report. The following is based on the factual portion of the report. The separated rotor blade was bowed upward and had fractured about 2 feet from the tip. The fracture was consistent with positive overload. There was orange paint and primer transfer marks on the top and upper leading edge (the tail cone was painted orange). The attached rotor blade was also bent upward. The propeller blades exhibited no strike marks. The rotor head and hub bar were intact. The hub bar, normally bent 2.5 degrees upward, was bent approximately 10 degrees upward. The roll pillow blocks bore evidence of hammering and were mushroomed. The pitch stops were similarly damaged. In the analytical portion of the report, the necessity of maintaining blade loading at all times in order to maintain main rotor blade rotation was noted. The fracture on the separated main rotor blade was in "a purely upward bending moment which could only have occurred if the blade rpm had dramatically slowed...If totally unloaded, the blade rpm can deteriorate as fast as 120 rpm/sec." Normal rotor blade rpm is 320 to 400 rpm. If rotor blade rpm were allowed to drop, increasing the velocity of air moving through the rotor system, severe blade "flapping" would result as evidenced by the pounding and mushrooming of the roll pillow blocks and bending of the hub bar on the rotor head. A toxicological test revealed 2.024 (ug/mL, ug/g) paroxetine in the blood and liver. The drug is an antidepressant and contraindicated for flight. The pilot's personal physician prescribed the drug for the treatment of fibromyalgia, a condition manifested by muscle soreness. Adverse effects of the drug include drowsiness, muscle weakness, agitation, and tremors.

Factual narrative

On September 8, 2002, approximately 0930 mountain daylight time, an Adler SA-1 gyroplane, N551SA, registered to and operated by the pilot, was destroyed when it impacted terrain and burned near Mead, Colorado. The private pilot was fatally injured. Day visual meteorological conditions prevailed, and no flight plan had been filed for the personal flight being conducted under Title 14 CFR Part 91. The local flight originated approximately 0900 from the Jefferson County (Jeffco) Airport, Broomfield, Colorado.

Two witnesses told a sheriff's deputy that the gyroplane sounded as if it was "struggling." Two other witnesses submitted written statements. One witness said that he "could tell the aircraft was having mechanical problems." The gyroplane dropped about 1,000 feet, "lost a wing" and began to "spin and tumble out of control." Another witness said he heard the engine either "miss or stall slightly," and also saw "a rotor or a wing" come off in flight. All four witnesses saw smoke as the gyroplane impacted terrain and immediately caught fire.

According to the deputy's report, a rotor blade was found about 150 feet north of the point of impact, and other debris was strewn to the southwest. The impact site was circular in shape, approximately 5 to 6 meters (16 to 20 feet) in diameter. The accident occurred 0.25-mile south of (Weld) county road 32 and 0.25-mile west of county road 13, at a location of 40 degrees, 12'48.30" north latitude, and 104 degrees, 57'02.80" west longitude.

The co-builder of the accident gyroplane --- a physician and a close friend of the pilot --- contacted three gyroplane experts: the designer of the SA-1 Dominator and President of Rotor Flight Dynamics; a gyroplane aerodynamist; and the designer of another gyroplane. They examined the wreckage and compiled both a factual and analytical report. The following is based on the factual portion of the report.

The separated rotor blade was bowed upward and had fractured about 2 feet from the tip. The fracture was consistent with positive overload. There was orange paint and primer transfer marks on the top and upper leading edge (the tail and nose cones were painted orange). The attached rotor blade was also bent upward. The propeller blades exhibited no strike marks. The rotor head and hub bar were intact. The hub bar, normally bent 2.5 degrees upward, was found bent approximately 10 degrees upward. The roll pillow blocks bore evidence of hammering and were mushroomed. The pitch stops were similarly damaged.

The analytical portion of the report noted the necessity of maintaining blade loading at all times in order to maintain main rotor blade rotation. The fractured main rotor blade was "a purely upward bending moment which could only have occurred if the blade rpm had dramatically slowed…If totally unloaded, the blade rpm can deteriorate as fast as 120 rpm/sec." Normal rotor blade rpm is 320 to 400 rpm. If rotor blade rpm were allowed to drop and the velocity of air moving through the rotor system were to increase, severe blade "flapping" would result. The rotor head had been subjected to severe blade flapping as evidenced by the pounding and mushrooming of the roll pillow blocks and the bent hub bar. The authors said there is no in-flight maneuver that can lead to blade flapping at normal rotor rpms. Only the unloading of the rotor blades will do this.

FAA's Civil Aeromedical Institute (CAMI) conducted a toxicological screen on specimens taken from the pilot and found 2.024 (ug/mL, ug/g) paroxetine in the blood. According to a CAMI toxicologist, paroxetine is an antidepressant and contraindicated. Some of the adverse effects include drowsiness, muscle weakness, agitation, and tremors." When advised of these results, the physician/co-builder of N551SA contacted the pilot's personal physician and learned that he had prescribed the drug for the treatment of fibromyalgia, a condition manifested by muscle soreness.

Aircraft

Registration
N551SA
Reported as
Adler SA-1
Category
Gyroplane, amateur-built
Serial number
001
Airframe hours
44
Engine
Rotax 912WLS, 100 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Steven H. Adler
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Condition · June 18, 2002 · 44 hours before
Departed
BJC · Broomfield, CO
Destination
BJC

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
51
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Last flight review
February 16, 2002
Seat
Single
Flight hours
280 total · 44 in this make and model · 222 as pilot in command · 44 in the last 90 days · 18 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 46 °F
Altimeter
30.12 inHg
Observed at
DEN, 25 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.