# NTSB ERA09LA198: McNear Explorer Coupe, N5098L, Okeechobee, FL, March 14, 2009 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: March 14, 2009, 10:02 local (14:02 UTC) - Place: Okeechobee, FL - Coordinates: 27.266387, -80.85028 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=27.2664&lon=-80.8503&mi=10 - Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping) - Defining event: [Taxi: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report July 14, 2009 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA Orlando FSDO - NTSB case key (mKey): 73490 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09LA198 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73490/pdf - Page: https://openairdocs.org/ntsb/ERA09LA198 ## Probable cause The pilot's failure to maintain directional control of the gyrocopter while taxiing for takeoff. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Mcnear Joseph P EXPLORER COUPE 2000, 1 case](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=056040A), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Mcnear Joseph P EXPLORER COUPE 2000, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=056040A), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Health/Fitness: predisposing condition](https://openairdocs.org/ntsb-findings/02013035): Personnel issues › Physical · Pilot; cases with it: [Mcnear Joseph P EXPLORER COUPE 2000, 1 case](https://openairdocs.org/ntsb-findings/02013035/cases.md?model=056040A), [All aircraft, 56 cases](https://openairdocs.org/ntsb-findings/02013035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Taxi: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Mcnear Joseph P EXPLORER COUPE 2000, 1 case](https://openairdocs.org/ntsb-events/230/sequence.md?model=056040A), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Taxi: Dragged wing/rotor/float/other](https://openairdocs.org/ntsb-events/093); cases with it: [Mcnear Joseph P EXPLORER COUPE 2000, 1 case](https://openairdocs.org/ntsb-events/093/sequence.md?model=056040A), [All aircraft, 319 cases](https://openairdocs.org/ntsb-events/093/sequence.md) - [Taxi: Roll over](https://openairdocs.org/ntsb-events/097); cases with it: [Mcnear Joseph P EXPLORER COUPE 2000, 1 case](https://openairdocs.org/ntsb-events/097/sequence.md?model=056040A), [All aircraft, 261 cases](https://openairdocs.org/ntsb-events/097/sequence.md) ## Analysis The pilot informed his friends that he was having problems with the pre-rotator not getting over 60 rpm. He stated that he might reengage the pre-rotator after he started his takeoff roll. Although there were no witnesses to the accident, a departing pilot observed the wreckage on the side of the runway. Examination of the accident site revealed evidence on the taxiway of the aircraft swerving to the right, continuing forward 106 feet before it started to roll to the left. The crash debris line was 230 feet long. Examination of the airframe, flight controls, engine assembly and accessories revealed no anomalies. The NTSB was informed that if the pre-rotator was reengaged while the engine was at a power setting higher than idle, the resulting torque forces could cause the aircraft to lurch to the right, thus causing a roll to the left. Additionally, the pilot had undergone coronary artery bypass surgery approximately 2 ½ years prior to the accident. On autopsy, the pilot’s heart was noted to be markedly enlarged, but all bypass grafts remained open. It could not be determined whether the pilot may have had an incapacitating event that precipitated the accident. The pilot did not hold a current medical certificate. ## Factual narrative HISTORY OF FLIGHT On March 14, 2009, at about 1002 eastern daylight time, a McNear, Explorer Coupe 2000, amateur-built gyrocopter, N5098L, rolled over on the taxiway adjacent to runway 14, under unknown circumstances, at the Okeechobee County Airport (OBE), Okeechobee, Florida. The personal flight was operating under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed and no flight plan was filed. The commercial pilot was killed. The accident was reported to Okeechobee County Sheriff's Department at 1016. According to a certified flight instructor (CFI), he and his student pilot landed on runway 14 at OBE. They taxied to the ramp and shut down for about 15 minutes. The CFI and student pilot returned to the airplane, started it, and taxied out to runway 14 for departure. While approaching the runway, the CFI observed what appeared to be some metal on the edge of the runway. When the airplane was taxied to the runway threshold, the CFI observed a gyrocopter laying on its back or side. The CFI shut the airplane down, exited the airplane, and went to the accident site. A deceased occupant was laying on the runway to the left of the gyrocopter. The CFI called the emergency 911 operators and reported the accident. A friend of the deceased pilot stated he and some other pilots went out to look at the gyrocopter after they completed their breakfast. The deceased pilot informed them that he was having problems with the pre-rotator on the gyrocopter getting over 60 rpm and that he might reengage the pre-rotator after he started his takeoff roll. Another pilot, who is a member of the Florida Popular Rotorcraft Association accident response team, stated to the Safety Board investigator, "if he did this with anything over idle power, the torque to the airframe would be extreme, causing the aircraft to lurch to the right, causing a left roll." PERSONNEL INFORMATION The pilot, age 76, held a commercial pilot certificate issued on May 10, 2001, with ratings for airplane single-engine land, airplane single-engine sea, airplane multiengine land, rotorcraft helicopter and gyrocopter, glider, instrument airplane and helicopter. In addition the pilot held a flight instructor certificate with ratings for airplane single-engine land, instrument airplane, and glider issued on October 28, 2007. The pilot held a ground instructor certificate issued on April 30, 1991. The pilot's last flight review could not be verified. The pilot was issued a second-class medical certificate on March 20, 2006, with the limitation, "must wear corrective lenses." The pilot indicated on his last application for the second-class medical certificate that he had accumulated 9,500 total flight hours; of which, 70 hours had been flown in the last 6 months. AIRCRAFT INFORMATION The McNear Explorer Coupe 2000 is a two-place single-engine experimental amateur-built gyrocopter, with a fixed tricycle landing gear, serial number H2-95-6-154,manufactured in 2000. A Subaru EJ25, 180-horsepower fuel injected engine powers the gyrocopter. Review of records on file with the FAA, Aircraft Registration Branch revealed the original builder applied for an aircraft registration on May 20, 1997. The builder was issued a special airworthiness certificate and experimental amateur-built aircraft operating limitations on April 9, 2000. The builder stated the gyrocopter had been sitting for a year in a closed trailer when he sold it to the deceased pilot on January 3, 2009. The gyrocopter did not have any logbooks or a current condition inspection when it was sold as required by Title 14 CFR Part 91.419. The engine had accumulated about 150 total hours and the airframe had accumulated about 2,000 hours. The deceased pilot did not register the gyrocopter with the FAA or obtain a new experimental airworthiness certificate. In addition, there is no record the deceased pilot recreated the logbooks or had a current condition inspection performed on the gyrocopter as required by Title 14 CFR 91.417. METEOROLOGICAL INFORMATION The OBE 1025 surface weather observation was: wind 190 degrees at 9-knots, visibility 10 miles, 6,000 scattered, temperature 26 degrees Celsius, dew point temperature 20 degrees Celsius, and altimeter setting 30.15 inches of mercury. WRECKAGE AND IMPACT INFORMATION Examination of the crash site revealed the gyrocopter came to rest on its left side on a heading of 080 degrees magnetic, near the edge of the OBE taxiway and runway 14 threshold. The deceased pilot was lying behind the gyrocopter to the left and aft across the double yellow lines marking the edge of the right side of the taxiway. There was evidence of one rotor blade strike in the grass off the left side of the taxiway. The gyrocopter swerved to the right on the taxiway. The gyrocopter traveled 106 feet and rolled to the left. Nine propeller blade strikes were present on the taxiway. The right main landing gear landing gear came off the taxiway with evidence of seven left main landing gear sidewall marks present on the taxiway. The gyrocopter continued forward 15 feet where the mast of the gyrocopter contacted the taxiway. A scrap mark from the mast was present on the taxiway extending 68 feet to the gyrocopter at rest. The rotor blades remained attached to their respective rotor hub and were lying across the aft portion of the cabin section. The leading edge of both main rotor blades and the bottom side were scratched. The nose main landing gear, left and right main landing gear, and the tail wheel remained attached to the airframe. The crash debris line extended 230 feet. Examination of the airframe, flight controls, engine assembly and accessories by an FAA safety inspector revealed no anomalies. MEDICAL AND PATHOLOGICAL INFORMATION The State of Florida District Nineteen Medical Examiner at Fort Pierce, Florida, conducted a postmortem examination of the pilot, on March 16, 2009. The cause of death was sharp and bluntforce injuries of head and neck. The Forensic Toxicology Research Section, Federal Aviation Administration, Oklahoma City, Oklahoma performed postmortem toxicology of specimens from the pilot. The results were negative for ethanol and testing for carbon monoxide and cyanide was not performed. The pilot's most recent application for a second-class medical certificate, dated March 20, 2006, indicated "No" for "Do you currently use any medication," for all items under "Medical History," including "Heart or vascular trouble," and for "Visits to Health Professional Within Last 3 Years." On that application, the pilot's height was noted as 65 inches and weight as 145 pounds. Review of the pilot's personal medical records by the NTSB Medical Officer, indicated that on October 16, 2006, the pilot had undergone coronary artery bypass surgery. Notes from that surgery indicated that the pilot "recently has had progressive exertional dyspnea [shortness of breath] and positive stress test, and cardiac cath revealed triple vessel coronary artery disease with good left ventricular function." The operation was described as "Coronary artery bypass graft x4; left internal mammary artery graft to the left anterior descending and saphenous vein graft to the obtuse marginal, saphenous vein graft to the posterolateral marginal, and saphenous vein graft to the right coronary artery." Notes from a follow-up visit on November 7, 2006, indicated that the pilot was "ambulating without angina [chest pain] or dyspnea." There are no later records of visits to the cardiothoracic surgeon. Notes from a November 21, 2008 primary care visit indicated that the pilot "feels well and has no complaints." On autopsy, the pilot's cardiovascular system was described as follows: "The heart weighs 590 grams and has normal distribution of right predominant coronary arteries. The right coronary artery has a markedly narrowed os measuring about 0.1 cm. The left coronary os is unremarkable. The coronary arteries pursue normal courses. There is 70% atherosclerotic stenosis of the distal left anterior descending branch and 80% stenosis of the mid right coronary artery. The remaining segments left main coronary artery and left circumflex branches, each have 50-60% stenosis. There is no thrombus. The epicardial fat is unremarkable in distribution. The myocardium is homogenous, dark red, and firm, without pallor hemorrhage, softening, or fibrosis. The left ventricular wall is 1.0 cm, the ventricular septum 1.1 cm, and the right ventricular wall 0.4 cm thick. The endocardial surfaces are thin and glistening. There are 0.2 - 0.3 cm fenestrations of the aortic valvular cusps. The tricuspid, pulmonary and mitral valves are unremarkable. The valvular circumferences are: tricuspid valve 12.6 cm, pulmonary valve 8.1 cm, mitral valve 11.6 cm, and aortic valve 8.2 cm. There is marked, calcific atherosclerosis of the descending aorta. The venae cavae and pulmonary arteries are without thrombus or embolus."The autopsy report also notes, "Remote left internal mammary artery and venous aortocoronary bypass graftings, intact," and the Associate Medical Examiner who conducted the autopsy confirmed by telephone that the grafts were patent with maximal occlusion of 30-50% in all grafts. ## Aircraft - Registration: [N5098L](https://openairdocs.org/deregistered/N5098L-2009-08-27), registration cancelled 2009-08-27, S/N H2-95-6-154, built 2000 (OpenAirDocs) - Reported make and model: McNear Explorer Coupe (2000) - Registry model: [Mcnear Joseph P EXPLORER COUPE 2000](https://openairdocs.org/model/mcnear-joseph-p-explorer-coupe-2000) (registry code 056040A) (OpenAirDocs) - Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs) - Category: Gyroplane, amateur-built - Serial number: H2-95-6-154 - Airframe hours: 2000 - Engines: Subaru EJ25 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Departed: OBE, Okeechobee, FL - Destination: OBE, Okeechobee, FL - Flight plan: Unknown - Airport: OBE, Okeechobee County Airport, runway 14, 4,000 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 76; injuries: fatal; flight instructor, commercial; airplane ratings: single-engine land, single-engine sea, multi-engine land; instrument ratings: helicopter, airplane; medical: class 2, with waivers/limitations; seat: left; toxicology performed; flight hours: 9,500 total ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 68 °F - Altimeter: 30.14 inHg - Observed at: OBE ## 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 20090314004059A](https://openairdocs.org/incident/20090314004059A), Mar 14, 2009: Mcnear EXPLORERCOU, Okeechobee, FL, Substantial damage, 1 fatal. (-23) On March 14, 2009, at 1016 eastern daylight time, an amateur built/experimental explorer coupe 2000, N5098L, experienced the loss operational control… 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.