# NTSB ERA20LA051: Parsons Two Place #1, N446PS, Naguabo, PR, December 8, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: December 8, 2019, 14:05 local (18:05 UTC) - Place: Naguabo, PR - Coordinates: 18.240833, -65.696945 - Nearby events: https://openairdocs.org/map.md?lat=18.2408&lon=-65.6969&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 100673 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA20LA051 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100673/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100673 - Page: https://openairdocs.org/ntsb/ERA20LA051 ## Probable cause A failure of the rudder attachment bolt, which resulted in the rudder’s subsequent inflight separation from the fuselage. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Empennage structure: rudder](https://openairdocs.org/ntsb-findings/01035540): Aircraft › Aircraft structures · Fatigue/wear/corrosion (probable cause); cases with it: [Ortiz-Rivera Luis Ramon PARSONS TWO PLACE #1, 1 case](https://openairdocs.org/ntsb-findings/01035540/cases.md?model=05630XF), [All aircraft, 15 cases](https://openairdocs.org/ntsb-findings/01035540/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) (defining event); cases with it: [Ortiz-Rivera Luis Ramon PARSONS TWO PLACE #1, 1 case](https://openairdocs.org/ntsb-events/333/sequence.md?model=05630XF), [All aircraft, 410 cases](https://openairdocs.org/ntsb-events/333/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Ortiz-Rivera Luis Ramon PARSONS TWO PLACE #1, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05630XF), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis About 10 minutes after departure while in cruise flight at 55-60 mph, the pilot began to feel a vibration in the airframe and an "abnormal drag." He reduced the engine power, and about that time, he felt the propeller sever the rudder cables. As he looked back, he saw the rudder separate from the airframe and the gyroplane began to spin. The pilot shut down the engine to reduce the torque and attempted to maintain control as the gyroplane rapidly descended until it impacted the ground. The fuselage and main rotor blades were substantially damaged during the accident sequence. An examination of photographs of the fractured bolt section that attached the rudder to the fuselage revealed that the bolt likely fractured as a result of reverse bending fatigue. ## Factual narrative On December 8, 2019, about 1405 Atlantic standard time, an experimental amateur-built Parsons Two Place #1 gyroplane, N446PS, was substantially damaged when it impacted terrain near Naguabo, Puerto Rico. The private pilot sustained serious injuries. The gyroplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, about 10 minutes after departure while in cruise flight at 55-60 mph, he began to feel a vibration in the airframe and an "abnormal drag." He reduced the engine power, and about that time, he felt the propeller sever the rudder cables. As he looked back, he saw the rudder separate from the airframe and the gyroplane began to spin. The pilot shut down the engine to reduce the torque and attempted to maintain control as the gyroplane rapidly descended until it impacted the ground. Examination of the wreckage by a Federal Aviation Administration inspector revealed that the gyroplane came to rest on the right side. The main rotor blades were impact damaged and cut branches were located nearby. The propeller blades remained attached to the engine and the engine remained attached to the airframe. The rudder was not located after the accident. Photographs of the fractured bolt section that attached the rudder to the fuselage were sent to the National Transportation Safety Board Materials Laboratory for examination, which revealed that the bolt fractured as a result of reverse bending fatigue. According to the preflight checklist for the gyroplane, the pilot should check the rudder for "condition and security, check surface for delamination, check rudder cables (rudder end) for fraying and nico clamps for security." After the accident, the manufacturer of the gyroplane kit updated the preflight checklist to include checking the rudder for "condition and bolt security, check surface for delamination, check rudder cables (rudder end) for fraying and nico clamps for security." ## Aircraft - Registration: [N446PS](https://openairdocs.org/aircraft/N446PS), registered now, S/N L ROR-01 (OpenAirDocs) - Reported make and model: PARSONS Two Place #1 - Registry model: [Ortiz-Rivera Luis Ramon PARSONS TWO PLACE #1](https://openairdocs.org/model/ortiz-rivera-luis-ramon-parsons-two-place-1) (registry code 05630XF) (OpenAirDocs) - Category: Gyroplane, amateur-built - Serial number: L ROR-01 - Year built: 2013 - Airframe hours: 66.8 - Engines: Rotax 912 S2 100 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, June 23, 2019, 5 hours before - Departed: RVR, Ceiba, PR - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; injuries: serious; private; airplane ratings: single-engine sea, single-engine land; medical: basicmed; last flight review May 26, 2019; seat: front; restraint: 4-point; flight hours: 311 total, 36 in this make and model, 233 as pilot in command, 3.7 in the last 90 days, 0.1 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 60° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 72 °F - Altimeter: 29.98 inHg - Observed at: TJNR, 3 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 20191208021279A](https://openairdocs.org/incident/20191208021279A), Dec 8, 2019: Ortiz-Rivera Luis Ramon PARSONS TWO PLACE #1, Naguabo, PR, Substantial damage. Gyrocopter N446PS departed from josÉ Aponte de la Torre airport, ceiba, p.r. (RVR) runway 7, at 1:51PM local time, heading west at 2,000FT, cruising between… ## Docket (7 files) The files NTSB released with the investigation on April 12, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100673. 21.4 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9438519&FileExtension=pdf&FileName=NTSB%206120%20N446PS_Redacted-Rel.pdf - Record of conversation - pilot (item 2, PDF, 2 pages, 788 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9468168&FileExtension=pdf&FileName=ROC%20Luis%20R%20Ortiz%20Rivera_Redacted-Rel.pdf - Memorandum for record - FAA inspector (item 3, PDF, 1 page, 118 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9472001&FileExtension=pdf&FileName=Memorandum%20Of%20Record%20Color%20FAA%20Inspector-Rel.pdf - Airframe maintenance logbook (item 4, PDF, 6 pages, 9.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9438952&FileExtension=pdf&FileName=N446PS%20Airframe%20Records_Redacted-Rel.pdf - Memorandum for record - NTSB materials laboratory (item 5, PDF, 2 pages, 2 photos, 824 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9440808&FileExtension=pdf&FileName=Memorandum%20Of%20Record%20Color%20Budinski-Rel.pdf - Investigative photographs (item 6, PDF, 3 pages, 3 photos, 6.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9440477&FileExtension=pdf&FileName=Photo%20Array%20LA051-Rel.pdf - Preflight checklist - before and after accident (item 7, PDF, 4 pages, 206 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9438691&FileExtension=pdf&FileName=Preflight%20Checklist-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.