# NTSB WPR16LA114: Michael Burton Calidus, N50NE, Fruitland, UT, May 20, 2016 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: May 20, 2016, 11:00 local (17:00 UTC) - Place: Fruitland, UT - Coordinates: 40.124168, -111.001663 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.1242&lon=-111.0017&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Turbulence encounter](https://openairdocs.org/ntsb-events/360) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report May 1, 2017 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration FSDO - NTSB case key (mKey): 93217 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR16LA114 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93217/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93217 - Page: https://openairdocs.org/ntsb/WPR16LA114 ## Probable cause The pilot's improper judgment in conducting a flight in a gyroplane over mountainous terrain near its demonstrated maximum operating altitude and his subsequent failure to maintain adequate clearance with terrain during cruise flight in turbulent weather conditions. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Michael Burton CALIDUS, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=05633B9), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Michael Burton CALIDUS, 1 case](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=05633B9), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Aircraft capability: climb capability](https://openairdocs.org/ntsb-findings/01061010): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Michael Burton CALIDUS, 1 case](https://openairdocs.org/ntsb-findings/01061010/cases.md?model=05633B9), [All aircraft, 183 cases](https://openairdocs.org/ntsb-findings/01061010/cases.md) - [Terrain: mountainous/hilly terrain](https://openairdocs.org/ntsb-findings/03021010): Environmental issues › Physical environment · Effect on operation (probable cause); cases with it: [Michael Burton CALIDUS, 1 case](https://openairdocs.org/ntsb-findings/03021010/cases.md?model=05633B9), [All aircraft, 329 cases](https://openairdocs.org/ntsb-findings/03021010/cases.md) - [Turbulence: terrain induced turbulence](https://openairdocs.org/ntsb-findings/03032010): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Michael Burton CALIDUS, 1 case](https://openairdocs.org/ntsb-findings/03032010/cases.md?model=05633B9), [All aircraft, 70 cases](https://openairdocs.org/ntsb-findings/03032010/cases.md) - [Health/Fitness: use of medication/drugs](https://openairdocs.org/ntsb-findings/02013020): Personnel issues › Physical · Pilot; cases with it: [Michael Burton CALIDUS, 1 case](https://openairdocs.org/ntsb-findings/02013020/cases.md?model=05633B9), [All aircraft, 73 cases](https://openairdocs.org/ntsb-findings/02013020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Turbulence encounter](https://openairdocs.org/ntsb-events/360) (defining event); cases with it: [Michael Burton CALIDUS, 1 case](https://openairdocs.org/ntsb-events/360/sequence.md?model=05633B9), [All aircraft, 423 cases](https://openairdocs.org/ntsb-events/360/sequence.md) - [Enroute-cruise: Loss of lift](https://openairdocs.org/ntsb-events/500); cases with it: [Michael Burton CALIDUS, 1 case](https://openairdocs.org/ntsb-events/500/sequence.md?model=05633B9), [All aircraft, 252 cases](https://openairdocs.org/ntsb-events/500/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Michael Burton CALIDUS, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=05633B9), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-flare/touchdown: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Michael Burton CALIDUS, 2 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=05633B9), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis After fueling the gyroplane, the private pilot and passenger embarked on a cross-country flight over rugged and mountainous terrain. The pilot reported that, as the gyroplane approached a ridge, about 200 ft above its peak, it encountered strong downdrafts and then descended into a box canyon. Unable to climb the gyroplane to clear terrain, the pilot guided it over a river at the base of the canyon until he could see a landing spot on the shore. As he approached the site and initiated the landing flare, the right wheel struck a boulder, and the gyroplane rolled over and then came to rest in the river. The canyon in which the gyroplane came to rest was at an elevation of about 7,300 ft mean sea level (msl), and the canyon walls rose about 1,000 ft above the accident site to the north and south. The gyroplane's demonstrated maximum operating altitude was 10,000 ft, and the pilot's intended flight route would have required clearing mountain peaks that were at an elevation of 8,200 ft msl. The pilot reported that there were no mechanical malfunctions or failures with the gyroplane. Local wind conditions, along with the rugged terrain, likely resulted in mechanical turbulence and strong downdrafts along the flight route, and it is likely that the weather conditions affected the gyroplane's ability to achieve a positive climb rate. Given the weather conditions and the gyroplane's maximum operating altitude of 10,000 ft, the pilot demonstrated improper judgment by attempting such a flight. The pilot stated that he could have avoided the accident if he had approached the mountain ridge at a higher altitude. The accident site was inaccessible to first responders, which resulted in the pilot's blood being drawn about 5 hours following the accident. Toxicological testing revealed strong evidence that he had used marijuana at some point before the accident. Although he had no significant active drug (tetrahydrocannabinol [THC]) in his blood at the time it was drawn, it could not be determined how much THC was in this blood at the time of the accident. Therefore, it could not be determined if impairment due to marijuana use contributed to the pilot's poor decision-making. ## Factual narrative On May 20, 2016, about 1100 mountain daylight time, an experimental amateur-built Michael Burton (AutoGyro GmbH) Calidus, N50NE, collided with mountainous terrain near Fruitland, Utah. The gyroplane was registered to the builder and operated by the pilot under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The private pilot and passenger were seriously injured, and the gyroplane sustained substantial damage. The cross-country personal flight departed Duchesne Municipal Airport, Duchesne, Utah, about 1015, with a planned destination of Spanish Fork Airport-Springville-Woodhouse Field, Spanish Fork, Utah. Visual meteorological conditions prevailed, and no flight plan had been filed. The pilot reported that they departed from Glenwood Springs Municipal Airport, Glenwood Springs, Colorado, earlier that morning and stopped at Duchesne for fuel. They then departed west towards Spanish Fork on a route over the Wasatch Mountain Range. As they approached the last ridge, about 200 ft above its peak, they encountered strong downdrafts and the gyroplane descended 500 ft and into a box canyon. Unable to out-climb the terrain, the pilot guided the gyroplane over a river at the base of the canyon until he could see a landing spot on the shore. As he approached the site and initiated the landing flare, the right wheel struck a boulder and the gyroplane rolled over, coming to rest in the river. A witness, who was fishing in the river, called 911 after climbing to a peak where he was able to acquire cell phone reception. Due to the remoteness of the site, the pilot and passenger were not recovered until later in the afternoon. The gyroplane came to rest within a canyon, at an elevation of about 7,300 ft mean sea level. The canyon walls rose about 1,000 ft above the accident site to the north and south. The projected route of flight would have required clearance over rugged 8,200 ft peaks, about 5 miles north of the 9,420 ft summit of Baldy Mountain. About the time of the accident, a weather observation station located at Carbon County Regional Airport/Buck Davis Field, 37 miles south-southeast of the accident site and at an elevation of 5,957 ft, reported wind from 170 degrees at 20 knots gusting 25 knots. About the same time, at Provo Municipal Airport, 38 miles west at an elevation of 4,497 ft, wind was reported from 130 degrees at 15 knots, gusting to 22 knots. The gyroplanes Pilot Operating Handbook specified a maximum demonstrated operating altitude of 10,000 ft. The pilot reported that the gyroplanes maximum gross weight was 1,256 pounds, and the that the weight at the time of the accident was 1,100 pounds. The pilot stated that the gyroplane did not experience any mechanical malfunctions or failures, and that the accident could have been avoided if he had approached the mountain ridge at a higher altitude. The Federal Aviation Administration Bioaeronautical Research Laboratory performed toxicology tests on a sample of blood that wascollected from the pilot at 1546 on the day of the accident. Results identified 0.0111 ug/ml of tetrahydrocannabinol carboxylic acid (THC-COOH) in his blood. Tetrahydrocannabinol carboxylic acid (THC-COOH) is the primary metabolite of tetrahydrocannabinol (THC), the main psychoactive compound in marijuana. The report did not document the presence of THC. The reporting cutoff for THC was 0.001 ug/ml. ## Aircraft - Registration: [N50NE](https://openairdocs.org/deregistered/N50NE-2020-09-04), registration cancelled 2020-09-04, S/N C00240, built 2014 (OpenAirDocs) - Reported make and model: MICHAEL BURTON Calidus - Registry model: [Michael Burton CALIDUS](https://openairdocs.org/model/michael-burton-calidus) (registry code 05633B9) (OpenAirDocs) - Registry engine: [Rotax 912 series](https://openairdocs.org/engine/rotax-912-series) (registry code 55569, 4 cycle) (OpenAirDocs) - Category: Gyroplane, amateur-built - Serial number: C00240 - Year built: 2014 - Airframe hours: 350 - Engines: Rotax 914 115 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, May 20, 2016, 25 hours before - Departed: U69, DUCHESNE, UT - Destination: U77, SPANISH FORK, UT - Equipment: Handheld GPS, Electronic multifunction display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: serious; private; medical: class 3, with waivers/limitations; last flight review January 25, 2016; seat: front; restraint: 4-point; toxicology performed; flight hours: 285 total, 235 in this make and model, 215 as pilot in command, 120 in the last 90 days, 60 in the last 30 days, 6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 170° at 20 knots, gusting 25 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 64 °F, dew point 34 °F - Altimeter: 29.81 inHg - Observed at: KPUC, 33 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 20160520024549A](https://openairdocs.org/incident/20160520024549A), May 20, 2016: Michael Burton CALIDUS, Fruitland, UT, Substantial damage. On a VFR flight the aircraft collided with mountainous terrain. The cross-country flight departed duchesne, Utah about 30 minutes prior to the accident with a… ## Other investigations on N50NE (1) 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. - [NTSB CEN15CA128](https://openairdocs.org/ntsb/CEN15CA128), Jan 6, 2015: Burton Calidus (N50NE), Grand Junction, CO, substantial damage. Probable cause: The pilot's failure to maintain clearance with terrain that was along the planned route of flight. ## Docket (3 files) The files NTSB released with the investigation on February 16, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93217. 779 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 596 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458911&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Calidus Pilot Operating Handbook Excerpt (item 2, .PDF, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449297&FileExtension=.PDF&FileName=Calidus%20Pilot%20Operating%20Handbook%20Excerpt-Master.PDF - Evidence Control Form (item 3, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449298&FileExtension=.PDF&FileName=Evidence%20Control%20Form-Master.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.