# NTSB WPR19LA221: AutoGyro Cavalon, N477AG, Shelton, WA, August 15, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: August 14, 2019, 18:00 local (Aug 15, 2019, 01:00 UTC) - Place: Shelton, WA - Coordinates: 47.232776, -123.15083 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=47.2328&lon=-123.1508&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 100065 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19LA221 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100065/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100065 - Page: https://openairdocs.org/ntsb/WPR19LA221 ## Probable cause The pilot’s failure to initiate the takeoff roll with inadequate rotor speed, and his failure to follow the published takeoff procedures, which resulted in a loss of control and impact with the ground. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [CSP Leasing CAVALON, 3 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05634DE), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: configuration](https://openairdocs.org/ntsb-findings/01062017): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [CSP Leasing CAVALON, 1 case](https://openairdocs.org/ntsb-findings/01062017/cases.md?model=05634DE), [All aircraft, 80 cases](https://openairdocs.org/ntsb-findings/01062017/cases.md) - [Main rotor system: main rotor blade system](https://openairdocs.org/ntsb-findings/01046210): Aircraft › Aircraft propeller/rotor · Incorrect use/operation (probable cause); cases with it: [CSP Leasing CAVALON, 2 cases](https://openairdocs.org/ntsb-findings/01046210/cases.md?model=05634DE), [All aircraft, 60 cases](https://openairdocs.org/ntsb-findings/01046210/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [CSP Leasing CAVALON, 2 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=05634DE), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Takeoff: Abnormal runway contact](https://openairdocs.org/ntsb-events/090); cases with it: [CSP Leasing CAVALON, 2 cases](https://openairdocs.org/ntsb-events/090/sequence.md?model=05634DE), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md) - [Takeoff: Roll over](https://openairdocs.org/ntsb-events/097); cases with it: [CSP Leasing CAVALON, 1 case](https://openairdocs.org/ntsb-events/097/sequence.md?model=05634DE), [All aircraft, 261 cases](https://openairdocs.org/ntsb-events/097/sequence.md) ## Analysis The pilot of the gyroplane was practicing takeoffs and landings. On the accident takeoff attempt, the pilot initiated the takeoff roll with a rotor rpm less than that recommended by the manufacturer. When he saw that the speed of the gyroplane was higher than normal and the gyroplane still had not lifted off the runway, he applied aft control stick to initiate the takeoff, contrary to the published takeoff procedures in the owner’s manual. The gyroplane then immediately lifted off the runway and rolled to the left. The rotor contacted the left vertical stabilizer and the runway. An examination of the wreckage revealed no preaccident mechanical malfunctions or failures with the gyroplane that would have precluded normal operation. It is likely that the pilot’s decision to initiate the takeoff with low rotor rpm and his failure to follow the published takeoff procedure resulted in a loss of control. ## Factual narrative On August 14, 2019, about 1800 Pacific daylight time, an experimental AutoGyro Cavalon gyroplane, N477AG, was substantially damaged when it was involved in an accident near Shelton, Washington. The pilot received minor injuries. The gyroplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he was conducting stop-and-go takeoffs and landings from runway 23. He reported that he had done three or four takeoffs and landings before the accident and the gyroplane had been lifting off the runway at about 52 miles per hour (mph). On the accident takeoff attempt, the pilot reported that, before the takeoff roll, the rotor indicated 190 rpm, which was 10 rpm less than recommended by the manufacturer. During the takeoff roll, he observed the speed of the gyroplane was almost 60 mph. He said that he pulled the control stick back and the gyrocopter pitched up and yawed to the right and came immediately down. He heard a loud bang, and the gyroplane impacted the runway. Examination of the accident site revealed that the gyroplane impacted the runway slightly left of centerline, rolled onto its left side, and slid about 170 ft to the left edge of the runway. Numerous rotor blade and propeller contact marks were present along the path, consistent with rotation of both components. All major components remained attached to the gyroplane. Examination of the empennage revealed damage to the top side of the left vertical stabilizer consistent with rotor impact. A visual inspection of the fuselage and engine revealed no pre-impact mechanical failures or malfunctions that would have precluded normal operation. A review of the pilot’s logbook revealed that he had accrued about 73 total hours of flight experience in the accident gyroplane. The last flight documented in the logbook was dated August 14, 2019, the day of the accident. The previous flight occurred on August 10, 2019. The FAA Rotorcraft Flying Handbook, FAA-H-8083-21, states in part: Using coordinated throttle and flight control inputs, balance the gyroplane on the main gear without the nose wheel or tail wheel in contact with the surface. At this point, smoothly increase power to full thrust and hold the nose at takeoff attitude with cyclic pressure. The gyroplane will lift off at or near the minimum power required speed for the aircraft. And On a gyroplane with a semi-rigid, teeter-head rotor system, blade flap may develop if too much airflow passes through the rotor system while it is operating at low r.p.m. This is most often the result of taxiing too fast for a given rotor speed. The Cavalon Owner’s Manual, Section 4.8, Take-off Procedures, states in part: Carefully increase throttle (~ 20 R-RPM/sec) to 200 R-RPM – max. 220 R-RPM. This section also contains a warning that states in part: Take Care! Slow rotors can stall and flap, causing expensive aircraft damage. If in doubt, abort the take-off run and restart. The Cavalon Owner’s Manual, Section4.9, Takeoff Run, states in part: Maintain attitude until speed increases and gyroplane lifts off (at about 50 mph, depending on loading and rotor). ## Aircraft - Registration: [N477AG](https://openairdocs.org/deregistered/N477AG-2022-07-02), registration cancelled 2022-07-02, S/N V00201, built 2015 (OpenAirDocs) - Reported make and model: AutoGyro Cavalon - Registry model: [CSP Leasing CAVALON](https://openairdocs.org/model/csp-leasing-cavalon) (registry code 05634DE) (OpenAirDocs) - Registry engine: [Rotax 914ULS](https://openairdocs.org/engine/rotax-914uls) (registry code 55552, 4 cycle) (OpenAirDocs) - Category: Gyroplane, amateur-built - Serial number: V00201 - Year built: 2015 - Airframe hours: 166.2 - Engines: Rotax 914ULS 115 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: 100 hour, September 9, 2018, 77 hours before - Destination: Same as departure - Airport: SHN, Sanderson Field, runway 23, 5,005 × 100 ft, asphalt - Equipment: Electronic primary flight display, ADS-B, Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 76; injuries: minor; sport pilot; medical: sport pilot, without waivers/limitations; seat: left; restraint: 4-point; flight hours: 374 total, 76 in this make and model, 297 as pilot in command, 1 in the last 90 days, 1 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 11 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 57 °F - Altimeter: 30.11 inHg - Observed at: SHN, 1 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 20190814016489A](https://openairdocs.org/incident/20190814016489A), Aug 14, 2019: Csp Leasing LLC CAVALON, Shelton, WA, Substantial damage. Accelerated on t.o. roll. Aircraft was not lifting off. Pilot pulled stick back slightly and nose pitched up. Aircraft yawed right and rolled left. Rotor… ## Other investigations on N477AG (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 WPR20LA155](https://openairdocs.org/ntsb/WPR20LA155), May 28, 2020: CSP Leasing Cavalon (N477AG), Roseburg, OR, destroyed, 1 fatal. Probable cause: A substantially unweighted rotor system for reasons that could not be determined, which resulted in contact between the main rotor blade and the gyrocopter’s keel tube and a loss of control and… ## Docket (6 files) The files NTSB released with the investigation on March 21, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100065. 5.6 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 7 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9664587&FileExtension=pdf&FileName=NTSB%20Form%206120_1%20Lee%20Pauley_Redacted-Rel.pdf - Pilot's statement (item 2, PDF, 1 page, 158 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12527978&FileExtension=pdf&FileName=Memo%20for%20Record%20Pilot%20Statement-Rel.pdf - Memo for record flight instructor statement (item 3, PDF, 1 page, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13437308&FileExtension=pdf&FileName=Memo%20for%20Record%20Gyroplane%20Flight%20Instructor%20R%20Nance-Rel.pdf - Airframe and engine examination report (item 4, PDF, 18 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13373829&FileExtension=pdf&FileName=Airframe%20and%20Engine%20Examination%20WPR19LA221-Rel.pdf - Excerpts from the pilot's operating handbook (item 5, PDF, 2 pages, 242 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13382479&FileExtension=pdf&FileName=Memo%20for%20Record%20Operators%20Handbook%20Excerpts-Rel.pdf - Photos (item 6, PDF, 9 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13438292&FileExtension=pdf&FileName=WPR19LA221%20Photos-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.