WPR20LA155

NTSB accident investigation · CSP Leasing Cavalon · Roseburg, OR · May 28, 2020

Accident · FatalClass 3 · LimitedFinal report
Date
May 28, 2020, 14:10 local (21:10 UTC)
Place
Roseburg, OR
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N477AGCSP Leasing Cavalon
Defining event
Enroute-cruise: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Cierva Services LLC, Federal Aviation Administration, ROTAX Aircraft Engines
FAA report
20200528008169A
Case key
101335

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

On this page

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 impact with terrain.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Main rotor system: main rotor blade systemAircraft › Aircraft propeller/rotor · Unknown/Not determinedCSP Leasing CAVALON: 2 casesAll aircraft: 60 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCSP Leasing CAVALON: 3 casesAll aircraft: 9,295 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot departed an airport on a cross country flight and had flown about 7 miles before witnesses observed the aircraft flying between 1,000 ft to 2,000 ft above ground level (agl), at which time they also heard the engine make an unusual noise as if something had come off the aircraft. They subsequently observed the gyrocopter enter an uncontrolled descent and impact terrain. One of the witnesses observed parts coming off the gyrocopter, which he believed was either the engine or the transmission coming apart. He also observed the “tail boom” break off, swing forward, and crash into the passenger side of the cockpit, which sent it into an uncontrollable spin and subsequent impact with terrain at about a 45° nose-down attitude. A postaccident examination of the gyrocopter revealed that the keel tube had signature strike marks consistent with a main rotor blade impact. This physical evidence was indicative of a substantially unweighted rotor system. This would have occurred while the aircraft was nosed over for a long period of time, at which time the rotor likely lost its directional orientation and spun out of axis and struck the keel tube. However, the duration of any nose over made by the gyrocopter during the accident flight could not be determined due to a lack of available evidence. The parts that departed the gyrocopter inflight were not identified during the investigation.

Factual narrative

On May 28, 2020, about 1410 Pacific daylight time, a CSP Leasing Cavalon rotorcraft, N477AG, was destroyed when it was involved in an accident near Roseburg, Oregon. The pilot was fatally injured. The gyrocopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to a family member, on May 27th, the pilot flew the gyrocopter from Petaluma, California, where it had just been repaired due to an accident the pilot had the previous summer, to Myrtle Creek Municipal Airport (16S), Myrtle Creek, Oregon. The following morning the pilot added 15 gallons of ethanol-free fuel prior to departing for Shelton, Washington. He subsequently departed 16S to the northwest about 1355, with a family member following by automobile. A witness to the accident, about 7 nautical miles (nm) north of 16S, observed the gyrocopter flying over his property at an estimated altitude between 1,500 ft above ground level (agl) and 2,000 ft agl. The witness further reported that shortly thereafter he heard the engine "sputter", followed by what he described as a “loud noise”, as if something had come off the aircraft. He stated that the aircraft "tumbled out of the sky straight own” before it impacted terrain and caught fire. A second witness, a retired military flight mechanic, reported he was outside and heard the noise of a helicopter, which caused him to immediately look up “…because it did not sound right,” and that he “knew the sound of a helicopter when it was about to crash.” He stated that the helicopter was about 1,000 ft agl, and that he could see parts coming off it. He believed either the engine or the transmission was coming apart. The witness opined that he observed the “tail boom” break off, swing forward, and crash into the cockpit, which sent it into an uncontrollable spin. It subsequently impacted terrain in a 45° nose-down attitude. According to the autopsy that was performed by the State Medical Examiner’s Office, Clackamas, Oregon, the cause of death was multiple blunt force traumatic injuries. Toxicology performed at the request of the medical examiner by the Department of State Police, Forensic Laboratory identified propranolol and ethanol at 0.012 gm/dL in chest cavity blood. Toxicology testing performed by the FAA Forensic Laboratory identified ethanol in cavity blood and did find propranolol in cavity blood and liver. Propranolol is a blood pressure medication and is not considered impairing. Ethanol is a social drug that acts as a central nervous system depressant. After ingestion, at low doses, it impairs judgment, psychomotor functioning, and vigilance; at higher doses alcohol can cause coma and death. Federal Aviation Regulations, Section 91.17 (a) prohibits any person from acting or attempting to act as a crewmember of a civil aircraft while having a 0.040 gm/dL or more alcohol in blood. Ethanol can also be produced in tissues by germs postmortem. No personal pilot records were recovered during theinvestigation. The accident site was located about 7 nm north of 16S, at an elevation of about 1,158 ft mean sea level (msl). The surrounding topography consisted of medium rolling hills populated by a farming community. Except for a few parts that were located about 75 yards uphill and to the south of the main wreckage site, which was estimated by local law enforcement personnel to be about 15 ft in diameter, all aircraft components necessary for flight were located within the main wreckage; there was no linear distribution of aircraft components. The parts that were located uphill from the main wreckage were photographed by local law enforcement personnel; however, they were not recovered. When an attempt to recover the parts was made later in the investigation, it was determined the parts had been recovered by the landowner and disposed of. Examination of the photographs of the parts that were not recovered failed to reveal the identity of the parts, as there were no closeup photographs of the parts. Postaccident examination of the airframe revealed no mechanical anomalies that would have precluded normal operation. According to a technical expert, “the depth of the keel tube and rotor strike indicate that this was the initial high rpm rotor impact. The impact would have produced a loud noise consistent with the sound observed by one of the witnesses. The angle of impact indicates an acute out of plane blade strike consistent with the rotor system being substantially unweighted. The strike would have impacted the empennage and propeller producing debris separating from the aircraft. All flight control connections were examined from the crash site were attached and intact and showed no malfunction or defect.” The technical expert stated that the rotor system on this aircraft is a self-regulating teetering hub. The aircraft can become “substantially unweighted” when nosed over at which time the gyrocopter’s downward trajectory will reduce the forces on the rotor system. He added that if “this occurs over a long enough period of time, the rotor will lose its directional orientation…[and without any downward force] the hub could cause the rotor to spin out of its axis and strike the keel tube.” Examination of the engine revealed no mechanical anomalies that would have precluded normal operation.

Aircraft

Registration
N477AG
Reported as
CSP Leasing Cavalon
Category
Gyroplane, amateur-built
Serial number
V00201
Built
2015
Engine
Rotax 914ULS, 115 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Departed
16S · Myrtle Creek, OR
Destination
SHN · Shelton, WA
Equipment
Unknown

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
77
Injuries
Fatal
Certificate
Sport Pilot
Medical
Sport pilot, Without waivers/limitations
Seat
Left
Restraint
4-point
Toxicology
Performed
Flight hours
379 total · 76 in this make and model · 298 as pilot in command · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
20° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 48 °F
Altimeter
29.90 inHg
Observed at
RGB, 7 nm away

Docket · 10

The files NTSB released with the investigation on May 24, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 37.8 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N477AG · 1

Matched to the same aircraft by N-number and date.