# NTSB WPR20LA155: CSP Leasing Cavalon, N477AG, Roseburg, OR, May 28, 2020 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: May 28, 2020, 14:10 local (21:10 UTC) - Place: Roseburg, OR - Coordinates: 43.117221, -123.31027 - Nearby events: https://openairdocs.org/map.md?lat=43.1172&lon=-123.3103&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - 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 - NTSB case key (mKey): 101335 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR20LA155 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101335/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101335 - Page: https://openairdocs.org/ntsb/WPR20LA155 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Main rotor system: main rotor blade system](https://openairdocs.org/ntsb-findings/01046210): Aircraft › Aircraft propeller/rotor · Unknown/Not determined (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) - [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) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Inflight upset](https://openairdocs.org/ntsb-events/271); cases with it: [CSP Leasing CAVALON, 1 case](https://openairdocs.org/ntsb-events/271/sequence.md?model=05634DE), [All aircraft, 74 cases](https://openairdocs.org/ntsb-events/271/sequence.md) - [Enroute-cruise: 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) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [CSP Leasing CAVALON, 2 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=05634DE), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N477AG-2022-07-02), registration cancelled 2022-07-02, S/N V00201, built 2015 (OpenAirDocs) - Reported make and model: CSP Leasing LLC 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 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 77; injuries: fatal; 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 ## 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 20200528008169A](https://openairdocs.org/incident/20200528008169A), May 28, 2020: Csp Leasing LLC CAVALON, Myrtle Creek, OR, Destroyed, 1 fatal. Gyrocopter was observed at 1410 flying nearby Myrtle Creek airpark. The witness heard the engine "sputtering" then followed by a loud explosion. The gyrocopter… ## 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 WPR19LA221](https://openairdocs.org/ntsb/WPR19LA221), Aug 15, 2019: AutoGyro Cavalon (N477AG), Shelton, WA, substantial damage. 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… ## Docket (10 files) The files NTSB released with the investigation on May 24, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101335. 37.8 MB in all. - Maps or charts of accident area (item 1, PDF, 9 pages, 10.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12614708&FileExtension=pdf&FileName=Accident%20site%20maps-Rel.pdf - Records of conversation (item 2, PDF, 3 pages, 175 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12614718&FileExtension=pdf&FileName=Records%20of%20Conversation-Rel.pdf - Aircraft examination report (item 3, PDF, 6 pages, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13803302&FileExtension=pdf&FileName=Cierva%20Narrative%20Summary_Redacted-Rel.pdf - Rotech investigation report (item 4, PDF, 17 pages, 20.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12616349&FileExtension=pdf&FileName=Rotech%20Investigation%20Report_Redacted-Rel.pdf - Rotech authorization to place report on public side of docket (item 5, PDF, 1 page, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12617304&FileExtension=pdf&FileName=Rotech%20authorization%20to%20place%20report%20on%20public%20side%20of%20docket_Redacted-Rel.pdf - NTSB review of FAA medical case review (item 6, PDF, 1 page, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12616806&FileExtension=pdf&FileName=NTSB%20review%20of%20FAA%20medical%20case%20review-Rel.pdf - Statement of party representatives to NTSB investigation (item 7, PDF, 2 pages, 885 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12614889&FileExtension=pdf&FileName=NTSB%20party%20forms_redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 8, PDF, 1 page, 701 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12615318&FileExtension=pdf&FileName=NTSB%20Release%20of%20Wreckage_Redacted-Rel.pdf - Toxicological report (item 9, PDF, 1 page, 145 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12814350&FileExtension=pdf&FileName=Toxicology%20report_Redacted-Rel.pdf - Memorandum of record, autopsy (item 10, PDF, 1 page, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13856980&FileExtension=pdf&FileName=Memorandum%20for%20record%20autopsy-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.