Human Factors: Stoned and stupefied

The pilot was frustrated. He’d purchased his AutoGyro Cavalon almost two years before he retired, but he’d only managed to rack up about 20 hours of training in it since.

The training was sporadic. He was based in east-central Oklahoma, and both his new-to-him aircraft and his flight instructor were located south of Dallas, Texas.

He’d make the commute, train for a few hours, then months would pass before he could get back to Texas for more training. Progress was slow but, it seems, it was the battery that was the final straw.

In the summer of 2021, after making that long commute for more air time, the AutoGyro’s battery was dead. The pilot decided to take the airplane home with him so that he could fly more, but by mid-autumn the aircraft was wrecked and the pilot was dead.

The Accident

The accident flight was actually no flight at all.

According to a witness, in the mid-afternoon of Oct. 18, 2021, the pilot pulled the AutoGyro out of his shop onto a 300-yard-long north/south pasture, jumped in, and with a healthy tailwind, blasted off down the makeshift runway. The AutoGyro never left the ground.

At the end of its 300-yard dash, the AutoGyro hit a barbed wire fence going full-bore, tilting it forward so its blades started chewing up the ground.

What happened next isn’t exactly clear, but it came to rest twisted and mangled, but upright, 125 feet beyond the fence, turned parallel to the fence line.

The rotor head was bent aft 45°, one blade bent to the root, the second fractured mid-span.

Pieces of barbed wire fencing were wrapped around both landing gear struts.

The engine was still running, shut down by bystanders, who called 911.

The pilot wasn’t wearing his seat belt, and first responders found a gaping hole in the windshield where the pilot, quite literally, punched out at some point during the accident.

His cause of death was listed as blunt force trauma to the head and neck.

Additional Findings

According to the NTSB, the pilot’s autopsy revealed levels of methamphetamine “consistent with abuse,” but the authorities couldn’t determine at which end of the usage cycle he was in.

The Final Report on the fatal accident notes that if he was experiencing “early” effects he might have been feeling “euphoric and invulnerable, with a tendency to make high-risk decisions;” while if he was suffering later effects, he might have been experiencing “restless, disorganized and uncoordinated” thoughts.

Complicating the analysis was the additional presence of THC, the levels of which were such that it was “impossible to infer specific impairing effects,” much less figure out how the two illegal (for pilots) drugs might have interacted.

But in a surprising move, the NTSB said it didn’t matter: “Given the pilot’s overall lack of experience, along with his decision to takeoff with a tailwind, it is likely he did not possess the necessary skill or experience to safely conduct solo flight. Therefore, it was impossible to determine whether impairment of his handling of the aircraft from drug effects contributed to the accident.”

So basically, the Feds said that it didn’t matter whether or not he was stoned. Sober or stoned, he didn’t have the skill set to fly safely.

The Unlicensed Pilot

The “pilot” was a 66-year-old male. I put the word pilot in quotes because there is no evidence that he had even so much as a student pilot certificate.

The NTSB made quite a lot of noise about him not having a medical as well, but I don’t think that the lack of a medical certificate means much, as it’s possible that he intended to pursue a Light Sport Gyroplane certificate on a driver’s license medical.

But the lack of a student pilot certificate is a different kettle of fish.

To solo — legally — requires both a student certificate and an instructor endorsement. The pilot had neither.

But that didn’t stop him, because according to a neighbor, the pilot’s first solo in the aircraft was a mere two days before the accident “flight.”

Analysis & Discussion

The pilot’s obituary says he had retired two years previously — about the time he purchased the autogyro — and that he “embraced life to the fullest. He was adventure loving and thrill seeking. He loved shooting sports, fishing, riding his motorcycle.”

He also, apparently, enjoyed gardening and growing watermelons that his dad would have been proud of.

Champion watermelons aside, does this description hint at someone who has an anti-authority hazardous attitude?

Of course, in fairness, the pilot didn’t just buy the AutoGyro and jump into it. He started flight training in the traditional manner.

Yet, the NTSB’s Aviation Accident Investigator assigned to the case, when interviewing the pilot’s Texas-based CFI, learned that the last of the sporadic flight lessons with the CFI had been in the mid summer, which was when the battery had failed and the pilot decided to take his toy with him and go home.

The CFI said he’d informed the pilot that “he needed more training and was not ready for solo flight,” whereupon, the pilot assured the instructor that he had another instructor “lined up” back home, but provided no details.

Tellingly, the CFI told the investigator that he was “very concerned” that the pilot was going to fly without additional flight training — but apparently the instructor took no action, nor made any effort to contact the authorities or family of the pilot.

The CFI also told the investigator that “there are very few gyroplane instructors.”

That’s no understatement. The Popular Rotorcraft Association lists only 46 active gyroplane instructors spread across 22 states (including one in Oklahoma). Only seven of those are willing to travel out of their home states to give training.

Could the lack of available instructors have led the pilot to take matters into his own hands?

Did his drug use give him an unrealistic self-assessment of his skill?

Did an anti-authority bias lead him to think the rules didn’t apply to him? We see some evidence of the latter in his cannabis use.

At the time, and still as of this writing, recreational use of cannabis wasn’t legal in Oklahoma and, of course, regardless of state, is never legal for pilots.

The state does have provisions for medical marijuana, but if the pilot had a medical marijuana card, it’s not mentioned in any of the reports, nor would it be compatible with aviation in any case.

As for the meth abuse, well, what is there to say?

Tied in with all of this is the seat belt. If he’d been wearing his seat belt, he probably would have survived the crash.

Did he simply forget to buckle up or did his drug use/abuse have a part to play in that?

Or was he just one of those people who — despite all scientific evidence and common sense — simply refuse to wear seat belts?

Meanwhile, what about the tailwind takeoff?

The witness estimated the wind at 10 to 15 miles per hour (9-13 knots), straight from the south. The nearest weather reporting station was seven miles to the northwest, and it clocked the wind as 8 knots, gusting to 17 knots, from 160°.

We covered before how dangerous tailwinds can be.

Just assume that for every 2 knots you need to add 10% to your takeoff roll. So in this case, that works out to something between 40% on the low end and, well, more than double for the maximum gusts.

Complicating this is the fact that the Pilot’s Operating Handbook (POH) for the Cavalon lists a maximum tailwind component of 5 knots for takeoff and landing.

Ignoring for the moment the max tailwind — because who doesn’t want to be a test pilot? — how much room did he need vs. what he had?

The manufacturer’s website lists two takeoff distances for the Cavalon: A “wheels up” takeoff distance of 357 feet and a “to clear 15-meter (it’s German-made) obstacle” roll of 854 feet.

But of course these things have two engine options, three propellor options, as well as different wheels, wheel pants, etc., so I’m sure the actual takeoff rolls vary quite a bit.

Adding to this, the turf of the pilot’s makeshift runway was far from manicured. The accident photos show a bumpy rolling prairie with tall weeds interspaced with bare earth and well-grazed grass. And there’s a hill at the barb-wire fence end.

If you take the 15-meter takeoff roll figure, he only had 46 feet to “spare,” so with even 1 knot of tailwind, his safety margin would have been measured in inches.

Granted, we don’t know how his loading compared to the baseline used by the manufacturer and, to be fair, he got it off the ground successfully once before, two days prior, although the witness noted that he saw the pilot land into the wind that day.

It was a warm afternoon, but not crazy hot, in the mid 70s. I reverse-engineered the density altitude as 1,873 feet — not hugely impactful, but enough to double the field elevation.

But it’s pretty clear that, no matter what takeoff distance he needed, and how the density altitude and tailwind affected that, he needed a lot more runway than he had.

Granted, his instruction was spotty and protracted, but every training flight starts with a takeoff. How was it that the student seemed to have been clueless about the effect of wind on takeoff operations?

The Takeaway

It’s the seat belt. That’s what stands out to me as the main takeaway. Not the meth, not the pot, not the illegal flying.

Because I would like to believe that there aren’t too many stoned uncertified folks sharing the sky with me. Yeah, I know that there are some, but I doubt they read this column, and if they did, I doubt anything I could write would change their behavior.

But a recommitment to everything to do with seat belts is a nice all-pilot takeaway from this travesty. Make sure you always take time to put yours on, put it on right, and keep the damn thing on.

And that goes for your passengers too. If you’ve got passengers who don’t want to wear seat belts, have them find a ride with someone else.

And when did you last give your seat belts a really good inspection? Granted, this guy didn’t use his at all, but a worn-out belt might as well be a non-worn belt, if you know what I mean.

A second takeaway, and we’ve talked about this before, is the responsibility of CFIs.

In this case the CFI was “very concerned” that the pilot was going to fly without additional instruction, which he did, and died doing it.

Having that concern, what should the instructor have done?

And speaking of the CFI, why did he give 20 hours of dual to someone without a student pilot certificate?

Sure, it’s not required before solo, but it’s not like they expire anymore, so why delay having a student get one?

Or if the student refused, shouldn’t that be a red flag for the instructor?

Did the student ever plan to finish training? Or was his plan to just get to solo and figure he was good to go?

The Numbers

Want to read more? Download the NTSB’s final report (CEN22FA016) here or view the items on docket here.