# NTSB CEN09LA263: Laseure Sonerai II, N232PE, Grantsburg, WI, April 22, 2009 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: April 22, 2009, 14:00 local (19:00 UTC) - Place: Grantsburg, WI - Coordinates: 45.683887, -92.686943 - Nearby events: https://openairdocs.org/map.md?lat=45.6839&lon=-92.6869&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report April 22, 2010 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA Minneapolis FSDO - NTSB case key (mKey): 73716 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN09LA263 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73716/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73716 - Page: https://openairdocs.org/ntsb/CEN09LA263 ## Probable cause The pilot's failure to maintain airspeed during initial climb which resulted in a stall/spin. Contributing to the accident was the degraded engine performance. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Laseure Edward Joseph SONERAI TWO, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=05659G9), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Health/Fitness: use of medication/drugs](https://openairdocs.org/ntsb-findings/02013020): Personnel issues › Physical · Pilot; cases with it: [Laseure Edward Joseph SONERAI TWO, 1 case](https://openairdocs.org/ntsb-findings/02013020/cases.md?model=05659G9), [All aircraft, 73 cases](https://openairdocs.org/ntsb-findings/02013020/cases.md) - [Alertness/Fatigue](https://openairdocs.org/ntsb-findings/02013500): Personnel issues › Physical · Pilot; cases with it: [Laseure Edward Joseph SONERAI TWO, 1 case](https://openairdocs.org/ntsb-findings/02013500/cases.md?model=05659G9), [All aircraft, 48 cases](https://openairdocs.org/ntsb-findings/02013500/cases.md) - [Power plant](https://openairdocs.org/ntsb-findings/01057100): Aircraft › Aircraft power plant · Damaged/degraded (probable cause); cases with it: [Laseure Edward Joseph SONERAI TWO, 1 case](https://openairdocs.org/ntsb-findings/01057100/cases.md?model=05659G9), [All aircraft, 198 cases](https://openairdocs.org/ntsb-findings/01057100/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Laseure Edward Joseph SONERAI TWO, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05659G9), [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. - [Takeoff: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [Laseure Edward Joseph SONERAI TWO, 1 case](https://openairdocs.org/ntsb-events/342/sequence.md?model=05659G9), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Laseure Edward Joseph SONERAI TWO, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=05659G9), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Laseure Edward Joseph SONERAI TWO, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05659G9), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The accident flight was the pilot’s first flight in the amateur-built, experimental airplane he had purchased about 7 months prior to the accident. A witness reported that the pilot was taxiing up and down the runway while revving the engine. The witness stated that the engine was missing on at least one cylinder during takeoff. He stated that the airplane climbed and made a left turn directly over his house, clearing it by about 80 feet. While in the turn, the wings dipped to the right, and then the wings dipped to the left “real hard.” The airplane rolled inverted and went down nose first. A Federal Aviation Administration airworthiness inspector examined the wreckage at the accident site. The inspection of the airplane revealed flight control continuity.The engine was a Continental O-200 series engine, but the engine data plate was missing so the exact model and serial number could not be identified. The mechanical and electrical engine controls were present. The magneto P-lead wires were still attached to the ignition switch and magnetos. There was oil in the engine and the crankshaft could rotate but not “very far.” The pilot had a history of depression, anxiety, and sleep apnea, and had been prescribed multiple medications for the conditions. The level of a prescription antidepressant found on post-accident toxicology was more than 10 times higher than expected given the pilot's prescription for the medication. He had broken his left ankle, and had surgical screws placed for the non-healing fracture a week prior to the accident. He had recently taken narcotic and over-the-counter pain medications. The pilot had not reported any of his chronic health problems to the FAA, and it is unlikely that the FAA would have approved medical certification for him had complete information been provided. ## Factual narrative On April 22, 2009, at 1400 central daylight time, an amateur-built experimental Laseure Sonerai II, N232PE, was destroyed by collision with the terrain and a post impact fire after takeoff from the Circle T private airstrip (WS77), near Grantsburg, Wisconsin. The private pilot, the sole occupant, received fatal injuries. The 14 Code of Federal Regulations Part 91 personal flight was departing from WS77 on a local flight at the time of the accident. Visual meteorological conditions prevailed at the time of the accident, and no flight plan was filed. A witness reported that the he heard the pilot “throttling” or revving the airplane’s engine to high RPM’s prior to takeoff. The witness stated that the engine sounded like it was missing on two of the four cylinders initially, and then it sounded like the third cylinder “kicked in” while the pilot was taxiing the airplane. He stated, “It sounded like the engine had a stuck valve and was not running right.” He heard the airplane taxiing up and down the runway numerous times. He stated that it sounded like three of the four cylinders were working when the airplane departed to the west. The airplane lifted off the ground and made a left turn directly over his house, clearing it by 80 feet. He stated that the pilot would normally fly straight past his house for another 300 – 500 yards before starting a turn. He stated that while the airplane was still in the left turn, the airplane’s wings dipped to the right, and then the wings dipped to the left “real hard.” The airplane rolled inverted so that the witness could see the airplane’s cockpit, and then it went down nose first. The airplane impacted the terrain in a wooded area. A ground fire ensued and much of the airplane wreckage was consumed by fire. The top branches of trees next to the initial impact site were found broken and lying next to the wreckage. The fabric over the entire fuselage was consumed by fire exposing the airframe’s metal tubing. The outboard half of the left wing was bent aft and up, and was charred by fire. The leading edge of the inboard half of the left wing was separated from the wing spar which was bent aft. The right wing was largely intact except for the aft crushing and buckling of the leading edge on the outboard half of the wing. The right wing remained attached to the fuselage and was not consumed by fire. The engine compartment was consumed by fire and the engine was separated from the engine mounts. The cockpit was consumed by fire. The metal tubing of the empennage was largely intact with no apparent damage to the horizontal or vertical stabilizer. A Federal Aviation Administration (FAA) airworthiness inspector examined the wreckage at the accident site. The inspection revealed that the engine was a Continental O-200 series engine, but the engine data plate was missing so the exact model and serial number could not be identified. The mechanical and electrical engine controls were present. The magneto P-lead wires werestill attached to the ignition switch and magnetos. There was oil in the engine and the crankshaft could rotate but not “very far.” The carburetor box was intact. All four upper spark plugs were automotive Auto-lite spark plugs and were set at different gaps. The magneto leads were all modified to slip onto automotive style spark plug tips. The carburetor mixture control was safety wired to the full rich position and no adjustment to the mixture was possible. All spark plugs were moist with the smell of fuel and the color was consistent with burning a fuel rich mixture. The wooden propeller was destroyed during the impact and ground fire. The rudder, elevator, aileron, and elevator trim controls exhibited continuity. All control surfaces were still attached to the airplane. The airplane’s airframe and engine logbooks were not recovered during the course of the investigation. FAA records indicated that the airplane was manufactured in 1979 as a two seat airplane originally equipped with a Volkswagen engine. The pilot purchased the airplane and it was registered in his name on September 13, 2008. According to a witness, the accident flight was the pilot’s first flight in the airplane. The 48-year-old pilot held a private pilot’s certificate with a single-engine land rating which was issued on February 12, 2004. He held a third-class medical certificate that was issued on March 6, 2008. He completed a flight review on March 6, 2008. The last entry in the pilot’s logbook was dated August 28, 2008. The pilot’s total flight time was about 402 hours. The Circle T private airstrip (WS77) was owned by the pilot and located on his property. National Transportation Safety Board (NTSB) records indicated that the pilot had two prior airplane accidents. The first accident was on February 6, 2008, at WS77. He was the pilot in command of an American Aviation AA-1A airplane that veered off the side of the runway when the left brake seized due to a buildup of ice between the rotor and brake pad. The NTSB accident number for that occurrence was CHI08CA076. The second accident occurred on July 21, 2008. The pilot was the pilot in command of an American Aviation AA-1A airplane that had an engine failure during takeoff from WS77. The airplane sustained substantial damage and the pilot received minor injuries during that accident. The NTSB accident number for that occurrence was CHI08CA226. An autopsy was conducted on April 23, 2009, at the Midwest Medical Examiner’s Office, in Ramsey, Minnesota. The autopsy stated, “The death could be classified as an accident and attributed to thermal injuries due to an airplane crash.” A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aeromedical Institute. The results were negative for cyanide, ethanol, and carbon monoxide. The report indicated the following: Citalopram detected in urine. 1.164 (ug/ml, ug/g) Citalopram detected in blood. Dihydrocodeine NOT detected in blood. 0.016 (ug/ml, ug/g)Dihydrocodeine detected in urine. Di-N-desmethylcitalopram detected in urine. 0.014 (ug/ml, ug/g) Di-N-desmethylcitalopram detected in blood. 0.025 (ug/ml, ug/g) Diphenhydramine detected in blood. Diphenhydramine detected in urine. 0.068 (ug/ml, ug/g) Hydrocodone detected in urine. Hydrocodone NOT detected in blood. Hydromorphone NOT detected in blood. 0.011 (ug/ml, ug/g) Hydromorphone detected in urine. Naproxen detected in urine. N-Desmethylcitalopram detected in urine. 0.33 (ug/ml, ug/g) N-Desmethylcitalopram detected in blood. Quetiapine (ug/ml, ug/g) detected in Urine. 0.112 (ug/ml, ug/g) Quetiapine detected in blood. Zolpidem detected in urine. 0.023 (ug/ml, ug/g) Zolpidem detected in blood. The NTSB Medical Officer reviewed the pilot’s medical records maintained by the FAA Aerospace Medical Certification Division and the pilot’s personal records obtained by subpoena. The pilot’s most recent application for a Third class Airman Medical Certificate on March 6, 2008, indicated a “No” in response to “Do You Currently Use Any Medication” and to all items under “Medical History,” including specifically “Mental disorders of any sort; depression, anxiety, etc.” and “Admissions to hospital.” Under “Visits to a Health Professional Within Last 3 Years” it noted only a single visit in 2007 for “flu.” The pilot’s medical records indicated that he was diagnosed with sleep apnea which required the use of a Continuous Positive Airway Pressure (CPAP) machine, and had a history of depression and panic attacks. Although he had major surgery for sleep apnea prior to June 2008, he indicated that he still had sleeping problems in December 2008. He reported thumb pain as a result of an aviation accident and had surgery on his thumb in February 2009. On February 6, 2009, he fractured his ankle and had surgery on April 15, 2009, (one week prior to the fatal accident) which required using two screws. The medications prescribed on April 13, 2009, included: Lexapro, Lorazepam, Seroquel, and Zolpidem. ## Aircraft - Registration: [N232PE](https://openairdocs.org/deregistered/N232PE-2013-06-07), registration cancelled 2013-06-07, S/N 406, built 1979 (OpenAirDocs) - Reported make and model: Laseure Sonerai II - Registry model: [Laseure Edward Joseph SONERAI TWO](https://openairdocs.org/model/laseure-edward-joseph-sonerai-two) (registry code 05659G9) (OpenAirDocs) - Registry engine: [Volkswagen CONVERSION](https://openairdocs.org/engine/volkswagen-conversion) (registry code 63501, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 406 - Engines: Continental O-200 reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Michael Shute - Registered owner: Michael Shute - Airworthiness certificate: Special, Experimental light sport (Special) - Departed: WS77, Grantsburg, WI - Destination: WS77, Grantsburg, WI - Airport: WS77, Circle T Airport, runway 27, 2,115 × 96 ft, grass/turf ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: center; toxicology performed; flight hours: 402 total, 0 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 290° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: 2,600 ft overcast - Temperature: 57 °F, dew point 18 °F - Altimeter: 29.90 inHg - Observed at: MSP, 60 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 20090422011279A](https://openairdocs.org/incident/20090422011279A), Apr 22, 2009: Amtr SONERAI2, Grantsburg, WI, Destroyed, 1 fatal. After takeoff the pilot made a left turn in a sonerai 2 airplane and crashed in a wooded area south of circle t, a private airstrip south of Grantsburg, WI. ## Docket (19 files) The files NTSB released with the investigation on December 14, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73716. 32.2 MB in all. - Record of Interviews (item 1, .PDF, 121 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321941&FileExtension=.PDF&FileName=Record%20of%20Interviews-Master.PDF - Pilot's Logbook (item 2, .PDF, 15.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321943&FileExtension=.PDF&FileName=Pilot%27s%20Logbook-Master.PDF - Circle T Airport Information (item 3, .PDF, 171 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322095&FileExtension=.PDF&FileName=Circle%20T%20Airport%20Information-Master.PDF - Aircraft Registration (item 4, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321945&FileExtension=.PDF&FileName=Aircraft%20Registration-Master.PDF - Medical Records Information (item 5, .PDF, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320030&FileExtension=.PDF&FileName=Medical%20Records%20Information-Master.PDF - Toxicological Report (item 6, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321947&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Photo 1. View of Broken Tree Branches (item 7, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321949&FileExtension=.PDF&FileName=Photo%201.%20%20View%20of%20Broken%20Tree%20Branches-Master.PDF - Photo 2. View From Left Front of Aircraft (item 8, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321950&FileExtension=.PDF&FileName=Photo%202.%20%20View%20From%20Left%20Front%20of%20Aircraft-Master.PDF - Photo 3. Left Landing Gear and Left Wing (item 9, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321951&FileExtension=.PDF&FileName=Photo%203.%20%20Left%20Landing%20Gear%20and%20Left%20Wing-Master.PDF - Photo 4. Left Side of Fuselage and Empennage (item 10, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321952&FileExtension=.PDF&FileName=Photo%204.%20%20Left%20Side%20of%20Fuselage%20and%20Empennage-Master.PDF - Photo 5. Right Wing (item 11, .PDF, 874 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321955&FileExtension=.PDF&FileName=Photo%205.%20%20Right%20Wing-Master.PDF - Photo 6. Nose of Aircraft (item 12, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321956&FileExtension=.PDF&FileName=Photo%206.%20%20Nose%20of%20Aircraft-Master.PDF - Photo 7. Cockpit Area (item 13, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321957&FileExtension=.PDF&FileName=Photo%207.%20%20Cockpit%20Area-Master.PDF - Photo 8. Empennage (item 14, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321958&FileExtension=.PDF&FileName=Photo%208.%20%20Empennage-Master.PDF - Photo 9. Empennage (item 15, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321962&FileExtension=.PDF&FileName=Photo%209.%20%20Empennage-Master.PDF - Photo 10. Left Wing (item 16, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321963&FileExtension=.PDF&FileName=Photo%2010.%20%20Left%20Wing-Master.PDF - Photo 11. Cockpit Area (item 17, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321965&FileExtension=.PDF&FileName=Photo%2011.%20%20Cockpit%20Area-Master.PDF - Photo 12. Magnetos (item 18, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321969&FileExtension=.PDF&FileName=Photo%2012.%20%20Magnetos-Master.PDF - Photo 13. Engine (item 19, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321970&FileExtension=.PDF&FileName=Photo%2013.%20%20Engine-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.