CEN12FA579

NTSB accident investigation · Lee Paul SQ 2000 · Pierre, SD · August 28, 2012

Accident · FatalField investigationFinal report
Date
August 28, 2012, 09:49 local (14:49 UTC)
Place
Pierre, SD
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N416Lee Paul SQ 2000
Defining event
Initial climb: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report February 27, 2013
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA FSDO
FAA report
20120828019289A
Case key
84829

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

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Probable cause

The airplane's entry into a pilot-induced oscillation and the pilot’s loss of airplane control during the takeoff initial climb. Contributing to the accident was the left entrance door opening in flight for undetermined reasons.

Findings · 3

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotLee Paul SQ 2000: 1 caseAll aircraft: 9,295 casesProbable cause
Performance/control parameters: pitch controlAircraft › Aircraft oper/perf/capability · Incorrect use/operationLee Paul SQ 2000: 1 caseAll aircraft: 526 casesProbable cause
Doors: passenger/crew doorsAircraft › Aircraft structures · Unintentional use/operationLee Paul SQ 2000: 1 caseAll aircraft: 86 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

During the airplane’s initial takeoff climb, two ground witnesses observed the left “gull-wing” entrance door to be open. They reported that when the airplane was about 50 feet above the ground, it entered a series of approximately four pitch oscillations. During the last pitch-down oscillation, the airplane impacted the runway at a steep descent angle and then skidded forward about 500 feet, coming to a stop near the right side of the runway. A postimpact fire ensued. Examination of the airframe, engine, propeller and the door did not reveal any anomalies associated with a preimpact failure or malfunction.

Factual narrative

HISTORY OF FLIGHT On August 28, 2012, about 0949 central daylight time, a Lee SQ-2000 experimental airplane, N416, owned and operated by the pilot, was substantially damaged during takeoff from Pierre Regional Airport (KPIR), Pierre, South Dakota. The certificated private pilot was fatally injured. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed during the flight. No flight plan was filed. The local flight was originating at the time of the accident. On takeoff leg at about 50 feet above the ground, two witnesses observed the left “gull-wing” entrance door to be open and the airplane enter into a series of four up and down pitch oscillations. During the last pitch down oscillation, the airplane impacted the runway at a steep descent angle. PERSONNEL INFORMATION The pilot of N416, age 69, held a private pilot certificate with an airplane single-engine land rating. On October 5, 2011, the pilot was issued a limited third-class medical certificate, with the limitation that corrective lenses be worn while flying. At the time of the medical examination, the pilot reported having 330 hours of flight experience, with 2 hours in the last six months. AIRCRAFT INFORMATION The accident airplane was a KLS Composites (Kit), SQ-2000, which the pilot purchased on December 25, 2001. The airplane was issued a special airworthiness certificate on March 18, 2004. During April 2012, the pilot completed the installation of a Continental IO-360C engine. The pilot maintained detailed construction records of the accident airplane, to include construction of the “gull-wing” entrance doors. In these records, the pilot wrote that during flight it was very easy to open the doors and had constructed a door lock “clip” to prevent inadvertent opening of the entrance door closing mechanism. In these records, the pilot also described the aircraft being very pitch sensitive. METEOROLOGICAL INFORMATION At 0953, the KPIR automated weather observation system reported the following weather conditions: Wind 090 degrees at 8 knots; sky clear; temperature 27 degrees Celsius (C); dew point 17 degrees C; altimeter setting 29.93 inches of mercury. WRECKAGE AND IMPACT INFORMATION Following impact with the runway, the airplane slid to a stop on the edge of the runway and a postimpact fire ensued. The distance from initial runway impact to the main wreckage location was about 500 feet. During examination, the engine crankshaft was rotated and a compression check was confirmed on all cylinders. Propeller impact with the runway resulted in the shredding of over half of the propeller’s diameter. Flight control surfaces were accounted for, although flight control continuity could not be confirmed due to impact and fire damage. Examination of the airframe, engine and propeller did not reveal any anomalies associated with a preimpact failure or malfunction. Both “gull-wing” entrance doors separated fromthe airplane during the impact sequence and were not fire damaged. Examination of the left entrance “gull-wing” door revealed a witness mark corresponding to the door closing mechanism in a “partially closed” position. Extensive fire damage of the fuselage surrounding the left entrance door prevented further analysis of door failure. MEDICAL AND PATHOLOGICAL INFORMATION On August 30, 2012, an autopsy was performed on the pilot at the Rapid City, South Dakota Regional Hospital. The cause of death was attributed to blunt force injuries. The FAA's Civil Aeromedical Institute in Oklahoma City, Oklahoma, performed toxicology tests on the pilot. No carbon monoxide, cyanide, or drugs were detected in the blood, and no ethanol was detected in vitreous.

Aircraft

Registration
N416
Reported as
Lee Paul SQ 2000
Category
Airplane, amateur-built
Serial number
0007
Engine
Continental IO-360, 210 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Departed
KPIR · Pierre, SD
Destination
KPIR · Pierre, SD
Airport
KPIR · Pierre Regional Airport, runway 13, 6,900 × 100 ft, asphalt

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
69
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
346 total · 4 in the last 90 days · 4 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
90° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 63 °F
Altimeter
29.93 inHg
Observed at
KPIR

Docket · 10

The files NTSB released with the investigation on January 16, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.2 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 N416 · 1

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