# NTSB CEN12FA579: Lee Paul SQ 2000, N416, Pierre, SD, August 28, 2012 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: August 28, 2012, 09:49 local (14:49 UTC) - Place: Pierre, SD - Coordinates: 44.37611, -100.284721 - Nearby events: https://openairdocs.org/map.md?lat=44.3761&lon=-100.2847&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report February 27, 2013 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA FSDO - NTSB case key (mKey): 84829 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN12FA579 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/84829/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=84829 - Page: https://openairdocs.org/ntsb/CEN12FA579 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Lee Paul SQ 2000, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=0561431), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: pitch control](https://openairdocs.org/ntsb-findings/01062022): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [Lee Paul SQ 2000, 1 case](https://openairdocs.org/ntsb-findings/01062022/cases.md?model=0561431), [All aircraft, 526 cases](https://openairdocs.org/ntsb-findings/01062022/cases.md) - [Doors: passenger/crew doors](https://openairdocs.org/ntsb-findings/01035210): Aircraft › Aircraft structures · Unintentional use/operation (probable cause); cases with it: [Lee Paul SQ 2000, 1 case](https://openairdocs.org/ntsb-findings/01035210/cases.md?model=0561431), [All aircraft, 86 cases](https://openairdocs.org/ntsb-findings/01035210/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Lee Paul SQ 2000, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=0561431), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Lee Paul SQ 2000, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=0561431), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## 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](https://openairdocs.org/deregistered/N416-2013-11-20), registration cancelled 2013-11-20, S/N 0007 (OpenAirDocs) - Reported make and model: LEE PAUL SQ 2000 - Registry model: [Lee Paul SQ 2000](https://openairdocs.org/model/lee-paul-sq-2000) (registry code 0561431) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 0007 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: fatal; 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 ## 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 20120828019289A](https://openairdocs.org/incident/20120828019289A), Aug 28, 2012: Lee Paul SQ 2000, Pierre, SD, Destroyed, 1 fatal. On 8/28/2012 at 09:49 CDT a experimental aircraft owned by the pilot crashed during takeoff climb out on a crf 14 part 91 pleasure flight. VMC prevailed, and… ## Other investigations on N416 (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 CHI06CA111](https://openairdocs.org/ntsb/CHI06CA111), Apr 13, 2006: Lee SQ 2000 (N416), Berrien Springs, MI, substantial damage. Probable cause: Failure of the right main landing gear assembly during landing and the pilot's subsequent inability to maintain directional control of the airplane. Contributing factors were the collapse of the left… ## Docket (10 files) The files NTSB released with the investigation on January 16, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=84829. 6.2 MB in all. - Retention / Release of Wreckage Form (item 1, .PDF, 141 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382179&FileExtension=.PDF&FileName=Retention%20%2F%20Release%20of%20Wreckage%20Form-Redacted.PDF - FAA wreckage diagram (item 2, .PDF, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382097&FileExtension=.PDF&FileName=FAA%20wreckage%20diagram-Master.PDF - Photo of airplane wreckage (item 3, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382176&FileExtension=.PDF&FileName=Photo%20of%20airplane%20wreckage-Master.PDF - Pilot description of entrance door construction (item 4, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382098&FileExtension=.PDF&FileName=Pilot%20description%20of%20entrance%20door%20construction-Master.PDF - Photo of Left Entrance Door in Open Position (item 5, .PDF, 595 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382100&FileExtension=.PDF&FileName=Photo%20of%20Left%20Entrance%20Door%20in%20Open%20Position-Master.PDF - Photo of Left Entrance Door in Closed Position (item 6, .PDF, 566 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382101&FileExtension=.PDF&FileName=Photo%20of%20Left%20Entrance%20Door%20in%20Closed%20Position-Master.PDF - Photo of Left Entrance Door in Partially Closed Position (depicts the impact mark location) (item 7, .PDF, 568 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382102&FileExtension=.PDF&FileName=Photo%20of%20Left%20Entrance%20Door%20in%20Partially%20Closed%20Position%20(depicts%20the%20impact%20mark%20location)-Master.PDF - Photo of Left Entrance Door Impact Mark (item 8, .PDF, 598 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382104&FileExtension=.PDF&FileName=Photo%20of%20Left%20Entrance%20Door%20Impact%20Mark-Master.PDF - Witness Statement (item 9, .PDF, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382171&FileExtension=.PDF&FileName=Witness%20Statement-Master.PDF - Toxicological Report (item 10, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382096&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.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.