CEN22LA302

NTSB accident investigation · Pitts S1 · Sturgeon Bay, WI · July 1, 2022

Accident · Minor injuriesClass 4 · LimitedFinal report
Date
July 1, 2022, 15:00 local (20:00 UTC)
Place
Sturgeon Bay, WI · Runway 2 at SUE
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N23RSPitts S1
Defining event
Landing-flare/touchdown: Loss of control on ground
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 4 - Basic report with no Prelim publish
NTSB office
Central Region
Parties
FAA Milwaukee FSDO
FAA report
20220701011549A
Case key
105416

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

On this page

Probable cause

The pilot’s failure to maintain airplane control during landing, which resulted in a runway excursion and nose over. Contributing to the accident was the pilot’s inadequate preflight inspection and the pilot’s lack of flight control system knowledge.

Findings · 5

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.

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

The pilot reported that during landing touchdown with all three wheels “down,” and the airplane “tracking fine,” he removed his feet from the lower rudder pedal bars to apply braking via the upper braking pedal bars. The pedals then fell rearward toward the pilot and his right foot got wedged between the lower rudder pedal bar and the upper braking pedal bar. The pilot reported this action caught him by surprise and he applied “heavy” right rudder, thinking it was braking application. The airplane departed the right side of the runway, nosed over, and came to rest inverted in the grass next to the runway. The airplane sustained substantial damage to the top right wing and the empennage. The pilot reported there were no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation. The pilot reported that he had recently purchased the airplane and did not know that the rudder pedal return springs were not installed. The investigation revealed that the airplane was previously modified for aerobatic competition with the addition of a large rudder and that due to cockpit spacing limitations, the rudder pedal return springs could not be installed. The pilot concluded that the accident could have been prevented by performing a “very thorough” inspection and understanding all the modifications made to the airplane before flying it.

Aircraft

Registration
N23RS
Reported as
Pitts S1 (S)
Category
Airplane, amateur-built
Serial number
8-0035
Built
1981
Airframe hours
608
Engine
Lycoming Engines IO-360 Series, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Annual · June 1, 2022
Departed
UNU · Juneau, WI
Destination
Same as departure
Airport
SUE · Door County Cherryland, runway 02, 4,000 × 75 ft, concrete
Equipment
Handheld GPS

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
73
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
March 17, 2022
Seat
Single
Restraint
5-point
Flight hours
2,500 total · 50 in this make and model · 2,500 as pilot in command · 3 in the last 90 days · 2 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 8 knots, gusting 14
Visibility
10 statute miles
Lowest ceiling
None
Temperature
72 °F, dew point 52 °F
Altimeter
29.95 inHg
Observed at
KSUE, 1 nm away
METAR
KSUE 011956Z AUTO 17008G14KT 120V180 10SM CLR 22/11 A2995 RMK AO2 SLP140 T02170106

Docket · 3

The files NTSB released with the investigation on August 5, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.6 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.