# NTSB CEN22LA302: Pitts S1, N23RS, Sturgeon Bay, WI, July 1, 2022 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 4 · Limited · Final report - Date: July 1, 2022, 15:00 local (20:00 UTC) - Place: Sturgeon Bay, WI · Runway 2 at SUE. - Coordinates: 44.837454, -87.424599 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.8375&lon=-87.4246&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-flare/touchdown: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: Minor injuries - Injuries: 1 minor - 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 - NTSB case key (mKey): 105416 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN22LA302 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105416/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105416 - Page: https://openairdocs.org/ntsb/CEN22LA302 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Siwik Ronald A PITTS SPECIAL S-1, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=7220789), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Siwik Ronald A PITTS SPECIAL S-1, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7220789), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Flight control system: rudder control system](https://openairdocs.org/ntsb-findings/01022720): Aircraft › Aircraft systems · Inadequate inspection (probable cause); cases with it: [Siwik Ronald A PITTS SPECIAL S-1, 1 case](https://openairdocs.org/ntsb-findings/01022720/cases.md?model=7220789), [All aircraft, 93 cases](https://openairdocs.org/ntsb-findings/01022720/cases.md) - [Knowledge: knowledge of equipment](https://openairdocs.org/ntsb-findings/02032015): Personnel issues › Experience/knowledge · Pilot (probable cause); cases with it: [Siwik Ronald A PITTS SPECIAL S-1, 1 case](https://openairdocs.org/ntsb-findings/02032015/cases.md?model=7220789), [All aircraft, 69 cases](https://openairdocs.org/ntsb-findings/02032015/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Siwik Ronald A PITTS SPECIAL S-1, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=7220789), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Siwik Ronald A PITTS SPECIAL S-1, 1 case](https://openairdocs.org/ntsb-events/030/sequence.md?model=7220789), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Landing-flare/touchdown: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Siwik Ronald A PITTS SPECIAL S-1, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=7220789), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Landing-flare/touchdown: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Siwik Ronald A PITTS SPECIAL S-1, 1 case](https://openairdocs.org/ntsb-events/230/sequence.md?model=7220789), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Siwik Ronald A PITTS SPECIAL S-1, 1 case](https://openairdocs.org/ntsb-events/300/sequence.md?model=7220789), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Siwik Ronald A PITTS SPECIAL S-1, 1 case](https://openairdocs.org/ntsb-events/096/sequence.md?model=7220789), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## 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](https://openairdocs.org/aircraft/N23RS), registered now, S/N 8-0035, built 1981 (OpenAirDocs) - Reported make and model: PITTS S1 (S) - Registry model: [Siwik Ronald A PITTS SPECIAL S-1](https://openairdocs.org/model/siwik-ronald-a-pitts-special-s-1) (registry code 7220789) (OpenAirDocs) - Registry engine: [Lycoming AEIO-360 series](https://openairdocs.org/engine/lycoming-aeio-360-series) (registry code 41522, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 8-0035 - Year built: 1981 - Airframe hours: 608 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 73; injuries: minor; 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 ## 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 20220701011549A](https://openairdocs.org/incident/20220701011549A), Jul 1, 2022: Siwik Ronald A PITTS SPECIAL S-1, Sturgeon Bay, WI, Substantial damage. On July 01, 2022, N23RS, a pitts special S1 aircraft landed on runway 02 at Sturgeon Bay airport(ksue). During roll out, [privacy data omitted] veered off the… ## Docket (3 files) The files NTSB released with the investigation on August 5, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105416. 5.6 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14221467&FileExtension=pdf&FileName=NTSB%20Form%206120_1%20Redacted-Rel.pdf - Accident photographs (item 2, PDF, 4 pages, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14221574&FileExtension=pdf&FileName=Accident%20Photographs-Rel.pdf - Additional statements (item 3, PDF, 2 pages, 236 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14221208&FileExtension=pdf&FileName=Additional%20Statements%20Redacted-Rel.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.