# NTSB ERA14LA005: Aerotek Pitts S 1T, N53CG, Punta Gorda, FL, October 19, 2013 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: October 19, 2013, 11:57 local (15:57 UTC) - Place: Punta Gorda, FL - Coordinates: 26.918888, -81.990837 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.9189&lon=-81.9908&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report February 4, 2015 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA - NTSB case key (mKey): 88243 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14LA005 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88243/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88243 - Page: https://openairdocs.org/ntsb/ERA14LA005 ## Probable cause The pilot’s loss of directional control during landing. Contributing to the accident was the pilot’s decision to operate the airplane with known ergonomic restrictions due to his size. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Aerotek PITTS S-1T, 2 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=0110303), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Aerotek PITTS S-1T, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=0110303), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Aerotek PITTS S-1T, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=0110303), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Physical characteristic: size](https://openairdocs.org/ntsb-findings/02011010): Personnel issues › Physical · Pilot (probable cause); cases with it: [Aerotek PITTS S-1T, 1 case](https://openairdocs.org/ntsb-findings/02011010/cases.md?model=0110303), [All aircraft, 3 cases](https://openairdocs.org/ntsb-findings/02011010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Aerotek PITTS S-1T, 2 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=0110303), [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: [Aerotek PITTS S-1T, 1 case](https://openairdocs.org/ntsb-events/300/sequence.md?model=0110303), [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: [Aerotek PITTS S-1T, 2 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=0110303), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The pilot/owner reported that he conducted a "normal" three-point landing on the runway centerline with a normal roll in the tailwheel-equipped airplane. While decelerating through 50 mph, the airplane "began to jerk to the right," and the pilot corrected with a left rudder input. The airplane responded "somewhat," but it continued to veer right. The pilot applied full power and full-aft control stick input to abort the landing, but the airplane departed the runway to the right and nosed over, which resulted in substantial damage to the engine compartment, cockpit, and vertical fin structures. The pilot was concerned that the airplane had sustained a structural failure in the area that surrounded the attachment point for the right main landing gear because it had been repaired and modified after the airplane experienced a similar loss of directional control event about 1 year previously. Therefore, he requested a detailed examination of the modifications, welding, and landing gear installation conducted during the previous repair. The examination of the welds revealed that they were intact, and no anomalies were noted. All of the damage to the landing gear system was due to overstress. In a written statement following the previous event, the pilot stated that the loss of directional control resulted from the length of his legs, the geometry of his size-13 shoe and the rudder pedals, and the confined space that enclosed them. He attempted to alleviate the issue by changing his footwear, but his alternate choice of footwear only aggravated the rudder control problem. He stated that the application of left rudder resulted in the inadvertent application of right brake and the subsequent loss of directional control. ## Factual narrative On October 19, 2013, at 1157 eastern daylight time, an Aerotek Pitts S-1T, N53CG, was substantially damaged during a runway excursion and nose-over event while landing at Punta Gorda Airport (PGD), Punta Gorda, Florida. The airline transport pilot/owner was not injured. Visual meteorological conditions prevailed, and no flight plan was filed for the local personal flight, which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. According to the pilot, he conducted a "normal" three-point landing on the runway centerline with a "normal" rollout. While decelerating through 50 mph, the airplane "began to jerk to the right" and the pilot corrected with left rudder input. The airplane responded "somewhat," but continued to the right. The pilot stated that he applied full power and a full aft control stick to abort the landing. The airplane departed the runway to the right, "refused to respond" to the control inputs, and eventually "plowed" into the grass and nosed over. An air traffic controller witnessed the accident from the airport tower, and was interviewed by telephone. She stated the airplane was cleared to land, and she watched as it approached the runway. According to the controller, "It was not a normal landing. It went side to side. It went down on one wheel, then over to the other, then [the airplane] went off the right side of the runway. It went off to the right, and that's where it flipped over." The controller stated that she had watched the pilot perform numerous landings in the past. She said he flies another airplane and "greases" the landings. She went on to say that the landings she witnessed by the pilot in the Pitts got her attention because they were unsteady and inconsistent, and unlike the landings he performed in his other airplane. The pilot/owner held an airline transport pilot certificate with a rating for airplane multi-engine land, and a commercial pilot certificate with ratings for airplane single engine land and instrument airplane. His most recent Federal Aviation Administration (FAA) third-class medical certificate was issued on March 5, 2013. He reported 25,000 total hours of flight experience, of which, 10 hours were in the accident airplane make and model. According to FAA records, the airplane was manufactured in 1982, and its most recent airworthiness certificate was issued to the pilot/owner March 11, 2013. The airplane's most recent annual inspection was completed February 8, 2013, at 1,050 aircraft hours. The wreckage and the accident site were examined by an FAA aviation safety inspector (airworthiness). According to the inspector, the marks on the left tire assembly, the runway, and the left main landing gear were consistent with a left side-load at touchdown, and overstress of the landing gear. Examination of photographs revealed substantial damage to the engine compartment, cockpit, and vertical fin structures. At 0914, the weather conditions reported at PGD included fewclouds at 3,000 feet, a broken ceiling at 10,000 feet, winds from 190 at 4 knots, and 10 miles visibility. The temperature was 31 degrees C, dew point 22 degrees C, and the altimeter setting was 29.97 inches of mercury. ADDITIONAL INFORMATION The pilot expressed his concern that the airplane had suffered a structural failure in the area which surrounded the attach point for the right main landing gear, and requested a second inspection of his airplane. This area had been repaired and modified after the pilot experienced a similar event in the accident airplane approximately 1 year previously. Therefore, a detailed examination of the airplane was performed by an airframe and powerplant mechanic under the supervision of the FAA aviation safety inspector. During the previous repair, the original 48-inch-wide main landing gear system was replaced with a new 62-inch-wide system. Welding of structural tubes was required to affect the installation, but inspection of the welds revealed they were intact, with no anomalies noted. All damage to the landing gear system was due to overstress. In a written statement following the previous event, the pilot stated the loss of directional control resulted from the length of his legs, the geometry of his size-13 shoe, the rudder pedals, and the confined space that enclosed them. He attempted to alleviate the issue with a change of footwear, but his choice of footwear only aggravated the rudder control problem. He stated that application of left rudder resulted in the inadvertent application of right brake, and the subsequent loss of directional control. ## Aircraft - Registration: [N53CG](https://openairdocs.org/deregistered/N53CG-2014-01-10), registration cancelled 2014-01-10, S/N 1007 (OpenAirDocs) - Reported make and model: AEROTEK PITTS S 1T - Registry model: [Aerotek PITTS S-1T](https://openairdocs.org/model/aerotek-pitts-s-1t) (registry code 0110303) (OpenAirDocs) - Registry engine: [Lycoming AEIO-360 series](https://openairdocs.org/engine/lycoming-aeio-360-series) (registry code 41522, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1007 - Year built: 1982 - Airframe hours: 1050 - Engines: Lycoming IO-360A1F6 190 hp reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Annual, February 8, 2013, 22 hours before - Departed: PGD, Punta Gorda, FL - Destination: PGD, Punta Gorda, FL - Airport: PGD, Punta Gorda, runway 15, 5,688 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 64; injuries: none; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review March 8, 2013; seat: single; restraint: 4-point; flight hours: 25,000 total, 10 in this make and model, 12,000 as pilot in command, 13 in the last 90 days, 13 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: 10,000 ft broken - Temperature: 88 °F, dew point 72 °F - Altimeter: 29.96 inHg - Observed at: PGD ## 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 20131019021879A](https://openairdocs.org/incident/20131019021879A), Oct 19, 2013: Aerotek PITTS S-1T, Punta Gorda, FL, Substantial damage. On October 19, 2013, at approximately 1153 EDT, an Aerotek pitts S1-T, N53CG, serial no. 1007, veered off the runway during roll-out, flipped upside down after… ## Docket (10 files) The files NTSB released with the investigation on December 30, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88243. 12.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420408&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot Statement (item 2, .PDF, 306 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420409&FileExtension=.PDF&FileName=Pilot%20Statement-Redacted.PDF - Memorandum for Record Phone Interview with Pilot (item 3, .PDF, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420410&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20Phone%20Interview%20with%20Pilot-Master.PDF - FAA Inspector's Statement (item 4, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420411&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Redacted.PDF - Pilot Statement & Photos(Previous Event) (item 5, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420412&FileExtension=.PDF&FileName=Pilot%20Statement%20%26%20Photos(Previous%20Event)-Redacted.PDF - Record of Conversation- Air Traffic Controller (item 6, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420413&FileExtension=.PDF&FileName=Record%20of%20Conversation-%20Air%20Traffic%20Controller-Master.PDF - Memorandum for Record PGD Weather (item 7, .PDF, 152 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420414&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20PGD%20Weather-Master.PDF - Photo 1 - View of Skid Marks on Runway (FAA) (item 8, .PDF, 4.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420415&FileExtension=.PDF&FileName=Photo%201%20-%20View%20of%20Skid%20Marks%20on%20Runway%20(FAA)-Master.PDF - Photo 2 - View of Airplane as Found (FAA) (item 9, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420416&FileExtension=.PDF&FileName=Photo%202%20-%20View%20of%20Airplane%20as%20Found%20(FAA)-Master.PDF - Photo 3 - View of Damage to Airplane (item 10, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420417&FileExtension=.PDF&FileName=Photo%203%20-%20View%20of%20Damage%20to%20Airplane-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.