Pilot Debrief

LEE PAUL SQ 2000 near Pierre, SD — 2012-08-28

Final reportCEN12FA579
Sign in to save
Date
2012-08-28
Location
Pierre, SD, USA
Airport
KPIR
Aircraft
LEE PAUL SQ 2000
Registration
N416
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

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.

Contributing factors

Contributing to the accident was the left entrance door opening in flight for undetermined reasons.

NTSB narrative

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.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have ensured doors were secured before takeoff.

NTSB coding

Evidence available

  • Photos
  • 10 docket documents
View NTSB final reportView NTSB docket

Docket documents10

Related mishaps