CEN16LA221

NTSB accident investigation · Flight Design Ctsw HXB · Sealy, TX · June 15, 2016

Accident · Minor injuriesLimited investigationFinal report
Date
June 15, 2016, 14:30 local (19:30 UTC)
Place
Sealy, TX
Injuries
2 minor
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N302CTFlight Design Ctsw HXB
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report January 26, 2017
Report
Approved by Office Director
NTSB office
Central Region
Parties
Rotech Flight Safety, FAA Flight Standards District Office
FAA report
20160615010439A
Case key
93395

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

Failure of maintenance personnel to comply with the engine manufacturer’s mandatory service bulletin, which resulted in failure of the mechanical fuel pump diaphragm and a subsequent total loss of engine power.

Findings · 4

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.

Fuel system: fuel pumpsAircraft › Aircraft systems · FailureFlight Design CTSW: 1 caseAll aircraft: 71 casesProbable cause
Fuel system: fuel pumpsAircraft › Aircraft systems · Incorrect service/maintenanceFlight Design CTSW: 1 caseAll aircraft: 71 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · Maintenance personnelFlight Design CTSW: 3 casesAll aircraft: 792 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · PilotFlight Design CTSW: 3 casesAll aircraft: 792 casesProbable cause

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

During the initial climb on an instructional flight, the light sport airplane experienced a total loss of engine power. The flight instructor initiated a 180-degree turn back toward the airport; however, the airplane impacted trees to the right of the runway. Postaccident examination revealed that the mechanical fuel pump diaphragm had deteriorated and was leaking fuel. A serviceable fuel pump was installed, and the engine operated normally and produced full power during a subsequent test run. The fuel pump was subject to a mandatory service bulletin (SB) issued by the manufacturer about 3 years before the accident. The SB required replacement of the fuel pump at the next scheduled maintenance due to instances of mechanical failure. Although the accident airplane had received three annual inspections between the issuance of the SB and the accident flight, the fuel pump was not replaced at any of these inspections.

Factual narrative

On June 15, 2016, about 1430 central daylight time, a Flight Design GMBH CTSW HXB, N302CT, collided with trees during a forced landing at Gloster Aerodrome (1XA7), Houston, Texas. The student pilot and flight instructor both sustained minor injuries. The airplane was destroyed. The airplane was registered to and operated by the student pilot under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed at the time of the accident, and no flight plan had been filed. The local flight had just originated.According to the flight instructor, the student pilot made the takeoff on runway 25. During the initial climb (about 500 feet AGL), the engine started running rough and lost all power. The instructor took control of the airplane and made a 180-degree turn back towards the airport. A forced landing to runway 07 was attempted but due to a strong tailwind, the airplane collided with trees to the right of the runway. On October 20, under the auspices of a Federal Aviation Administration (FAA) inspector, the engine was examined at the facilities of South Mississippi Light Aircraft in Lucedale, Mississippi. A Rotax engine representative was also in attendance. Reportedly, the engine would not start on the first attempt. It was determined that the engine was not receiving fuel due to a leak in the fuel pump diaphragm. When an electric fuel pump on the engine test stand was turned on, fuel poured out of the fuel pump drain hole. Disassembly of the fuel pump confirmed that the rubber diaphragm had deteriorated and was leaking. When a serviceable fuel pump was installed, the engine operated normally and produced full power. No further anomalies were noted. According to the engine logbook, Rotax Service Bulletin SB-912-053-UL (Replacement of fuel pump for Rotax Engine Type 912), dated April 13, 2007, had been complied with on May 24, 2006 (see page 5 of manual). However, Rotax Service Bulletin SB-912-063-UL (Replacement for fuel pumps for Rotax Engine Type 912), dated August 21, 2013, had not been performed. The fuel pump that was installed on the engine (part number 892 542, serial number 07.002314) was manufactured in 2009 and was affected by this service bulletin but it was not listed in the log book. The fuel pump was also affected by Bombardier's Recreational Products Maintenance Manual, requiring a mandatory replacement time of 5 years. Following the recommended replacement date of May 24, 2012, annual inspections of the engine were conducted on November 12, 2012, May 2, 2014, and June 6, 2016. A conditional engine examination was performed on June 13, 2015.

Aircraft

Registration
N302CT
Reported as
Flight Design Ctsw HXB
Category
Airplane
Serial number
07-06-06
Built
2007
Airframe hours
200
Engine
Rotax 912 UL, 100 horsepower, reciprocating
Damage
Destroyed
Flight
Instructional · Part 91
Airworthiness certificate
Special, Special light-sport (Special)
Last inspection
Annual · June 11, 2016 · 0 hours before
Departed
1XA7 · Houston, TX
Destination
KAXH · Arcola, TX
Airport
1XA7 · Gloster Aerodrome, runway 07, 3,450 × 75 ft, grass/turf
Equipment
Electronic primary flight display, Stall warning system, Airframe parachute, Angle of attack indicator, Electronic multifunction display, Auto-pilot

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
70
Injuries
Minor
Certificates
Commercial, Flight instructor, Sport Pilot
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
April 8, 2014
Seat
Right
Restraint
4-point
Flight hours
2,600 total · 75 in this make and model · 2,400 as pilot in command · 50 in the last 90 days · 21 in the last 30 days
Role
Student pilot
Age
63
Injuries
Minor
Certificate
Student
Seat
Left
Restraint
4-point
Flight hours
90 total · 60 in this make and model · 1 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
200° at 12 knots
Visibility
9 statute miles
Lowest ceiling
None
Temperature
93 °F, dew point 72 °F
Altimeter
29.98 inHg
Observed at
KTME, 9 nm away

Docket · 9

The files NTSB released with the investigation on December 1, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.4 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.