# NTSB CEN16LA221: Flight Design Ctsw HXB, N302CT, Sealy, TX, June 15, 2016 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: June 15, 2016, 14:30 local (19:30 UTC) - Place: Sealy, TX - Coordinates: 29.733333, -96.059165 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.7333&lon=-96.0592&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report January 26, 2017 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Rotech Flight Safety, FAA Flight Standards District Office - NTSB case key (mKey): 93395 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN16LA221 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93395/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93395 - Page: https://openairdocs.org/ntsb/CEN16LA221 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Fuel system: fuel pumps](https://openairdocs.org/ntsb-findings/01022822): Aircraft › Aircraft systems · Failure (probable cause); cases with it: [Flight Design CTSW, 1 case](https://openairdocs.org/ntsb-findings/01022822/cases.md?model=0600001), [All aircraft, 71 cases](https://openairdocs.org/ntsb-findings/01022822/cases.md) - [Fuel system: fuel pumps](https://openairdocs.org/ntsb-findings/01022822): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Flight Design CTSW, 1 case](https://openairdocs.org/ntsb-findings/01022822/cases.md?model=0600001), [All aircraft, 71 cases](https://openairdocs.org/ntsb-findings/01022822/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Maintenance personnel (probable cause); cases with it: [Flight Design CTSW, 3 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=0600001), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Flight Design CTSW, 3 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=0600001), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Flight Design CTSW, 6 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=0600001), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Flight Design CTSW, 13 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=0600001), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N302CT-2016-12-12), registration cancelled 2016-12-12, S/N 07-06-06, built 2007 (OpenAirDocs) - Reported make and model: FLIGHT DESIGN GMBH CTSW HXB - Registry model: [Flight Design CTSW](https://openairdocs.org/model/flight-design-ctsw) (registry code 0600001) (OpenAirDocs) - Registry engine: [Rotax 912ULS series](https://openairdocs.org/engine/rotax-912uls-series) (registry code 55572, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 07-06-06 - Year built: 2007 - Airframe hours: 200 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 70; injuries: minor; 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 - Student pilot; age 63; injuries: minor; 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 ## 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 20160615010439A](https://openairdocs.org/incident/20160615010439A), Jun 15, 2016: Flight Design Gmbh CTSW, Sealy, TX, Destroyed. The aircraft lost power during climb out and attempted to return to the airport. Because of a tail wind and short field, the aircraft landed at the edge of the… ## Docket (9 files) The files NTSB released with the investigation on December 1, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93395. 3.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 256 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458998&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Flight Instructor's Statement (item 2, .PDF, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446954&FileExtension=.PDF&FileName=Flight%20Instructor%27s%20Statement-Master.PDF - Engine Examination Report from Jordan Paskevich, Rotax Engines (item 3, .PDF, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446955&FileExtension=.PDF&FileName=Engine%20Examination%20Report%20from%20Jordan%20Paskevich,%20Rotax%20Engines-Master.PDF - Engine Logbook (item 4, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446956&FileExtension=.PDF&FileName=Engine%20Logbook-Master.PDF - Excerpt from Bombardier Recreational Products Maintenance Manual (item 5, .PDF, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446957&FileExtension=.PDF&FileName=Excerpt%20from%20Bombardier%20Recreational%20Products%20Maintenance%20Manual-Master.PDF - Rotax Service Bulletin SB-912-053-UL, dated April 13,2007 (item 6, .PDF, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446958&FileExtension=.PDF&FileName=Rotax%20Service%20Bulletin%20SB-912-053-UL,%20dated%20April%2013,2007-Master.PDF - Rotax Service Bulletin SB-912-063-UL, dated August 21, 2013 (item 7, .PDF, 684 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446959&FileExtension=.PDF&FileName=Rotax%20Service%20Bulletin%20SB-912-063-UL,%20dated%20August%2021,%202013-Master.PDF - Weather Reports and Records (item 8, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446960&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Report Photos (item 9, .PDF, 4 photos, 930 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446961&FileExtension=.PDF&FileName=Report%20Photos-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.