# NTSB CEN16LA363: CGS Hawk Aero II, N4513S, Holland, MI, September 3, 2016 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: September 3, 2016, 18:30 local (22:30 UTC) - Place: Holland, MI - Coordinates: 42.796665, -86.161666 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.7967&lon=-86.1617&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report August 15, 2018 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration; GRR FSDO - NTSB case key (mKey): 93978 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN16LA363 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93978/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93978 - Page: https://openairdocs.org/ntsb/CEN16LA363 ## Probable cause The improper installation of quick release connectors in the fuel lines, which was not in accordance with the engine manufacturer's maintenance instructions and allowed air to be introduced into the fuel system and resulted in a partial loss of engine power. Also causal to the accident was the pilot's failure to maintain adequate airspeed and exceedance of the airplane's critical angle of attack, which resulted in an aerodynamic stall and impact with power lines. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine fuel and control: fuel distribution](https://openairdocs.org/ntsb-findings/01057310): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Flora Wayne R CGS HAWK ARROW, 1 case](https://openairdocs.org/ntsb-findings/01057310/cases.md?model=05615EI), [All aircraft, 55 cases](https://openairdocs.org/ntsb-findings/01057310/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Flora Wayne R CGS HAWK ARROW, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=05615EI), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Flora Wayne R CGS HAWK ARROW, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=05615EI), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Flora Wayne R CGS HAWK ARROW, 1 case](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=05615EI), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Flora Wayne R CGS HAWK ARROW, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05615EI), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Object/animal/substance: wire](https://openairdocs.org/ntsb-findings/03022032): Environmental issues › Physical environment · Effect on operation (probable cause); cases with it: [Flora Wayne R CGS HAWK ARROW, 1 case](https://openairdocs.org/ntsb-findings/03022032/cases.md?model=05615EI), [All aircraft, 588 cases](https://openairdocs.org/ntsb-findings/03022032/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: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Flora Wayne R CGS HAWK ARROW, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=05615EI), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [Flora Wayne R CGS HAWK ARROW, 1 case](https://openairdocs.org/ntsb-events/342/sequence.md?model=05615EI), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Flora Wayne R CGS HAWK ARROW, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05615EI), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Flora Wayne R CGS HAWK ARROW, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05615EI), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The private pilot stated that the experimental light sport airplane experienced a partial loss of engine power during climb after takeoff about 80 to100 ft above ground level. The airplane entered an aerodynamic stall, so the pilot decreased the pitch attitude to recover, but the airplane then impacted power lines. Postaccident examination of the engine revealed numerous items that had not been performed in accordance with the engine manufacturer's maintenance instructions, one of which was the correct installation of a quick release connector in the fuel lines. When the quick release connector was tested, it leaked a substantial amount of air into the fuel system; therefore, it is likely that air entered the fuel system during the flight and resulted in the partial loss of engine power. ## Factual narrative On September 3, 2016, at 1830 eastern daylight time, an experimental light sport CGS Aviation Hawk Aero II airplane, N4513S, collided with power line(s) and terrain during an en route climb following takeoff from Park Township Airport (HLM), Holland, Michigan. The airplane was destroyed. The pilot sustained serious injuries. The airplane was registered to and operated by the pilot under 14 Code of Federal Regulations Part 91 as a personal flight that was not operating on a flight plan. Day visual meteorological conditions prevailed at the time of the accident. The local flight was originating at the time of the accident. A National Transportation Safety Board (NTSB) Pilot/Operator Accident/Incident Report (form 6120.1) was not received from the pilot. The pilot, who was the airplane owner, stated in a telephone conversation with the NTSB Investigator-In-Charge, that the engine never stopped running and was not running at a high engine speed. During the climbout after takeoff, the engine started to sputter about 80-100 feet above ground level. The airplane "started stalling," so he pushed the nose down to increase airplane airspeed to recover from the aerodynamic stall. He said that if the airplane had not hit the power line(s), he would not have been involved in an accident. Post-accident examination of the airplane and an engine run were performed at the pilot's hangar by a representative from the engine manufacturer and by the Federal Aviation Administration Coordinator for the accident. The engine was a Rotax 582 MOD 99, serial number 543 7309. The examination revealed that all the spark plugs were NGK BR8ES that had removable resistor caps, which was not in accordance with the engine manufacturer's maintenance manual. The spark plug gaps were 0.29 - 0.30 inch (the engine maintenance manual specifies a gap size of 0.020 inch). All the spark plugs' electrodes exhibited a color consistent with a rich fuel mixture. The number 4-cylinder spark plug on the magneto side of the engine was loose and did not meet the torque specification in accordance with the engine manufacturer's maintenance manual. The power takeoff and magneto sides of the engine had both carburetors equipped with larger main jets, which were 190 size jets instead of the engine manufacturer's original equipment, which were 165 size jets (higher jet numbers equate to a richer mixtures). Both carburetor chokes were blocked off and removed from service. Both jet needles clip positions were in the number 4 position and not in the number 3 position, as specified in the engine manufacturer's maintenance manual. There were no fuel filters installed between the fuel pumps and carburetors as specified in the engine manufacturer's maintenance manual. The pneumatic fuel pump was found installed on the engine with the small drain hole near the impulse connection, positioned horizontally. The engine manufacturer's maintenance manual states that "The fuel pump should be installed in a coolplace (not on the engine itself), with the small drain hole near the impulse connection towards the bottom. This hole drains oil condensate from the pump diaphragm chamber". The gascolator was installed with industrial style (non-airplane) brass plumbing fittings and an industrial style (non-airplane) shut-off valve. Plumbers thread seal tape was present on the threads of the fuel line fittings. There was no fire sleeve on any of the fuel lines. The fuel header tank was a white plastic container that was consistent with a water jug. The threaded cap of the header tank had a fuel system quick release type connector attached with a pick-up tube that extended to the bottom of the container. When the quick release type connector was tested, it leaked a substantial amount of air into the fuel system. The engine manufacturer's maintenance manual stated: "Quick release type connectors can cause air leaks and produce fuel flow restrictions and possible blockage sites" "the tiniest flaw in any joint will cause air to be sucked into the fuel system, considerably reducing the capacity of the fuel pump. Air leaks are much more dangerous when the fuel tank is mounted below the fuel pump and carburetors" The engine was run for several minutes with multiple throttle inputs during which no anomalies in engine power occurred. Following the accident, the engine manufacturer issued a publication, "Two-Stroke Safety Issues", which in part discussed fuel system air leaks and the use of quick release connectors in the fuel system. ## Aircraft - Registration: [N4513S](https://openairdocs.org/aircraft/N4513S), registered now, S/N H II 159-A-582-TRI (OpenAirDocs) - Reported make and model: CGS AVIATION HAWK AERO II - Registry model: [Flora Wayne R CGS HAWK ARROW](https://openairdocs.org/model/flora-wayne-r-cgs-hawk-arrow) (registry code 05615EI) (OpenAirDocs) - Registry engine: [Bombardier ROTAX (ALL)](https://openairdocs.org/engine/bombardier-rotax-all) (registry code 09050, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: H II 159-A-582-TRI - Year built: 2001 - Engines: Rotax 582 65 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Pilot - Registered owner: Pilot - Airworthiness certificate: Special, Experimental light sport (Special) - Departed: HLM, Holland, MI - Destination: HLM, Holland, MI - Airport: HLM, Park Township Airport, runway 23, 2,999 × 50 ft, asphalt - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; flight hours: 216 total ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 77 °F, dew point 54 °F - Altimeter: 30.18 inHg - Observed at: AZO, 43 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 20160903021539A](https://openairdocs.org/incident/20160903021539A), Sep 3, 2016: Flora Wayne R CGS HAWK ARROW, Holland, MI, Destroyed. On sept. 3, 2016, pilot was flying his experimental home built aircraft N4513S out of Holland park township airport (hlm), Michigan, for recreational purpose.… ## Docket (5 files) The files NTSB released with the investigation on March 12, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93978. 2.7 MB in all. - Record of Conversation - Pilot (item 1, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460774&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilot-Master.PDF - Email Request to Pilot for NTSB 6120 Form (item 2, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460775&FileExtension=.PDF&FileName=Email%20Request%20to%20Pilot%20for%20NTSB%206120%20Form-Master.PDF - Record of Examination (item 3, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460776&FileExtension=.PDF&FileName=Record%20of%20Examination-Master.PDF - Rotax Maintenance Manual Excerpts (item 4, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460777&FileExtension=.PDF&FileName=Rotax%20Maintenance%20Manual%20Excerpts-Master.PDF - Rotax Two-Stroke Safety Issues Publication (item 5, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460778&FileExtension=.PDF&FileName=Rotax%20Two-Stroke%20Safety%20Issues%20Publication-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.