# NTSB CHI96LA007: Roisum Team MINI-MAX, N42BX, Neenah, WI, October 11, 1995 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: October 11, 1995, 18:25 local (23:25 UTC) - Place: Neenah, WI - Coordinates: 44.160545, -88.470268 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.1605&lon=-88.4703&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report December 19, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 10130 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI96LA007 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/10130/pdf - Page: https://openairdocs.org/ntsb/CHI96LA007 ## Probable cause Fuel starvation due to fuel filter blockage. Factors associated with the accident were the manufacturers design of the fuel filter and the builder/pilots decision to use an automotive type fuel filter. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, cruise - fuel system,filter - blocked(total) (cause) - fuel system - inadequate, owner/pilot mechanic (contributing factor) - aircraft/equipment inadequate, manufacturer (contributing factor) - Forced landing, emergency descent/landing - On ground/water encounter with terrain/water, landing - roll - terrain condition - ditch ## Analysis THE PILOT REPORTED HE WAS CRUISING AT 2000 FEET WHEN THE AIRCRAFT EXPERIENCED A TOTAL LOSS OF ENGINE POWER. THE AIRCRAFT WAS SUBSTANTIALLY DAMAGED DURING AN OFF AIRPORT LANDING. AN INVESTIGATION FOUND A FUEL FILTER RETAINING NUT ON THE AUTOMOTIVE TYPE FUEL FILTER HAD ROTATED CAUSING THE FUEL INLET HOLES TO BECOME BLOCKED. THE AUTOMOTIVE TYPE FUEL FILTER WAS PURCHASED BY THE AIRCRAFT OWNER FROM A HOMEBUILT AIRCRAFT PART SUPPLIER. ## Factual narrative On October 11, 1995, at 1825 central daylight time (cdt), a Roisum Team Mini-Max, N452BX, piloted by a private pilot, was substantially damaged after a forced landing on a road. The aircraft avoided hitting a semi trailer, but collided with a ditch. The pilot reported a total loss of engine power while on a cross country flight. Visual meteorological conditions prevailed at the time of the accident. The personal 14 CFR Part 91 flight was not operating on a flight plan. The pilot reported minor injuries. The flight departed Sturgeon Bay, Wisconsin, at 1650 cdt. An on scene investigation was conducted by an FAA Principal Maintenance Inspector (PMI). The PMI found a fuel filter retaining nut on the automotive type fuel filter had rotated, causing its inlet holes to become blocked. The fuel filter was purchased by the builder/pilot from a homebuilt aircraft supplier. The PMI said that the fuel filter nut could have been safetied to prevent rotation. During a phone conversation with the builder/pilot he agreed with the PMI as to the cause of the total power loss. The aircraft's fuel filter was also examined by the NTSB IIC. The IIC confirmed that the N452BX's fuel filter retaining nut could loosen causing complete blockage of the fuel inlet holes. A new fuel filter the same part number as the one on N452BX was obtained. The IIC found the new fuel filter's retaining nut was easily removed by hand. Investigation also revealed that complete blockage of the new fuel filter was not possible, due to the differences in shaft length between the accident aircraft's fuel filter and the new fuel filter. The reason for the differences in shaft length was not determined. ## Aircraft - Registration: [N42BX](https://openairdocs.org/aircraft/N42BX), registered now, S/N 188, built 1994 (OpenAirDocs) - Reported make and model: ROISUM TEAM MINI-MAX - Registry model: [Roisum David R TEAM MINIMAX](https://openairdocs.org/model/roisum-david-r-team-minimax) (registry code 05623QK) (OpenAirDocs) - Registry engine: [Bombardier ROTAX (ALL)](https://openairdocs.org/engine/bombardier-rotax-all) (registry code 09050, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 177 - Airframe hours: 179 - Engines: ROTAX 503 55 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: David R. Roisum - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Annual, July 7, 1995, 23 hours before - Departed: SUE, STURGEON BAY, WI - Destination: 79C, WI ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 40; private; airplane ratings: single-engine land; medical: class 3, valid medical--no waivers/lim.; seat: front; flight hours: 391 total, 179 in this make and model, 324 as pilot in command, 25 in the last 90 days, 9 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Dusk - Wind: 240° at 13 knots - Visibility: 20 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 61 °F - Altimeter: 29.00 inHg - Observed at: ATW, 7 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 19951011032929A](https://openairdocs.org/incident/19951011032929A), Oct 11, 1995: Amtrsm MINIPLANE*, Neenah, WI, Substantial damage. Engine lost power at cruise. Crash landed on road. Auto fuel filter nut loosend. Rotated. Blocking fuel. Bogus type (-23) pilot state engine lost power and… 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.