# NTSB ERA11LA416: Champion 7ECA, N5191X, Hinesville, GA, July 23, 2011 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: July 23, 2011, 07:52 local (11:52 UTC) - Place: Hinesville, GA - Coordinates: 31.871389, -81.561668 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=31.8714&lon=-81.5617&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: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed, report March 8, 2012 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 81198 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA11LA416 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/81198/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=81198 - Page: https://openairdocs.org/ntsb/ERA11LA416 ## Probable cause The total loss of engine power due to the improper installation of the carburetor air filter by maintenance personnel, which resulted in the filter becoming dislodged and obstructing the carburetor. Contributing to the accident was the pilot did not maintain adequate airspeed during the forced landing, which resulted in an aerodynamic stall. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Power plant: air intake](https://openairdocs.org/ntsb-findings/01057160): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Champion 7ECA, 1 case](https://openairdocs.org/ntsb-findings/01057160/cases.md?model=21101NN), [All aircraft, 50 cases](https://openairdocs.org/ntsb-findings/01057160/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Maintenance personnel (probable cause); cases with it: [Champion 7ECA, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=21101NN), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Fuel system](https://openairdocs.org/ntsb-findings/01022800): Aircraft › Aircraft systems · Not specified (probable cause); cases with it: [Champion 7ECA, 1 case](https://openairdocs.org/ntsb-findings/01022800/cases.md?model=21101NN), [All aircraft, 181 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Champion 7ECA, 5 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=21101NN), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Champion 7ECA, 19 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=21101NN), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/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: [Champion 7ECA, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=21101NN), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Champion 7ECA, 4 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=21101NN), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Champion 7ECA, 4 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=21101NN), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Emergency descent: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Champion 7ECA, 8 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=21101NN), [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: [Champion 7ECA, 20 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=21101NN), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that the airplane had climbed to about 900 feet above ground level after takeoff when the engine experienced a total loss of engine power. The pilot initiated a turn back toward the airport. While on final approach, the airplane stalled and collided with a fence. A postaccident examination of the engine carburetor revealed that a large piece of foam from the air filter element was lodged in the venturi of the carburetor. A review of the airplane’s logbooks revealed that an air filter element was installed during the engine overhaul 31 hours before the accident. It is likely that the air filter was installed incorrectly, thus causing the air filter element to become dislodged and drawn into the carburetor venturi. ## Factual narrative On July 23, 2011, about 0752 eastern daylight time, a Champion 7ECA, N5191X, experienced a total loss of engine power after takeoff from the Midcoast Regional Airport (LHW), Hinesville, Georgia. The certificate private pilot sustained serious injuries and the passenger reported minor injuries. The airplane sustained substantial damage to the fuselage and wings. The airplane was registered to and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and no flight plan was filed. The flight was originating at the time of the accident. The pilot reported the airplane had climbed to about 900 feet after takeoff when the engine experienced a total loss of engine power. He initiated a turn back towards the airport. During the approach to land, the airplane stalled and collided with an airport fence. Examination of the wreckage by a Federal Aviation Administration inspector revealed no anomalies with the airframe or flight controls. Examination of the carburetor revealed a large piece of foam from the air filter element was lodged in the carburetor venturi inlet. The FAA Inspector stated the air filter element had been installed improperly resulting in the foam element separating and being drawn into the carburetor inlet. Review of the airplane logbooks revealed an engine overhaul was completed 31 hours before the accident. According to the pilot, a Brackett Aero Filter air filter element was installed during the engine overhaul. Review of performance data for the Champion 7ECA revealed the airplane will stall at 44 knots. ## Aircraft - Registration: [N5191X](https://openairdocs.org/deregistered/N5191X-2013-08-06), registration cancelled 2013-08-06, S/N 692, built 1969 (OpenAirDocs) - Reported make and model: CHAMPION 7ECA - Registry model: [Champion 7ECA](https://openairdocs.org/model/champion-7eca) (registry code 21101NN) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 692 - Airframe hours: 2015 - Engines: LYCOMING O-235 SERIES 115 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Manning Richard F Jr - Registered owner: Manning Richard F Jr - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 15, 2010, 31 hours before - Departed: LHW, Hinesville, GA - Destination: LHW, Hinesville, GA - Airport: LHW, Midcoast Regional Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 53; injuries: minor; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review May 1, 2010; seat: front; flight hours: 2,100 total, 55 in this make and model, 10 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 73 °F - Altimeter: 30.09 inHg - Observed at: LHW ## 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 20110723015979A](https://openairdocs.org/incident/20110723015979A), Jul 23, 2011: Champion 7ECA, Hinesville, GA, Destroyed. At 7:57 am (local), citabria N5191X departed runway 24R and initiated a climb-out. Upon reaching approximately 900 feet (AGL), the engine lost power. The pilot… ## Docket (11 files) The files NTSB released with the investigation on January 5, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=81198. 3.6 MB in all. - Record of Conversation-Pilot-Manning (item 1, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356793&FileExtension=.PDF&FileName=Record%20of%20Conversation-Pilot-Manning-Master.PDF - FAA Statement (item 2, .PDF, 10 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360306&FileExtension=.PDF&FileName=FAA%20Statement-Redacted.PDF - Record of Conversation-FAA (item 3, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356796&FileExtension=.PDF&FileName=Record%20of%20Conversation-FAA-Master.PDF - Aircraft Logbooks (item 4, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357191&FileExtension=.PDF&FileName=Aircraft%20Logbooks-Redacted.PDF - Engine Logbooks (item 5, .PDF, 237 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357194&FileExtension=.PDF&FileName=Engine%20Logbooks-Redacted.PDF - Miscellaneous-American Champion 7ECA-Performance data (item 6, .PDF, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357063&FileExtension=.PDF&FileName=Miscellaneous-American%20Champion%207ECA-Performance%20data-Master.PDF - Photo 1- Courtesy of FAA-Discovery of lodged air Filter element (item 7, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356802&FileExtension=.PDF&FileName=Photo%201-%20Courtesy%20of%20FAA-Discovery%20of%20lodged%20air%20Filter%20element-Master.PDF - Photo- 2-Courtesy of FAA-removed lodged air filter element (item 8, .PDF, 733 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356803&FileExtension=.PDF&FileName=Photo-%202-Courtesy%20of%20FAA-removed%20lodged%20air%20filter%20element-Master.PDF - Photo 3-Courtesy of FAA-Leftside view of airplane (item 9, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356804&FileExtension=.PDF&FileName=Photo%203-Courtesy%20of%20FAA-Leftside%20view%20of%20airplane-Master.PDF - Photo 4-Courtesy of FAA-Front view of airplane (item 10, .PDF, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356805&FileExtension=.PDF&FileName=Photo%204-Courtesy%20of%20FAA-Front%20view%20of%20airplane-Master.PDF - Photo 5-Courtesy of FAA-rear view of airplane (item 11, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356806&FileExtension=.PDF&FileName=Photo%205-Courtesy%20of%20FAA-rear%20view%20of%20airplane-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.