# NTSB ERA19LA224: Zenith CH601, N601MR, Carlisle, PA, July 13, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: July 13, 2019, 08:50 local (12:50 UTC) - Place: Carlisle, PA - Coordinates: 40.187778, -77.169441 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.1878&lon=-77.1694&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel contamination](https://openairdocs.org/ntsb-events/193) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 99829 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA224 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99829/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99829 - Page: https://openairdocs.org/ntsb/ERA19LA224 ## Probable cause Water contamination of the fuel system, which resulted in a total loss of engine power. Contributing to the accident was the pilot's inadequate preflight inspection, which failed to remove all the water from the airplane's fuel system. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Inadequate inspection (probable cause); cases with it: [Makibbin Thomas O ZODIAC 601XL, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=05628YG), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid condition (probable cause); cases with it: [Makibbin Thomas O ZODIAC 601XL, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=05628YG), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Makibbin Thomas O ZODIAC 601XL, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=05628YG), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Fuel contamination](https://openairdocs.org/ntsb-events/193) (defining event); cases with it: [Makibbin Thomas O ZODIAC 601XL, 1 case](https://openairdocs.org/ntsb-events/193/sequence.md?model=05628YG), [All aircraft, 225 cases](https://openairdocs.org/ntsb-events/193/sequence.md) - [Initial climb: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Makibbin Thomas O ZODIAC 601XL, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=05628YG), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis The pilot noted water in the fuel tanks while performing a preflight inspection and sampled the fuel until it appeared clear of contamination. He refueled the airplane, performed an engine run-up, and took off. During the initial climb, the airplane reached about 200 ft above ground level before the engine lost total power; the pilot landed on the remaining runway. The airplane overran the departure end of the runway and impacted a ditch, which resulted in substantial damage. Postaccident examination of the airplane's fuel system revealed that it was contaminated with water throughout. Testing of the airport fuel tank revealed no evidence of contamination, and no other airplanes fueled around the time of the accident airplane reported contamination. It is likely that some water remained in the airplane's fuel system after the preflight inspection, which resulted in a total loss of power in flight when the contaminated fuel reached the engine. ## Factual narrative On July 13, 2019, about 0850 eastern daylight time, an experimental amateur-built Zodiac CH 601XL, N601MR, was substantially damaged during a forced landing after takeoff from Carlisle Airport (N94), Carlisle, Pennsylvania. The private pilot was not injured. The airplane was privately owned and operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident and no flight plan was filed for the flight to York Airport (THV), York, Pennsylvania. The accident occurred during the airplane's first flight of the day. According to the pilot, the airplane was stored outdoors with half-empty fuel tanks in hot, humid weather prior to the accident flight. The pilot observed water in the fuel tanks while performing a preflight inspection and sampled the fuel until it appeared clear of contamination. He then taxied to the fuel pump, where he added 15 gallons of fuel into the tanks. He restarted the engine and completed the engine run-up and takeoff roll with no anomalies noted. After takeoff and during the initial climb, about 200 ft above the runway, the engine stopped producing power and the propeller stopped. The pilot stated that he elected to touch down on the remaining runway. The airplane overran the departure end of the runway and impacted a ditch. The airplane came to rest upright in low brush about 225 ft from the departure end of runway 28. The airplane was pitched nose down and the nose landing gear was collapsed. Examination by a Federal Aviation Administration (FAA) airworthiness inspector revealed that the engine cowling was crushed aft and the engine mounts were damaged. Fuel drained from the wing tank sumps and gascolator contained water. According to FAA airman records, the pilot held a private pilot certificate with a rating for airplane single-engine land. The pilot reported 402.7 total hours of flight experience of which 313 hours were in the accident airplane make and model. According to FAA records, the pilot/owner manufactured the airplane in 2009. An FAA Designated Airworthiness Representative (DAR) inspected the accident airplane and issued a special airworthiness certificate in the experimental category on November 15, 2010. The airplane was equipped with a Jabiru 3300A, 120-horsepower engine that drove a Sensenich propeller. The airplane was maintained under an annual condition inspection program. According to the airplane maintenance logbooks, the most recent condition inspection was completed on November 12, 2018, at 300.5 total aircraft hours. The tachometer located in the airplane at the time of the accident indicated 309.1 hours, which was 8.6 hours since the last condition inspection. At 0856, the weather reported at Capital City Airport (CXY), about 15 miles east of the accident site, included wind from 240° at 8 knots, visibility of 10 miles, clear sky, temperature 24° C, dew point 17° C, and an altimeter setting of30.00 inches of mercury. Examination of the airplane after recovery revealed that the gascolator was full of water, and that there was water in the fuel lines and carburetor float bowl. Testing of the airport fuel tank did not reveal evidence of water, and no airplanes that fueled before or after the accident airplane reported fuel quality issues. Literature describing the formation of water in aircraft fuel due to condensation published by the Aircraft Owners and Pilots Association entitled "Checking Fuel Samples" stated: "Humid air trapped in a partially full tank can condense on the tank's walls, just as dew forms on the grass. In either case, this water won't reach the fuel lines until shortly after takeoff when a few turns or bumps have shaken the water free. To avoid this problem, gently rock the wings at the start of the preflight, and sump the tanks at the end of the inspection." The FAA Advisory Circular 20-125, "Water in Aviation Fuels," stated the following: "An important part of the preflight inspection is to drain aircraft fuel tanks sumps, reservoirs, gascolators, filters and other fuel system drains to assure that the fuel supply is free of water." "Aircraft fuel tanks are constructed with sumps to trap water. Since it is practically impossible to drain all water from the tanks through the fuel lines, the fuel tank sumps should be regularly drained in order to remove all water from the system. It may be necessary to gently rock the wings of some aircraft while draining the sumps in order to completely drain all the water." ## Aircraft - Registration: [N601MR](https://openairdocs.org/aircraft/N601MR), registered now, S/N 6-5414, built 2010 (OpenAirDocs) - Reported make and model: Zenith CH601 (XL) - Registry model: [Makibbin Thomas O ZODIAC 601XL](https://openairdocs.org/model/makibbin-thomas-o-zodiac-601xl) (registry code 05628YG) (OpenAirDocs) - Registry engine: [Jabiru 3300](https://openairdocs.org/engine/jabiru-3300) (registry code 34802, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 6-5414 - Year built: 2009 - Airframe hours: 309.1 - Engines: Jabiru 3300A 120 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, November 12, 2018, 9 hours before - Departed: N94, Carlisle, PA - Destination: THV, York, PA - Airport: N94, Carlisle, runway 28, 4,008 × 60 ft, asphalt - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: none; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review October 26, 2016; seat: left; restraint: 3-point; flight hours: 402.7 total, 313 in this make and model, 331.7 as pilot in command, 11.3 in the last 90 days, 5 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 75 °F, dew point 63 °F - Altimeter: 30.00 inHg - Turbulence: Unknown - Observed at: KCXY, 15 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 20190713015339A](https://openairdocs.org/incident/20190713015339A), Jul 13, 2019: Makibbin Thomas O ZODIAC 601XL, Carlisle, PA, Substantial damage. On July 13, 2019, [privacy data omitted] arrived at Carlisle Airport and preflighted the aircraft. He discovered water in the fuel while sumping the tanks.… ## Docket (8 files) The files NTSB released with the investigation on October 29, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99829. 12.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 8.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477276&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot's Statement (item 2, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477277&FileExtension=.PDF&FileName=Pilot%27s%20Statement-Master.PDF - FAA Inspector Statements (item 3, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477278&FileExtension=.PDF&FileName=FAA%20Inspector%20Statements-Master.PDF - Maintenance Log Excerpts (item 4, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477279&FileExtension=.PDF&FileName=Maintenance%20Log%20Excerpts-Master.PDF - AOPA Checking Fuel Samples (item 5, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477280&FileExtension=.PDF&FileName=AOPA%20Checking%20Fuel%20Samples-Master.PDF - Weather Reports (item 6, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477281&FileExtension=.PDF&FileName=Weather%20Reports-Master.PDF - Investigative Photographs (item 7, .PDF, 4 photos, 979 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477282&FileExtension=.PDF&FileName=Investigative%20Photographs-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 8, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477283&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.