# NTSB ERA20LA050: Zenith Zodiac CH-650, N914AR, Willow Springs, MO, December 8, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: December 8, 2019, 15:15 local (21:15 UTC) - Place: Willow Springs, MO - Coordinates: 36.984165, -91.955558 - Nearby events: https://openairdocs.org/map.md?lat=36.9842&lon=-91.9556&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 100670 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA20LA050 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100670/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100670 - Page: https://openairdocs.org/ntsb/ERA20LA050 ## Probable cause Improper maintenance practices on the fuel system causing fuel starvation and a total loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Misc hardware: hoses and tubes](https://openairdocs.org/ntsb-findings/01071410): Aircraft › Fluids/misc hardware · Incorrect service/maintenance (probable cause); cases with it: [Hook Ronald G ZODIAC CH-650, 1 case](https://openairdocs.org/ntsb-findings/01071410/cases.md?model=056280Q), [All aircraft, 40 cases](https://openairdocs.org/ntsb-findings/01071410/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Hook Ronald G ZODIAC CH-650, 1 case](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=056280Q), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) - [Fuel system: fuel pumps](https://openairdocs.org/ntsb-findings/01022822): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Hook Ronald G ZODIAC CH-650, 1 case](https://openairdocs.org/ntsb-findings/01022822/cases.md?model=056280Q), [All aircraft, 71 cases](https://openairdocs.org/ntsb-findings/01022822/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Hook Ronald G ZODIAC CH-650, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=056280Q), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/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: [Hook Ronald G ZODIAC CH-650, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=056280Q), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Hook Ronald G ZODIAC CH-650, 1 case](https://openairdocs.org/ntsb-events/191/sequence.md?model=056280Q), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) ## Analysis According to the pilot of the experimental, amateur-built airplane, he was taking the airplane out for a test flight after making some adjustments to the propeller blade angles. During the initial climb, the engine lost power, restarted on its own and lost power again. The pilot turned back to the airport, but the airplane could not reach the runway and he conducted a forced landing off-field, which resulted in substantial damage to the airplane. Examination of the airplane by a certified mechanic revealed that the fuel pump was weak on pressure and the electric fuel pump was installed incorrectly between the engine driven pump and the carburetor. The fuel flow meter was installed using pipe fittings connected to flare fittings. All fittings were finger tight. These discrepancies were consistent with improper maintenance practices on the fuel system and likely resulted in a reduction in fuel flow during the initial climb after takeoff, and a loss of engine power due to fuel starvation. ## Factual narrative On December 8, 2019, about 1515 central standard time, an experimental, amateur-built Zenith Zodiac CH-650, N914AR, was substantially damaged when it was involved in an accident at Willow Springs, Missouri. The private pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he adjusted the ground adjustable propeller and was going to test fly the airplane. During the initial climb, the engine lost total power. A few seconds later, the engine restarted on its own, but shortly lost total power again. He turned back to the runway but knew he would not make it and set up for an off-field landing. The pilot did not recall additional events leading up to the accident. Examination of the airplane by a Certified Airframe and Powerplant mechanic revealed that the fuel pump was weak on pressure and the diaphragm was leaking. The electric fuel pump was installed between the engine driven pump and the carburetor, causing low fuel pressure. The fuel flow meter was not installed correctly using the proper fittings. The fuel flow meter was installed using a pipe fitting connected to a flare fitting. All fittings were finger tight. ## Aircraft - Registration: [N914AR](https://openairdocs.org/deregistered/N914AR-2022-03-29), registration cancelled 2022-03-29, S/N 65-7533, built 2012 (OpenAirDocs) - Reported make and model: Zenith ZODIAC CH-650 (No Series) - Registry model: [Hook Ronald G ZODIAC CH-650](https://openairdocs.org/model/hook-ronald-g-zodiac-ch-650) (registry code 056280Q) (OpenAirDocs) - Registry engine: [Lycoming O-290-D](https://openairdocs.org/engine/lycoming-o-290-d) (registry code 42089, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 65-7533 - Year built: 2012 - Airframe hours: 8.6 - Engines: Lycoming 290-D 150 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, June 28, 2017, 9 hours before - Departed: 1H5, Willow Springs, MO - Destination: 1H5, Willow Springs, MO - Airport: 1H5, Willow Springs Memorial, runway 35, 3,502 × 60 ft, asphalt - Equipment: Electronic multifunction display, Auto-pilot, Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 78; injuries: minor; flight instructor, commercial, airline transport; airplane ratings: multi-engine land, single-engine land, single-engine sea; instrument ratings: airplane, helicopter; medical: basicmed; last flight review January 5, 2019; seat: left; restraint: 5-point; flight hours: 14,461 total, 8.6 in this make and model, 9,701 as pilot in command, 3.9 in the last 90 days, 3.9 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 140° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: 700 ft overcast - Temperature: 45 °F, dew point 41 °F - Altimeter: 29.90 inHg - Observed at: KUNO, 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 20191208017069A](https://openairdocs.org/incident/20191208017069A), Dec 8, 2019: Hook Ronald G ZODIAC CH-650, Willow Springs, MO, Substantial damage. The pilot completed an oil change after completing 3.5 hours of engine run for the replacement of the engine cylinders. The ground adjustable propeller was set… ## Other investigations on N914AR (1) 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. - [NTSB CEN13CA268](https://openairdocs.org/ntsb/CEN13CA268), May 2, 2013: Hook Zodiac CH-650 (N914AR), Gainesville, MO, substantial damage. Probable cause: The pilot misjudged the landing approach, which resulted in the airplane hitting a tree. ## Docket (6 files) The files NTSB released with the investigation on August 15, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100670. 2.6 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 5 pages, 279 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9288640&FileExtension=pdf&FileName=6120.1_Redacted-Rel.pdf - Memorandum for record a�� telephone interview, pilot (item 2, PDF, 1 page, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8878553&FileExtension=pdf&FileName=Record%20of%20Interview-pilot-Rel.pdf - Mechanic email - engine examination (item 3, PDF, 1 page, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14109572&FileExtension=pdf&FileName=mechanic%20report_Redacted-Rel.pdf - Pilot logbook (excerpt) (item 4, PDF, 2 pages, 165 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8878544&FileExtension=pdf&FileName=pilot%20logbook_Redacted-Rel.pdf - Maintenance records (item 5, PDF, 5 pages, 271 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8878998&FileExtension=pdf&FileName=Maintenance%20Logbooks_Redacted-Rel.pdf - Investigative photo's (item 6, PDF, 6 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9196129&FileExtension=pdf&FileName=Investigative%20Photo%27s-Rel.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.