Thursday, July 28, 2016

Flight Design CTLS, N527TS: Fatal accident occurred July 28, 2016 at Fond du Lac County Airport (KFLD), Wisconsin

The National Transportation Safety Board traveled to the scene of this accident.

Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Investigation Docket  - National Transportation Safety Board:  https://dms.ntsb.gov/pubdms

http://registry.faa.gov/527TS

Location: Fond du Lac, WI
Accident Number: CEN16FA290
Date & Time: 07/28/2016, 0821 CDT
Registration: N527TS
Aircraft: FLIGHT DESIGN GMBH CTLS
Aircraft Damage: Substantial
Defining Event: Fuel contamination
Injuries: 1 Fatal, 1 Serious
Flight Conducted Under: Part 91: General Aviation - Personal 

HISTORY OF FLIGHT

On July 28, 2016, about 0821 central daylight time, a Flight Design GMBH model CTLS airplane, N527TS, impacted terrain following a loss of engine power after takeoff. The pilot was fatally injured and the passenger was seriously injured. The airplane was substantially damaged. The airplane was registered to, and operated by a private individual as a 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed at the accident site about the time of the accident, and the flight was operated without a flight plan. The flight originated from Fond du Lac County Airport (FLD), Fond du Lac, Wisconsin at the time of the accident and its destination was not determined.

Witnesses reported seeing the airplane take off to the north and turn left, towards the airport, while still over airport property. They added that the engine sounded abnormal. The airplane did not climb above treetop height before it rolled into a steep left turn and descended into terrain. An additional witness did not see the accident occur, but heard the pilot on the radio state he was making an immediate return to the airport.

Pilot

No pilot logbooks were located during the investigation and the pilot's time in the make and model of the accident airplane could not be determined. The pilot reported 110 total hours on his last application for medical certificate dated April 15, 2002. The pilot did not hold a current FAA medical certificate; however, he was operating the airplane under the Sport Pilot Medical rule.

Pilot-Rated Passenger

No pilot logbooks belonging to the pilot-rated passenger were located during the investigation. The pilot-rated passenger reported 2,136 total hours on his last application for medical certificate dated July 15, 1996.

AIRCRAFT DESCRIPTION

A review of the airplane's maintenance records revealed a 200 hr Carburetor Service Requirement per SI-912-021, Inspections of Carburetors, was complied with on December 9, 2014. According to the records the Hobbs meter read 829.5 hrs at the time of the inspection.

WRECKAGE DESCRIPTION

During impact, both wings separated from the fuselage and the engine intruded into the cockpit area. Flight control continuity to the elevator and rudder was verified continuous from the cockpit to each control surface. Flight control continuity was interrupted to both wings, but all observed breaks in continuity were consistent with overload failure during impact. A slight fuel smell was present at the accident scene. Both the left and right fuel tanks were compromised. Several ounces of liquid consistent with aviation fuel were recovered from the right-wing fuel tank, which appeared light blue in color and free of contaminants. The three composite propeller blades were broken and had separated near the propeller hub. The blade sections that were observed were absent chord wise scratches or leading-edge damage. The engine was removed from the wreckage and examined separately at a secure location.

MEDICAL AND PATHOLOGICAL INFORMATION

The pilot died on August 9, 2016. An autopsy was authorized and conducted on the pilot by the Fond du Lac County Medical Examiner's Office. The cause of death was attributed to multiple injuries sustained in an airplane accident. Forensic toxicology was not performed.

TESTS AND RESEARCH

Engine examination.

The engine was examined on August 17, 2016, in the presence of the NTSB Investigator in Charge. When examined, the engine remained attached to the engine mount.. The exhaust system was damaged and the muffler was not attached to the engine. No anomalies were noted of the ignition system. The fuel pump was removed and hand actuated. Liquid consistent in smell and color to aviation fuel was contained within the pump and squirted out when the pump was actuated. The oil cooler was detached and impact damaged. The engine was equipped with a non-approved aftermarket oil filter. The filter was cut open and inspected for ferrous material; no anomalies were noted. No anomalies were noted with the cylinders and cylinder heads. The engine was hand rotated; continuity was verified and no anomalies were noted. The radiator was impact damaged. The air filtration system was not available for examination.

The engine was equipped with two carburetors; one carburetor fed the number 1 and 3 cylinder, while the second carburetor fed the number 2 and 4 cylinders.

The 1/3-cylinder carburetor float bowl was removed. Flaking was noted on the floats and unidentified contamination, along with corrosion on the bottom of the float bowl. The main jet was clear of obstructions. No fuel was found within the carburetor.

The 2/4-cylinder carburetor float bowl was removed. Flaking was noted on the floats and contamination and corrosion on the bottom of the float bowl. The main jet was clear and no fuel was found within the carburetor. The piston slide was stuck on the carburetor chamber top. The piston was removed from the chamber top. An unknown substance was present that prevented the piston from sliding up and down within its respective bore. The piston slide was stuck in the idle position. Both carburetors were sent to the NTSB Materials Laboratory for further examination.

Carburetor examination.

The NTSB's laboratory removed the float bowls from each of the carburetors. Two black floats were present in each bowl, and all four floats moved freely on their respective posts. The floats were removed from the bowls and labeled by carburetor number and position relative to the side of the carburetor with the control lever. Next, each float was weighed and subsequently submerged for 12 hours in a covered container of automobile gasoline. After soaking, the floats were removed from the gasoline and then weighed again after the soak. Each float had a total weight gain of less than 1%. Additionally, the sum of the weights for the two floats from each carburetor was 5.668 grams and 5.674 grams for the 1/3 carburetor and the 2/4 carburetor, respectively. The maximum allowable combined weight for carburetor floats in each carburetor is 7 grams per the BRP-Powertrain Maintenance Manual for the Rotax 912-series engines.

The interior surfaces of the bowls had black areas along with areas of white film and other accumulations of white and yellow corrosion products. The black areas were mostly circular in shape and located on the lower surfaces of the bowls.

A white film was present in many areas, particularly on the lower surface and side of the bowl for carburetor 1/3. Isolated areas with thicker accumulations of white material was observed in some areas. When disturbed with tweezers, the accumulation had a powdery consistency, and the underlying surface of the bowl was black.

Some areas had an accumulation of yellow material. When disturbed with tweezers, the formation largely maintained its shape, but was easily broken into smaller crystalline chunks when pressure was applied. The surface under the yellow accumulation was also colored black.

Samples of the white and yellow accumulations were removed from the surface and placed onto carbon tape stuck to an aluminum stub to facilitate a compositional analysis using energy dispersive x-ray spectroscopy (EDS). Both samples had large peaks of zinc and oxygen consistent with oxides associated with the cast zinc bowl. Both samples also showed smaller peaks of sulfur and lead. The yellow sample and areas of the white sample also showed a peak of aluminum. Additionally, the yellow sample showed peaks of iron and potassium and a higher peak of carbon. Some areas of the yellow sample also showed a peak of silicon.

During the examination, the plunger from the 2/4 carburetor was reinserted into the 2/4 carburetor, and the springs and covers were put into place on their respective carburetors, and subsequently, the plungers were moved up and down. It was noted that the plunger from the 1/3 carburetor moved relatively easily while the plunger from the 2/4 carburetor had a tendency to stick. The plungers were removed from the carburetors with the housings and were manipulated again. The plunger from the 2/4 carburetor tended to stick compared to the plunger in the 1/3 carburetor.

The plungers were removed from the covers again, and accumulations of white material of varying thickness were present within the interior surface.

The surface of the plunger shaft housing on the 1/3 carburetor cover also had white material on the surface, but the material appeared to be more evenly distributed around the housing surface.

A sample of the white material from the plunger shaft housing from the 2/4 carburetor cover was removed and examined using EDS. The resulting spectrum showed high peaks of aluminum and oxygen, consistent with oxidation from the carburetor cover, which was made of an aluminum alloy.

ADDITIONAL INFORMATION

Rotax Aircraft Engines issued Service Instruction (SI)-912-021 on November 9, 2009. The following was extracted from that SI:

1.5) Compliance

- After engine installation/initial operation/return to service of an engine.

- When engine is running rough.

- And/or at the next scheduled maintenance event of carburetor (see Maintenance Manual for engine type 912/914 Series, current issue).

WARNING: Non-compliance with these instructions could result in engine damages, personal injuries or death.

3.1) General

Several carburetors have been found with contamination (dirt, remains of rubber from fuel lines and Loctite, resin-like substance, sediments etc.) in the float chamber.

WARNING: This contamination could possibly cause a partial or complete blockage of the idle or main jet or of other ducts vital for operation, leading to poor performance or stoppage of engine.

3.1.1) Possible shortcomings in the fuel system

- Dirt in the fuel system

- Missing or unsuitable fuel filter

- Clogged fuel filter

- Unsuitable fuel lines

- Dirt in fuel manifold

- Poor float chamber venting

- Insufficient flushing of the fuel system prior to initial engine operation

- Fuel pressure too low or too high

- Unsuitable fuel tanks and tank coatings

- Contaminated float chambers (e.g. corrosion caused by high water content in the fuel)

3.1.2) Fuel

Use only quality fuel as specified.

- EN 228 regular, EN 228 premium, EN 228 Super plus or AVGAS 100LL.

NOTE: The exact defined minimum requirements for fuel are specified in the relevant operators manual (for the relevant engine type) and the Service Instructions SI-912-016/SI-914-019 and SI-2ST-008 „Selection of suitable operating fluids", current issue.

The Rotax 912ULS engine maintenance manual specifies removal/assembly of both carburetors every 200 hours. 

Pilot Information

Certificate: Private
Age: 78, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Sport Pilot Unknown
Last FAA Medical Exam: 04/15/2002
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: 110 hours (Total, all aircraft), 0 hours (Total, this make and model) 

Pilot-Rated Passenger Information

Certificate: Flight Instructor; Commercial
Age: 71, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s):
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Single-engine; Instrument Airplane
Toxicology Performed: No
Medical Certification: None None
Last FAA Medical Exam: 07/15/1996
Occupational Pilot: No
Last Flight Review or Equivalent: 
Flight Time: 2136 hours (Total, all aircraft), 0 hours (Total, this make and model) 

Aircraft and Owner/Operator Information

Aircraft Manufacturer: FLIGHT DESIGN GMBH
Registration: N527TS
Model/Series: CTLS
Aircraft Category: Airplane
Year of Manufacture: 2008
Amateur Built: No
Airworthiness Certificate: Special Light-Sport
Serial Number: 08-02-04
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 01/24/2015, Annual
Certified Max Gross Wt.: 2950 lbs
Time Since Last Inspection: 135 Hours
Engines: 1 Reciprocating
Airframe Total Time: 960 Hours at time of accident
Engine Manufacturer: ROTAX
ELT: Installed, activated, did not aid in locating accident
Engine Model/Series: 912ULS
Registered Owner: On file
Rated Power: 100 hp
Operator: On file
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KFLD, 807 ft msl
Observation Time: 1321 UTC
Distance from Accident Site: 1 Nautical Miles
Direction from Accident Site: 188°
Lowest Cloud Condition: Scattered / 1700 ft agl
Temperature/Dew Point: 19°C / 17°C
Lowest Ceiling: Broken / 5000 ft agl
Visibility:  10 Miles
Wind Speed/Gusts, Direction: 8 knots, 60°
Visibility (RVR):
Altimeter Setting: 29.97 inches Hg
Visibility (RVV):
Precipitation and Obscuration: Light - Rain
Departure Point: Fond du Lac, WI (FLD)
Type of Flight Plan Filed: None
Destination:
Type of Clearance: None
Departure Time: 0820 CDT
Type of Airspace: Class G

Airport Information

Airport: FOND DU LAC COUNTY (FLD)
Runway Surface Type: Asphalt
Airport Elevation: 808 ft
Runway Surface Condition: Unknown
Runway Used: 36
IFR Approach: None
Runway Length/Width: 5941 ft / 100 ft
VFR Approach/Landing: None 

Wreckage and Impact Information

Crew Injuries: 1 Fatal, 1 Serious
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal, 1 Serious
Latitude, Longitude:  43.780000, -88.488889

NTSB Identification: CEN16FA290
14 CFR Part 91: General Aviation
Accident occurred Thursday, July 28, 2016 in Fond du Lac, WI
Aircraft: FLIGHT DESIGN GMBH CTLS, registration: N527TS
Injuries: 2 Serious.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On July 28, 2016, about 0821 central daylight time, a Flight Design GMBH model CTLS airplane, N527TS, impacted terrain while returning to land after initial takeoff. The pilot and single passenger were seriously injured. The airplane was substantially damaged. The airplane was registered to, and operated by a private individual as a 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed at the accident site about the time of the accident, and the flight was operated without a flight plan. The flight originated from Fond du Lac County Airport (FLD), Fond du Lac, Wisconsin at the time of the accident and its destination was not determined.

Witnesses reported seeing the airplane takeoff to the north and start a left turn back to the airport. They stated the engine sounded abnormal and the airplane did not climb above treetop height before it rolled into a steep left turn and descended into terrain. An additional witness did not see the accident occur, but said they heard the pilot on the radio state he was making an immediate return to the airport.

During the impact both wings separated from the fuselage and the engine intruded into the cockpit area. Flight control continuity to the elevator and rudder was verified continuous from the cockpit to each control surface. Flight control continuity was interrupted to both wings, but all observed breaks in continuity were consistent with failure in overload during impact. Some fuel smell was present at the accident scene, but both the left and right fuel tanks were compromised. Several ounces of fuel were recovered from the right wing tank, which appeared light blue in color and free of contaminants. The three composite propeller blades were separated from the propeller hub. The blade sections that were observed were absent chord wise scratches or leading edge damage. The engine and wreckage were recovered to a secure storage location and retained for further examination.




SANTA FE – Two Santa Fe men injured in the crash of their lightweight plane in Wisconsin were still listed in critical condition on Friday.

The men have been identified as David D. Spencer, 78, who owned and piloted the plane that crashed after take-off on Thursday, and his passenger Rafael J. Chavez, 71.

Sgt. Paul Rottscholl of the Fond du Lac County Sheriff’s Office said Friday the plane appeared to lose power soon after taking off from the Fond du Lac County Airport about 8:20 a.m. Thursday. “It appeared as if the pilot was attempting to turn around and land back at the airstrip, but it didn’t make it and crashed into an open field,” he said.

Rottscholl said the crash was witnessed by employees of a nearby medical clinic. “A couple of nurses and doctors and a trauma surgeon ran over to the crash site and stated attending to the passenger, who was sitting outside the plane semiconscious,” he said.

The pilot was still inside the aircraft but pinned under the engine and also semiconscious when Rottscholl arrived a few minutes after the crash. “Myself and the firefighters there made the decision to pick up the plane to get him free, and we were able to do that,” he said.

Spencer and Chavez were separately transported by medical helicopter to ThedaCare Regional Medical Center in Neenah, Wis.

Cameron Humphres, manager of the Santa Fe Municipal Airport, confirmed the plane — a two-seat, fixed wing CTLS model manufactured in 2008 by Flight Design  —was registered there. He said pilots flying under visual flight rules aren’t required to file a flight plan, but it is believed the plane left Santa Fe last Saturday morning.

Spencer and Chavez were likely in Wisconsin to attend AirVenture, a week-long convention of the Experimental Aircraft Association held at Whittman Regional Airport in Oshkosh, Wis. that according to its website attracts about 500,000 people and 10,000 airplanes each year. Sgt. Rottscholl and said many people attending that event use the Fond du Lac airport due to the overflow.

New Mexico Lt. Gov. John Sanchez, staff members with the Department of Transportation’s Aviation Division, and representatives from some of the state’s economic development organizations attended the EAA AirVenture this week. “Our state is in a prime position to benefit from the growing demands of the global market, and this is one of the best venues to showcase all we have to offer the aerospace, aviation, and defense industries,” Sanchez said in a news release earlier this week.




FOND DU LAC COUNTY (WLUK) -- Two men are in critical condition after their plane crashed Thursday morning at The Fond du Lac County Airport.

The plane crashed at an airport that's especially busy this time of year, because of EAA AirVenture up the road in Oshkosh.

Investigators say the plane had taken off, but had to turn back because of mechanical issues.

Investigators combed through the field at the northwest corner of the Fond du Lac County Airport, looking for clues as to why a small white plane crashed early Thursday morning.

"The witnesses said they saw it coming down. And said it made an abrupt turn. They thought it was going to be turning to get to the runway, and then it hit the ground," said Rick Olig, Fond du Lac County Sheriff's Office Captain.

Two people were on board. They've been identified as 78-year-old David Spencer and 71-year-old Rafael Chaves. Both men are from Santa Fe, New Mexico.

"When our medical people got to the scene, we began to treat those people, and they were both injured severely," said Peter O'Leary, Fond du Lac Fire Chief.

Flight for Life and ThedaStar helicopters transported the two men to ThedaCare Regional Medical Center-Neenah.

According to The Federal Aviation Administration, the light sport aircraft took off from the Fond du Lac airport, but the pilot soon asked to return. The plane had clearance to land, but crashed about a half-mile short of the runway.

"We do have quite a few witnesses that actually saw it prior to, and actually saw the crash. The preliminary indications are that the engine was functioning at the time of the crash. They didn't hear anything that appeared to be out of the ordinary," said Olig.

Investigators say The Fond du Lac County Airport is very busy this time of year, handling numerous flights to and from EAA AirVenture in Oshkosh.

"The number of planes that come in and out of here everyday, during EAA is significant. And significant enough the FAA wants to have a staffed tower here," said O'Leary.

The airport was closed for about an hour Thursday morning.

The FAA says its investigation will take about three weeks to complete.

It is unknown whether the men were attending EAA AirVenture in Oshkosh.

Story and video:   http://fox11online.com



FOND DU LAC, Wis.-- - The victims of Thursday morning's plane crash at the Fond du Lac County Airport have been identified. They are 78 year old David Spencer and 71 year old Rafael Chaves, both from Santa Fe, New Mexico. The victims suffered serious injuries and are in ThedaCare Regional Medical Center in Neenah for treatment.

Original Story:

A plane has crashed at the Fond du Lac County Airport. 

The Fond du Lac County Sheriff's office says that two men are critically injured and were flown to a hospital.

Witnesses say the plane was flying low, and it appeared as if it was going to land. That's when the plane banked abruptly and crashed.

Fond du Lac County Fire and Rescue chief Peter O'Leary says crews are responding. 

The FAA is investigating the crash. 

The airport was closed during rescue operations but has since opened up.

Source:   http://www.wtmj.com



FOND DU LAC - A single-engine plane crashed about 8:20 a.m Thursday in the northwest corner of the Fond du Lac County Airport. White smoke burst from the engine as firefighters and an ambulance arrived on scene.

Two men, about the age of 60, were seriously injured and transported separately by Flight for Life and ThedaStar to ThedaCare Regional Medical Center- Neenah, said Rick Olig, captain of operations for the Fond du Lac County Sheriff's Office.

Witnesses of the crash say the plane was flying low and appeared as if it was going to land, Olig said. The plane banked abruptly and crashed.

The crash area was on an open field several hundred yards from the north/south runway.

The two-seat, fixed-wing plane is a model CTLS manufactured by Flight Design, based in Germany, and was last registered in Santa Fe, New Mexico, according to the Aircraft Lookup app.

The Fond du Lac County Airport reopened about 10 a.m., said John Wehner, manager of the Fond du Lac County Airport. This is the first crash at the airport since the 1990s, Wehner said.

Since Sunday, the county airport has been busy as flyers arrive for the EAA AirVenture in Oshkosh. Wehner estimated that the airport would handle 5,000 flights from July 24 to 31, which is 625 flight operations a day. Normally the airport has about 150 daily operation flights, he said.

The sheriff's office is working with federal agencies to determine the cause of the crash.

Story and video: http://www.fdlreporter.com






FOND DU LAC COUNTY, Wis. (WBAY) – Two people were airlifted from the scene of a plane crash at Fond du Lac County Airport, according to Fond du Lac Fire/Rescue.

Officials tell Action 2 News the small, single engine plane crashed west of the runway in a field at about 8:21 Thursday morning.

The Fond du Lac County Sheriff’s Office says witnesses reported the plane was low and it appeared as if it was going to land.

“The plane banked abruptly and crashed,” according to a Sheriff’s Office statement.

Two men believed to be in their 60s or older suffered critical injuries and were airlifted to a local hospital.

The Federal Aviation Administration is investigating the crash.

Fond du Lac Fire/Rescue, Town of Fond du Lac Fire, the Sheriff’s Office, Flight for Life, Theda Star, and the FAA responded to the crash scene.

Fond du Lac County Sheriff’s Office is working with federal agencies to determine what may have caused the crash.  The airport was closed while rescue operations were ongoing, but has since opened up for normal operations.

Source:  http://wbay.com






Two men were injured when a small plane crashed at Fond du Lac County Airport.

The crash happened Thursday morning. The Fond du Lac Action Reporter says white smoke burst from the engine as an ambulance arrived.

Fond du Lac Sheriff's Office captain of operations Rick Olig says the victims were men. He described their injuries as critical. Both were flown to the hospital.

Fond du Lac fire Chief Peter O'Leary says the single engine aircraft crashed on the northwest corner of the airport property, several hundred yards west of a runway.

Olig says witnesses told authorities the plane was flying low and appeared as if it was going to land when it abruptly banked and crashed.

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