Tuesday, November 6, 2018

Flight Design GMBH CTLS, N21ZA: Accident occurred November 04, 2018, Incidents occurred September 16, 2018 and October 17, 2012; Accident occurred July 19, 2012 in Lorain County, Ohio

Federal Aviation Administration / Flight Standards District Office; Cleveland, Ohio

RAS Aviation LLC

https://registry.faa.gov/N21ZA

NTSB Identification: GAA19CA049
14 CFR Part 91: General Aviation
Accident occurred Sunday, November 04, 2018 in LORAIN/ELYRIA, OH
Aircraft: Flight Design CTLS, registration: N21ZA

NTSB investigators will use data provided by various entities, including, but not limited to, the Federal Aviation Administration and/or the operator, and will not travel in support of this investigation to prepare this aircraft accident report.

Gear collapsed.


Date: 04-NOV-18
Time: 18:35:00Z
Regis#: N21ZA
Aircraft Make: FLIGHT DESIGN
Aircraft Model: CTLS
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: PERSONAL
Flight Phase: LANDING (LDG)
Operation: 91
City: LORAIN
State: OHIO

Federal Aviation Administration / Flight Standards District Office; Cleveland, Ohio

September 16, 2018: Landed in a field.

Date: 16-SEP-18
Time: 17:25:00Z
Regis#: N21ZA
Aircraft Make: FLIGHT DESIGN
Aircraft Model: CTLS
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: MINOR
Activity: UNKNOWN
Flight Phase: LANDING (LDG)
Operation: 91
City: LORAIN
State: OHIO

Aviation Incident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

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

Aviation Incident Data Summary - National Transportation Safety Board:  https://app.ntsb.gov/pdf

Location: Elyria, OH
Incident Number: CEN13IA024
Date & Time: 10/17/2012, 1330 EDT
Registration: N21ZA
Aircraft: FLIGHT DESIGN CTLS
Aircraft Damage: Minor
Defining Event: Landing gear collapse
Injuries: 2 None
Flight Conducted Under: Part 91: General Aviation - Instructional

Analysis

The flight instructor reported that the airplane’s fixed right main landing gear collapsed during landing. He reported that the landing was “not extraordinarily hard” and that it should have been well within the airplane’s typical performance.

Postincident examination of the composite right main landing gear leg revealed several manufacturing defects, including wrinkled layers and layers that terminated at the surface when they should have been continuous, which reduced the landing gear leg’s strength and its ability to resist longitudinal cracks. As a result of this investigation, the airplane manufacturer conducted an audit of the subcontractor that manufactured the landing gear legs. The audit revealed that, before the incident, the landing gear manufacturer had become aware of quality issues related to the mold closing process of the landing gear legs during manufacture and had implemented steps to reduce the recurrence of these issues. Based on the available evidence, the manufacturing defects in the composite main landing gear leg likely reduced the leg’s load-carrying capacity and resulted in its eventual failure. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this incident to be:
The manufacturing defects in the main landing gear leg, which resulted in its eventual failure.

Findings

Aircraft
Main gear strut/axle/truck - Failure (Cause)

Organizational issues
Equipment manufacture - Manufacturer (Cause)

Factual Information

On October 17, 2012, about 1330 eastern daylight time, a Flight Design GMBH model CTLS, N21ZA, sustained substantial damage while landing on runway 25 at the Lorain County Airport (LPR), Elyria, Ohio. The flight instructor and student pilot were not injured. The airplane sustained minor damage to the landing gear during the mishap. The aircraft was registered to RAS Aviation LLC, Elyria, Ohio, and operated by Zone Aviation, Elyria, Ohio, under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed for the flight, which was not operated on a flight plan. The local flight originated at an unconfirmed time.

The flight instructor reported that the flight was a training flight and on the first landing the right main landing gear collapsed. He stated that the landing was "not extraordinarily hard". He went on to add that based on his experience in the same model airplane that the landing should have been well within typical performance of the airplane.

During the investigation it was discovered that this same airplane was involved in a landing accident on July 19, 2012 (CEN12LA676). The July accident also resulted in a fracture of the right main landing gear leg.

The damaged right main landing gear leg from this incident was retained for further examination.  The main landing gear leg was made of composite material. The fiber reinforcements used in the composite construction included unidirectional glass fibers, glass fiber fabric, and basalt fiber fabric. Flexible plastic tubes extended the length of the legs enclosed within ribbed plastic tubes located near the leading and trailing edges of the leg. Foam filled space between the plastic tubes and a center internal cavity. The legs were manufactured in a mold with the split line at the leading and trailing edges. During the layup process, layers were placed in a mold half representing the upper half of the leg, and layers were wrapped around the internal tubes, foam, center cavity, and preformed layers. The mold was then closed with a mold piece representing the lower half of the landing gear, and the center internal cavity was pressurized during curing. Examination and sectioning of the landing gear leg showed wrinkling of the fibers resulting in their orientation being angled with relation to the surface rather than parallel to the surface. Additionally several layers terminated at the leading and trailing edges. The location of theses terminating layers corresponded with the location of longitudinal cracks found along the leading and trailing edges of the landing gear.

As a result of the investigation, the manufacturer of the airplane was contacted regarding the landing gear manufacturing process. The landing gear legs were manufactured by a sub-contractor to the airplane manufacturer. The airplane manufacture conducted an audit of the sub-contractor and determined that there were some previous quality issues with regard to mold closing during the manufacture of the landing gear legs. It was reported that the landing gear manufacturer had recognized these issues and had implemented steps to reduce the risk of recurrence of these issues. The airplane manufacturer also conducted a search of part requests and difficulty reports related to the main landing gear. This records search showed 3 occurrences which resulted in complete collapse of the landing gear leg out of a fleet of 370 airplanes. All other reported landing gear leg fractures were discovered either during inspection after a hard landing, or during taxi operation when significantly reduced stiffness was encountered.

History of Flight

Landing-landing roll
Landing gear collapse (Defining event) 

Flight Instructor Information

Certificate: Commercial
Age: 38
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used: Seatbelt, Shoulder harness
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine; Instrument Airplane
Toxicology Performed: No
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 10/04/2011
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time:  910 hours (Total, all aircraft), 425 hours (Total, this make and model), 135 hours (Last 90 days, all aircraft)

Student Pilot Information

Certificate: Student
Age: 23
Airplane Rating(s): None
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Seatbelt, Shoulder harness
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 10/18/2011
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  30 hours (Total, all aircraft), 30 hours (Total, this make and model)

Aircraft and Owner/Operator Information

Aircraft Make: FLIGHT DESIGN
Registration: N21ZA
Model/Series: CTLS
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Special Light-Sport
Serial Number: F-10-09-04
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection:  Unknown
Certified Max Gross Wt.: 1320 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time:
Engine Manufacturer: ROTAX
ELT: Installed, not activated
Engine Model/Series: 912
Registered Owner: RAS Aviation LLC
Rated Power: 100 hp
Operator: Zone Aviation
Operating Certificate(s) Held: None
Operator Does Business As: Zone Aviation
Operator Designator Code:

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: LPR, 793 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1353 EDT
Direction from Accident Site: 0°
Lowest Cloud Condition:
Visibility: 8 Miles
Lowest Ceiling: Overcast / 9000 ft agl
Visibility (RVR):
Wind Speed/Gusts: 9 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 190°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.77 inches Hg
Temperature/Dew Point: 18°C / 8°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Elyria, OH (LPR)
Type of Flight Plan Filed: None
Destination: Elyria, OH (LPR)
Type of Clearance: None
Departure Time:  EDT
Type of Airspace:

Airport Information

Airport: Lorain County Regional Airport (LPR)
Runway Surface Type: Asphalt
Airport Elevation: 793 ft
Runway Surface Condition: Dry
Runway Used: 25
IFR Approach: None
Runway Length/Width: 5002 ft / 100 ft
VFR Approach/Landing: Traffic Pattern

Wreckage and Impact Information

Crew Injuries: 2 None
Aircraft Damage: Minor
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 None
Latitude, Longitude: 41.344167, -82.177778

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

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


Aviation Accident Data Summary - National Transportation Safety Board: https://app.ntsb.gov/pdf

Location: Elyria, OH
Accident Number: CEN12LA676
Date & Time: 07/19/2012, 2200 EDT
Registration: N21ZA
Aircraft: FLIGHT DESIGN CTLS
Aircraft Damage: Substantial
Defining Event: Abnormal runway contact
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis

The pilot reported that, on the day of the accident, he had accomplished three landings in the accident airplane and that he was pleased with these landings. Forty-five minutes after the last day landing, he took off for a night flight. During the first attempted landing, he misjudged the flare, and the airplane bounced. He subsequently performed a go-around and again misjudged the landing flare. The airplane subsequently bounced hard on the runway, which resulted in a flat nosewheel tire and firewall and right main landing gear damage. Although examination of the right main landing gear leg revealed several manufacturing defects that have since been addressed by the landing gear leg manufacturer, the accident was likely caused by the pilot’s misjudged landing flare, which resulted in a hard landing and the subsequent right main landing gear damage.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

The pilot’s misjudged landing flare, which resulted in a hard landing.

Findings


Aircraft

Landing flare - Not attained/maintained (Cause)

Personnel issues
Aircraft control - Pilot (Cause)

Organizational issues
Equipment manufacture - Manufacturer

Factual Information

On July 19, 2012, about 2200 eastern daylight time, a Flight Design GMBH model CTLS, N21ZA, sustained substantial damage while landing on runway 7 at the Lorain County Airport (LPR), Elyria, Ohio. The private pilot who was the sole occupant was not injured. The airplane sustained damage to the landing gear, engine mount and firewall during the mishap. The aircraft was registered to RAS Aviation LLC, Elyria, Ohio, and operated by Zone Aviation, Elyria, Ohio, under the provisions of 14 Code of Federal Regulations Part 91. The airplane was rented by the pilot for a personal flight. Visual meteorological conditions prevailed for the flight, which was not operated on a flight plan. The local flight originated at an unconfirmed time.

The accident was not initially reported to authorities and was discovered while investigating another incident that happened with this airplane. On October 17, 2012, about 1330 the airplane sustained minor damage while landing on runway 25 at LPR (CEN13IA024). In both instances, the right composite landing gear leg fractured. 

Regarding the July accident, the pilot reported that he was performing takeoff and landing practice. He performed 3 landings during the daylight and he reported that he was pleased with these landings.  After a 45 minute break he took off again to perform night landings to regain night currency requirements. He reported that on the first night landing he misjudged the landing and bounced. He performed a go-around and came back in for another landing. He again misjudged the landing and "bounced hard". The airplane came back down striking the nose wheel. As the airplane came to a stop the pilot realized there was something wrong and upon de-planing, discovered a flat nose tire. He pushed the airplane from the runway and acquired a tow from ramp personnel.

The damaged right main landing gear leg was retained for further examination.  The main landing gear leg was made of composite material. The fiber reinforcements used in the composite construction included unidirectional glass fibers, glass fiber fabric, and basalt fiber fabric. Flexible plastic tubes extended the length of the legs enclosed within ribbed plastic tubes located near the leading and trailing edges of the leg. Foam filled space between the plastic tubes and a center internal cavity. The legs were manufactured in a mold with the split line at the leading and trailing edges. During the layup process, layers were placed in a mold half representing the upper half of the leg, and layers were wrapped around the internal tubes, foam, center cavity, and preformed layers. The mold was then closed with a mold piece representing the lower half of the landing gear, and the center internal cavity was pressurized during curing. Examination and sectioning of the landing gear leg showed wrinkling of the fibers resulting in their orientation being angled with relation to the surface rather than parallel to the surface. Additionally several layers terminated at the leading and trailing edges. The location of theses terminating layers corresponded with the location of longitudinal cracks found along the leading and trailing edges of the landing gear.

As a result of the investigation, the manufacturer of the airplane was contacted regarding the landing gear manufacturing process. The landing gear legs were manufactured by a sub-contractor to the airplane manufacturer. The airplane manufacture conducted an audit of the sub-contractor and determined that there were some previous quality issues with regard to mold closing during the manufacture of the landing gear legs. It was reported that the landing gear manufacturer had recognized these issues and had implemented steps to reduce the risk of recurrence of these issues. The airplane manufacturer also conducted a search of part requests and difficulty reports related to the main landing gear. This records search showed 3 occurrences which resulted in complete collapse of the landing gear leg out of a fleet of 370 airplanes. All other reported landing gear leg fractures were discovered either during inspection after a hard landing, or during taxi operation when significantly reduced stiffness was encountered. 

History of Flight

Landing-flare/touchdown

Abnormal runway contact (Defining event) 

Pilot Information

Certificate: Private
Age: 55
Airplane Rating(s):  Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Seatbelt, Shoulder harness
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 09/20/2010
Occupational Pilot: No
Last Flight Review or Equivalent: 
Flight Time: 119 hours (Total, all aircraft), 48 hours (Total, this make and model), 59 hours (Pilot In Command, all aircraft), 1 hours (Last 90 days, all aircraft), 1 hours (Last 30 days, all aircraft), 1 hours (Last 24 hours, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: FLIGHT DESIGN
Registration: N21ZA
Model/Series: CTLS
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Special Light-Sport
Serial Number: F-10-09-04
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 
Certified Max Gross Wt.: 1320 lbs
Time Since Last Inspection: 
Engines: 1 Reciprocating
Airframe Total Time:
Engine Manufacturer: Rotax
ELT:
Engine Model/Series: 912
Registered Owner: RAS Aviation LLC
Rated Power: 100 hp
Operator: Zone Aviation
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan


Conditions at Accident Site: Visual Conditions
Condition of Light: Night
Observation Facility, Elevation: LPR, 793 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 2153 EDT
Direction from Accident Site: 0°
Lowest Cloud Condition: Scattered / 10000 ft agl
Visibility: 9 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 9 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 70°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.91 inches Hg
Temperature/Dew Point: 23°C / 20°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Elyria, OH (LPR)
Type of Flight Plan Filed: None
Destination: Elyria, OH (LPR)
Type of Clearance: None
Departure Time:  EDT
Type of Airspace:

Airport Information


Airport: Lorain County Regional Airport (LPR)
Runway Surface Type: Asphalt
Airport Elevation: 793 ft
Runway Surface Condition: Dry
Runway Used: 07
IFR Approach: None
Runway Length/Width: 5002 ft / 100 ft
VFR Approach/Landing: Traffic Pattern

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude:   41.344167, -82.177778

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