Sunday, July 11, 2021

Fuel Related: Zenair CH 601XL, N601MR; accident occurred July 13, 2019 at Carlisle Airport (N94), Cumberland County, Pennsylvania

Aviation Accident Final Report - National Transportation Safety Board 

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Harrisburg, Pennsylvania

Investigation Docket - National Transportation Safety Board:

Location: Carlisle, Pennsylvania 
Accident Number: ERA19LA224
Date & Time: July 13, 2019, 08:50 Local
Registration: N601MR
Aircraft: Zenith CH601 
Aircraft Damage: Substantial
Defining Event: Fuel related 
Injuries: 1 None
Flight Conducted Under: Part 91: General aviation - Personal


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.

Probable Cause and Findings

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


Aircraft Fuel - Inadequate inspection
Aircraft Fuel - Fluid condition
Personnel issues Preflight inspection - Pilot

Factual Information

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 of 30.00 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."

History of Flight

Initial climb Fuel related (Defining event)
Initial climb Off-field or emergency landing

Pilot Information

Certificate: Private 
Age: 58, 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: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 With waivers/limitations 
Last FAA Medical Exam: September 24, 2009
Occupational Pilot: No
Last Flight Review or Equivalent: October 26, 2016
Flight Time: 402.7 hours (Total, all aircraft), 313 hours (Total, this make and model), 331.7 hours (Pilot In Command, all aircraft), 11.3 hours (Last 90 days, all aircraft), 5 hours (Last 30 days, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Zenith
Registration: N601MR
Model/Series: CH601 XL 
Aircraft Category: Airplane
Year of Manufacture: 2009
Amateur Built: Yes
Airworthiness Certificate: Experimental (Special) 
Serial Number: 6-5414
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: November 12, 2018
Condition Certified Max Gross Wt.: 1320 lbs
Time Since Last Inspection: 9 Hrs
Engines: 1 Reciprocating
Airframe Total Time: 309.1 Hrs at time of accident
Engine Manufacturer: Jabiru
ELT: C91 installed, activated, did not aid in locating accident
Engine Model/Series: 3300A
Registered Owner: 
Rated Power: 120 Horsepower
Operator: On file
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC) 
Condition of Light: Day
Observation Facility, Elevation: KCXY,347 ft msl 
Distance from Accident Site: 15 Nautical Miles
Observation Time: 08:56 Local 
Direction from Accident Site: 83°
Lowest Cloud Condition: Clear
Visibility: 10 miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 8 knots /
Turbulence Type Forecast/Actual: None / Unknown
Wind Direction: 240°
Turbulence Severity Forecast/Actual: N/A / Unknown
Altimeter Setting: 30 inches Hg
Temperature/Dew Point: 24°C / 17°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Carlisle, PA (N94) 
Type of Flight Plan Filed: None
Destination: York, PA (THV) 
Type of Clearance: None
Departure Time: 08:50 Local
Type of Airspace: Class G

Airport Information

Airport: Carlisle N94 Runway
Surface Type: Asphalt
Airport Elevation: 510 ft msl 
Runway Surface Condition: Dry
Runway Used: 28 
IFR Approach: None
Runway Length/Width: 4008 ft / 60 ft 
VFR Approach/Landing: Forced landing

Wreckage and Impact Information

Crew Injuries: 1 None Aircraft
Damage: Substantial
Passenger Injuries:
Aircraft Fire: None
Ground Injuries: N/A 
Aircraft Explosion: None
Total Injuries: 1 None 
Latitude, Longitude: 40.187778,-77.169441(est)

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