BLUM MATTHEW AVENTURA II near Boca Raton, FL — 2009-09-06

Probable cause

The improper assembly of both carburetors, resulting in an excessively rich fuel to air ratio and subsequent partial loss of engine power.

NTSB narrative

The pilot had not flown the airplane for the 2 ½ months prior to the accident. The pilot departed to practice full-stop landings, and as he turned onto the crosswind leg a witness reported hearing the engine sputtering. Postaccident examination of the airplane revealed an improper assembly of both carburetors which could have caused an excessively rich fuel to air ratio. While maneuvering, the airplane stalled and impacted a road. No airframe preimpact failure or malfunction was noted, and no determination could be made as to who improperly assembled the carburetors.

Analysis

Primary failure mode

Loss of control

First missed decision gate

Pilot could have aborted the maneuver before losing control.

NTSB coding

• Loss of control in flight · Approach-VFR pattern crosswind

Evidence available

• ATC audio
• Photos
• 21 docket documents

Docket documents21

• FAA Form 5010 for Boca Raton Airportform
• Release of Aircraft Wreckage, NTSB Form 6120.15form
• FAA Inspector Statementinterview
• Personnel Statementinterview
• Statement of Party Representatives to NTSB Investigationinterview
• Witness Statementsinterview
• E-mail From Pilot's Daughterother
• Excerpts from Airworthiness Fileother
• Excerpts from Carburetor Illustrated Parts Catalogother
• Excerpts from Maintenance Recordsother
• Excerpts from Pilot Logbookother
• Google Earth Plotother
• Photo 1: Digital Photograph Provided by FAA. View of the Wreckage at the Accident Site.photos
• Photo 2: Digital Photograph Provided by FAA. View of the Wreckage During Recovery from the Site.photos
• Photo 3: Digital Photograph Provided by Rotax. View Showing Improper Assembly of the Needle Clip for One of the Caburetors.photos
• Photo 4: Digital Photograph Provided by Rotax. View of the Power Take Off (Propeller Side) Spark Plugs.photos
• Photo 5: Digital Photograph Provided by Rotax. View of the MAG (Ignition Side) Spark Plugs.photos
• Reports from Parties to the Investigation-Rotax Flying & Safety Clubreport
• Toxicological Reportsreport
• Weather Reports and Recordsreport
• Transcript of Radio Communicationstranscript

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