Piston Plane Refueled with Jet Fuel Kills Pilot

[ChickenHouse]

Maybe we can shift the discussion to - what you can do to prevent things like this?

So, when can you recognize getting the wrong fuel?
1. its written on the fuel truck or the tap
2. it smells wrong when put in the tank
3. the color of the tank filler does not match the fuel pistol (not on every field)
4. at drain it does not look blue
5. at confirmation of filled tank by open & look at it it smells wrong (again)
6. warming up the machine shows rough run
7. ? what else

[Flying Lawyer]

NTSB preliminary information

NTSB Identification: WPR15LA111
14 CFR Part 91: General Aviation
Accident occurred Sunday, February 22, 2015 in Spokane, WA
Aircraft: PIPER PA46 - 350P, registration: CGVZW
Injuries: 1 Fatal.

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 may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On February 22, 2015, at 1405 Pacific standard time, a Piper Aircraft, Inc., PA46-350P airplane, Canadian registry CGVZW, experienced a loss of engine power during climb out from runway 22R at Felts Field Airport (SFF), Spokane, Washington. The Canadian certificated pilot, the sole occupant, succumbed to his injuries on February 24, 2015. The airplane was destroyed during the attempted emergency landing after it struck a railroad track. Visual meteorological conditions prevailed for the instrument flight rules (IFR) flight that originated shortly before the accident. The flight was destined for the Stockton Metropolitan Airport (SCK) Stockton, California.

A National Transportation Safety Board (NTSB) investigator and a Federal Aviation Administration (FAA) inspector responded to the accident site and identified two different groups of witnesses. The first set of witnesses observed the airplane with the engine sputtering. They observed the left wing drop and the nose pitch up. The right wing then dropped, and the witnesses lost sight of the airplane as it passed behind a building. The second set of witnesses reported that the right wing struck a railroad track at the top of a hill and subsequently traveled down an embankment. The witnesses reported that the airplane slid across a road and came to rest inverted adjacent to the bottom of a railroad bridge.

Responding investigators stated that the majority of the airplane came to rest at the accident site, with additional wreckage strewn throughout the debris path. Both of the wings had separated from the airplane fuselage; however, they remained near the main wreckage. The investigators stated that the fuel tanks ruptured during the accident sequence, and there was a strong smell of Jet fuel present.

The FAA inspector obtained the fueling log from Western Aviation at SFF; the fuel log indicated that the accident airplane had been refueled with 52 gallons of Jet fuel prior to takeoff.

skyhighfallguy

Thank you for drawing attention to the 'wrong fuel' hazard that might lead to our death or, in ordinary language, might kill us.

On the limited information currently available:
But for the refuelling error -
- there is no reason to suppose that the pilot would have had to try to cope with a serious emergency shortly after take-off.
- there is no reason to suppose that the poor man would have died.

When the lawsuit happens (and it will), what will the jury find?

My guess (on the limited information currently available) is the same as yours.




Current 'unknowns' include:

• Who fuelled the aircraft? The (visiting) pilot or an FBO employee?
  
  
• How easy/difficult is it to cope with an EFATO from that airfield?
• Did the pilot have many or limited options?

The aircraft went down about 4 miles from Felts Field - before it reached the open land which can be seen at the top of the first pic. (The locations of Spokane International and Fairchild AFB.


FL

[9 lives]

The first set of witnesses observed the airplane with the engine sputtering. They observed the left wing drop and the nose pitch up. The right wing then dropped,

This report makes it appear that the pilot did not continue to fly the aircraft after the engine produced less power.

So, the cause of the fatality was a crash. The cause of the crash was failure to maintain flying speed following a loss of power. The cause of loss of power was misfueling. The cause of the misfueling included inattention by the pilot.

A departure toward the built up area looks like it would be messy to force land into, but not necessarily fatal, if the aircraft returned to earth under control.

If the fuel were correct, would there have been a crash? Probably not - this time. But, the underlying fact seems to be the the pilot did not continue to fly the plane. Any number of other anomalies could put that pilot in a position where "flying" the plane was immediately required.

I'm going to have a look at Mary's EFATO thread. After a bit of research, I'll have some comments on "best glide speed" as it relates to EFATO....

[skyhighfallguy]

Step turn and others. IF the fuel had been correct, and the engine was well maintained, why would the engine quit?


How do we know the engine quitting didn't also somehow cause a stroke or other health concern to rear its head causing the pilot to be incapable of flying the plane.

YES, we should all know what to do if the engine quits at any time. But if you have ever taken off from airports surrounded by urban scene there simply isn't much choice.


Should we ban these airports?

Lindbergh knew if his engine quit on takeoff it was probably all over. He knew that if his engine quit over the north atlantic, it was all over.

He took precautions, including filtering the fuel through chamois, and selecting the engine which had been through amazing tests (for the time) to ensure reliability.


Engines don't quit all the time. Wings don't fall off all the time, pilots don't die at the controls all the time, this plane crashed because the fuel was wrong.

[Flying Lawyer]

skyhighfallguy

How do we know the engine quitting didn't also somehow cause a stroke or other health concern to rear its head causing the pilot to be incapable of flying the plane.

We don't.

YES, we should all know what to do if the engine quits at any time. But if you have ever taken off from airports surrounded by urban scene there simply isn't much choice.

Coping with such an emergency (and flying in general) is much easier when sitting at a keyboard.



Courts have made adverse findings regarding the manner in which pilots/crews have dealt with an emergency/malfunction but it depends very much upon the circumstances.
An example here: http://www.pprune.org/aviation-histo...-bradford.html
NB:
The facts were very different.
In this example, the Judge's findings against the crew did not determine the outcome of the case.

[barit1]

YES, we should all know what to do if the engine quits at any time. But if you have ever taken off from airports surrounded by urban scene there simply isn't much choice.

I think the recent Harrison Ford EFATO in his PT-22/ST3KR illustrated this very well. This 72-year-old pilot handled it very well, even though we have no idea of the failure cause yet. (The 75-year fatal accident history of this model is dominated by stall/spin accidents in the traffic pattern.)

But given the reputation of the Kinner engine (indeed, many engines of that era), one might question his judgement in basing the Ryan at that airport. He was lucky in being in position to avail himself of the #8 fairway to land.

[skyhighfallguy]

When I first was selecting an airport to learn the art of flying, I was faced with two reasonable choices based upon distance from my home.

KSQL or KPAO. Next to KSQL was a major freeway and a junkyard. Next to KPAO was a very nice golf course.

Even back then I chose the airport near the golf course. I told the chief flight instructor I chose his school because of the golf course. He said: oh, you must like golf

No, I said, I thought the golf course would be good for an emergency landing.

He smiled. We got along fine.

as Baritone (barit1) mentioned the reputation of the kinner engine, regarding the KSMO crackup, isn't it odd that KSMO bans JETS? (well sort of)

A two engine jet might have been safer than a one engine kinner powered plane.


All I am saying is that reasonable care (and certainly ford cared) will prevent most engine failures. Refueling with the wrong type of fuel goes in the category of NOT reasonable care. Would you put diesel fuel in a gasoline automobile? ONLY ONCE!

[Gertrude the Wombat]

Would you put diesel fuel in a gasoline automobile? ONLY ONCE!

Yeahbut everybody does, once (well, or the other way round, as in my case) - the garage man didn't laugh at me, he just said "yeah, I've done that, we all have, there's them as has and them as will". Putting petrol in a diesel car isn't usually expected to be fatal.

[Victorian]

I think an aspect worth pointing out is the convenience of FBO refuelling in the US. Unlike UK, where 'customer service' extends to (begrudgingly) switching the pump on for you (if they are not too busy), FBO's in the US expect to refuel your plane while you are doing something more productive.

It's all part of the genuine utility of light aircraft as a means of transport in America and probably leads to fewer fuel exhaustion incidents compared to UK and Europe, where 'topping off' can be a gruelling experience.

[maxred]

Very valid point Victorian. The FBO fueler in the US does expect you, the customer/pilot, to be doing something much more productive than standing watching him fuel your aeroplane.

Yes, here, well......

[sunday driver]

Well maybe I'm fortunate. My experience with being fuelled is ...
'G-XXXX to the pumps'
By the time I get there the pump crew (who are also the fire crew) are ready. I hop out and have a friendly chat with them while I see how much they put in, compared with my request (and, in future, what they put in).
Then a friendly thankyou, a shake of the wingtips, check of the fuel drains and off we go again.
I have assumed that water will very quickly separate from avgas and a shake of the wingtips will help it to migrate to the lowest part of the tanks.
I actually have no proof for either of these assumptions.

The fuellers here are people motivated by a desire to not use their rescue skills; I am motivated to treat them as responsible, decent people.
If I don't care about people, some day, someone important may not care about me.
SD

[On Track]

So I infer from the preceding posts that in Britain you can't just taxi up to the pumps, swipe your fuel card and serve yourself avgas/avtur.

Is that the position?

[maxred]

Correct. There may be such a place, I have just not visited it yet....

[Prop swinger]

Depends where you are. I don't even swipe a card, I just refuel.

[avturboy]

Originally Posted by PA28181

When I was working in engineering in the transport industry, we always looked for the "root cause" of failure of a component or system. This took some weeks in fact to solve some of the more complicated faults, so what is the "root" cause here, I would say without a doubt the wrong fuel was loaded ...

I fully agree, then you apply root cause analysis to the actual 'mis-fuelling' activity to identify the cause(s) then we're in a good place to develop some control to eliminate, or at least reduce the frequency in future.

In an ideal world you would want to engineer out (by mechanical means) the possibility of misfuelling, in the real world that simply isn’t possible. The width of the aircraft fuelling port is crucial to any mechanical method of preventing misfuelling. There are fuelling industry guidelines for the size of Avgas and Jet refueling nozzles, but these are not universally adopted by aircraft manufacturers. The wide ‘duck bill’ nozzle for jet fuel should be a minimum of 67mm across to prevent it going into smaller (40mm) Avgas fuelling port, the problem is that without 100% take up of the smaller port on every Avgas powered aircraft there cannot be a mechanical solution to the problem.

The only way to control misfuelling is by consistent application of a rigorous refueling procedure. There are people in the refueling industry who have produced such robust procedures, which IF applied will prevent misfuelling. That said following a procedure relies heavily on human performance, if that slips then a misfuel can occur. It is this weakness, the inconsistency of human performance, that is behind misfuelling.

In the environment I’ve come from (oil co – airfield refueling operations) misfuelling was taken incredibly seriously, it was without doubt the worst event a fuelling operator could be involved with. There was a good chance the operator would loose their job because the fact that a misfuel occurred was going to highlight that they had not followed procedure. As a consequence adherence to the procedure was good and it was an issue that operators were constantly reminded about during recurrent training and tool box talks. It certainly was not trained once and forgotten about.

A consequence of fuelling operators adhering to the procedure was that if there was a problem they would not continue with the fuelling; I've seen occasions when this would cause confrontation with flight crews/ operations staff, who for their own reasons might not be so interested in the finer detail of the fuelling procedure, and would be more focused on the speed of turnaround. The single most common cause of this problem was lack of grade placard by the fuelling port. If you are going to operate a misfuelling prevention policy then having clearly placarded fuel ports is a fundamental requirement. Placarding is becoming a more complex issue with the introduction of UL91 in addition to 100LL and that's before we consider that many aircraft now operate on road fuels (petrol and diesel) which adds even more potential for ambiguity and confusion

Within the fuelling operation there are many opportunities to put misfuel prevention controls in place. As already mentioned the size of fuelling nozzles and correct positioning of clear accurate grade placards are a good start but there are other controls which can be used. Before the fuel truck turns a wheel there may well be a verbal request for fuel, this is the first opportunity to ‘read back’ the request and confirm what grade is being requested. The fuelling nozzle can be colour coded and placarded with the grade so as to give an immediate cross check before the nozzle is introduced to the fuelling port. If something doesn’t look right “don’t assume – confirm”. The use of written fuel orders which clearly state the quantity and grade of fuel required. The use of colour coded documents for each fuel, black on white for jet and red on white for avgas.

However the one key feature of any and all elements of the procedure is that the fuelling operator must follow them. The working environment for the operator is very important, high quality effective training is vital. Although the captain is ultimately responsible for his aircraft a conscientious well-trained fuelling operator is often the key to a safe delivery of the correct grade of fuel.

[9 lives]

Great post Avturboy.

If you are going to operate a misfuelling prevention policy then having clearly placarded fuel ports is a fundamental requirement.

Just to support this, and at the risk of really angering some unsuspecting pilots, technically, if each fuel filler opening is not placarded with the quantity and grade of fuel for that tank, the plane is not legally airworthy. A fueller could refuse to fuel it. In the real world this would seem extreme, but if I were the FBO, I'd cover my liability by requiring a copy of the flight manual limitations page, which would also show that placard.

Many checks and balances are already in place to prevent errors. You have to fail at a couple of layers to actually get an accident to occur (the Swiss cheese model). That's why every placard specified for the aircraft is reproduced in the flight manual.

[cockney steve]

It would be interesting to know if any research has been done, on the combustibility of Avgas/Jet mixes.
Years ago, it was common for boats to start on petrol and switch to paraffin, (Morris Vedette was a very popular one in the 50's/60's)- once the engine was warm.....now, I would guess that carb heat could be used to keep the mixture warm -enough to "burn 'n turn".
I have only handled a couple of car misfuels....road-diesel is ,IIRC, 35 second burning-oil, whereas Kerosene/Paraffin/ jet A1/ (Avtur?) is more the 28sec. mark. IE much thinner and more readily atomised. the other complication, isa the fact that Avgas and petrol are markedly different and MOGAS is not the same as pump-petrol either!
What I can confirm, is a warm car engine will continue to run on a 50/50 Diesel/petrol mix....The exhaust will cloud -out thick white smelly smoke and power is much reduced, but better than none at all!

The above applies to carburetted engines, the modern, fuel-injected electronically- controlled stuff may well not be as tolerant.
Perhaps a TMG would be a good test-bed?...A really old car, of course, had manual mixture adjustment, as well as an advance-retard for the spark.

I can now claim over 50 years of motoring-experience and have not misfuelled....YET! (and served a goodly few thousand gallons of petrol, Derv and Paraffin, during that time.)

I would imagine the symptoms in a SEP would be similar to those of icing.....so, full carb. heat...but would leaning or richening be the best bet to keep the Donk running?.....this *could* be someone's "get out of jail " card.

[thing]

So I infer from the preceding posts that in Britain you can't just taxi up to the pumps, swipe your fuel card and serve yourself avgas/avtur.

Depends on the airfield, some do some don't. Off the top of my head Breighton has card swipes, I know others do but I can't be bothered trolling through the Pooleys to remind me of where they are!

[avturboy]

Originally Posted by cockney steve

It would be interesting to know if any research has been done, on the combustibility of Avgas/Jet mixes.

I doubt that any research has been done, better to focus on getting the correct grade of fuel in the tank in the first place, however I understand your point.

I think the problem is that if we introduce the idea that 'there is a tolerance' with regard to misfueling then we will divert attention from the significant most important issue, don't let it happen in the first place.

It is a fact that misfuelling Avgas into a Jet powered aircraft is less like to have a fatal outcome than the other way around, but I would not want to introduce the idea that a 'tolerance' of misfuel is in any way acceptable.

Fuelling operations will be far better served if everyone concentrates their efforts on a zero tolerance of activity that could result in misfuelling.

After 25 years in the aviation fuelling industry I know of many instances of misfuelling, some have resulted in the closest of 'near misses' others have resulted in fatal outcomes. My continued effort will be to train those involved to have 'zero tolerance' of any ambiguity that could lead to a misfuelling. I would much rather explain a delay than be involved in a fatal accident investigation.

I don't want that to sound over dramatic, but if you look into the circumstances of misfuelling I hope you'll understand where i'm coming from.

[barit1]

A light piston twin accident nearby, 30 years ago, was found to be fueled with Jet-A rather than 100LL.

Yes, pilot negligence, because he had signed the fuel receipt stating clearly "Jet-A".

And the lineboy had seen the "Turbo" logo on the nacelles (i.e. turbosupercharged) so he was confident he had selected the right fuel.

Neither the first nor last time, unfortunately.