Piston Plane Refueled with Jet Fuel Kills Pilot

[skyhighfallguy]

NTSB: Wrong fuel used in fatal plane crash | Spokane - KXLY.com (http://www.kxly.com/news/spokane-news/ntsb-wrong-fuel-used-in-east-spokane-plane-crash/31734008)

[westhawk]

One more in a long line of lives lost to misfueling.

The FAA recognized and reacted to the problem decades ago by requiring placards (part 23, 25, 27 and 29) next to the fuel filler openings on all aircraft. Another amendment to the certification regs requires a smaller filler opening for Avgas burners than for those aircraft requiring Jet fuel. Further, fuel service providers were "encouraged" to use "duckbill" nozzles (of a size larger than the maximum 2.36" diameter of an Avgas filler opening) and provide more comprehensive training to line service personnel. Some FBOs won't even fuel your aircraft without a signed service request detailing the type and amount of fuel you want.

These measures appear to have helped to some degree, along with a widely promoted pilot awareness campaign. but still the problem persists. It happens less often perhaps, but it still happens. After losing both engines on takeoff and landing off airport due to his Shrike Commander being serviced with Jet-A, well known airshow pilot Bob Hoover pitched in with the FAA in a safety initiative intended to reduce or prevent misfueling related accidents. Yeah Bob knew he screwed up and admitted it. He knew he should have monitored the fueling and should have sampled the fuel. Yet the carnage continues...

Even with all the layers of safety and error catching available, there is apparently still a lack of awareness in the pilot and line service community regarding fueling error prevention and detection. This kind of accident is so easily preventable by what most pilots would consider normal precaution or what lawyers call "ordinary care" in their lawsuit filings. Routine stuff for most. But apparently still not all.

If a single root cause for these kind of accidents can be identified, I believe that root cause is complacency. Laziness and misplaced priorities contribute in many cases as well. In a hurry, distracted by other factors, etc... The pilot is the last line of defense against, is the one responsible and the one who (along with any pax and/or innocent people on the ground) will pay the ultimate price. The chump who put the fuel in will/should feel guilty but the pilot was responsible.

With this in mind, why don't we pilots care to supervise the fueling and sample/inspect fuel from the sump drains EVERY time we refuel our Avgas burners when they are so intolerant of Jet fuel or water contamination? Is it a lack of understanding or just pure complacency?

Sorry for long rant but these kinds of accidents just make me angry!

I see from the above posted news article that one of the big aviation law practices in already on the case, so to speak. If pilots supervise the fueling, ensure the correct fuel goes in and drain/inspect fuel samples from the tank sumps after fueling, the law industry would have to look elsewhere for their parasitic sustenance. Let's all do our part to send those lawyers back to working penny-anty supermarket slip & fall cases!


westhawk

[Jan Olieslagers]

Your title is highly misleading, for this once the media title is much more correct.
The pilot was not killed by the wrong fuel having been used - he suffered an EFATO which can happen to all us, and which we must always be prepared for. Obviously this EFATO did not work out, I will not speculate on why.
R.I.P.

[PA28181]

Are you serious?

[skyhighfallguy]

PA28181

thanks for stating what we were all thinking about Jan's comment.

The purpose of a headline is to get your attention to read the story.

Most likely if the plane had gas instead of jet fuel the engine would not have failed and we would have never heard of this guy.

We don't even use the term: EFATO . I suppose it means Engine Failure After Takeoff.

We would just say engine failure. Saves words. And isn't a cruise descent engine failure still an engine failure after takeoff?

Sheesh.


An engine failure can happen when the plane is not maintained properly and wrong fuel certainly is part of the equation. Engine failure does not just happen , it happens because someone screws up, somewhere. OK, sure , sucking birds is a little tough on the engine, or ingesting hail, but come on.

This plane crashed because someone put JET A into a GASOLINE ENGINE>


Funny, if it had been a jet engine and someone put gas into it, it would have run ok.


Some of the headlines on pprune are less than perfect , but it got you to read the article jan.

[Heston]

Jan is making a perfectly valid point. Mis-fuelling was only one of the lined up holes in the swiss-cheese that led to this accident. Others were that the mis-fuelling was not noticed, and that the EFATO when it occurred led to a fatal crash. There were probably other swiss-cheese holes in there too.

[BackPacker]

Just out of curiosity, if you put Jet-A in a tank half filled with Avgas (or vice versa), will the two mix, or will they stay separate, even after sloshing about for a bit?

And if they stay separate, I presume the Jet-A will sink to the bottom (from higher SG) so in a plane designed to fly on Avgas, you would notice the Jet-A when you drain. That's good.

But in a plane designed to fly on Jet-A (Diamond & other diesels for instance), when you sample the tank from the bottom drain, I presume you'll be drawing straight Jet-A? Which is as you would expect. So how do you detect the presence of Avgas?

We don't even use the term: EFATO . I suppose it means Engine Failure After Takeoff.

We would just say engine failure. Saves words. And isn't a cruise descent engine failure still an engine failure after takeoff?

Sheesh.

Got out of the wrong side of the bed this morning?

Obviously EFATO is an engine failure. But it's just about the worst possible moment to have an engine failure: You're nose high, at low altitude and low speed. If you don't lower the nose immediately you'll stall. And you have only seconds to determine where you are going to point the nose to make a successful landing. This means that there is no time to run through the normal engine failure drills (trim for best glide, switch tanks, fuel pump on, check carb heat, check magnetos, whatnot). So handling an engine failure just after take-off requires a different drill than handling an engine failure in the cruise. That is a good enough reason for me to give that situation a unique name.

Heck, even gliders have a special drill, and a special name, for when the cable snaps during a winch launch. Two even, depending on altitude gained. And they don't even have engines!

[Shaggy Sheep Driver]

Jan has it. It would be interesting to know more of the circumstances AFTER the engine failed. Was the aeroplane under control when it hit the ground?

[On Track]

On the contrary. It would be more useful to know how the wrong fuel was put into the tanks in the first place.

This is a fundamental and inexcusable ****-up. No excuses whatsoever!

[Jan Olieslagers]

Excuses were not demanded nor even mentioned. I totally agree that this was a blatant error and ought never to have happened.

[C172Navigator]

There is a lot of bickering taking place here.

Thank you for the orginal poster highlighting something any of us could fall foul of. Hopefully we will all monitor our refuelling a little better.

[9 lives]

A factor in the history of misfueling jet fuel into piston aircraft was the word "Turbo" appearing on fancy stickers on the side of the engine. Fueling people were understandably confused. The requirement for the identity of the required fuel has been in place for a long time, but some people still overlook it. Unfortunately, some aircraft types lend themselves more to this error, as a very similar version of the aircraft is available both gasoline and jet fuel. While flying the Lycoming powered DA-42, I paid extreme attention to what fuel was being put in.

Sadly, the pilot had multiple opportunities to detect this error, and not fly the plane that way. I've been as guilty as the next pilot of sometimes just jumping into a fueled plane, without confirming what was put in. More recently, I've been simply looking at what the label on the supply of fuel says is there. You also have a super opportunity when you pay for it.

That said, it seems to me that it was a crash shortly after takeoff associate with an engine failure which was the fatal event. Misfueling was a large causal factor in that crash, one which was a failing on several people's part, detectable and preventable. But it left the pilot as being the sole person who affect the outcome, and it did not work out well. I accept that an EFATO (as opposed to an EFA cruise flight) will nearly always result in a damaging off airport landing, but few need to be fatal.

How pilots handle and preplan for EFATO is a separate and worthy topic as to misfueling. Every now and again, I'll be taking off, knowing that that takeoff has a much less good possible outcome in the case of EFATO. I'll usually adjust my technique to optimize things. I certainly witness takeoffs where I think that the pilot missed opportunities to make the takeoff more safe and survivable were an EFATO occur.

This sad event is a good reminder on two topics of airmanship....

[Shaggy Sheep Driver]

Agree with step. the mis-fuelling was unfortunate and led to the EFATO, but it would be interesting to know more about how the pilot handled the EFATO.

Those on here who say that does not matter as if the misfuelling hadn't happened there'd have been no EFATO should have good long think about their flying.

EFATOs can happen for all sorts of reasons, some not pilot induced. You should consider every take off to be a potential EFATO because one day it might be. It was once for me, and it was once for a bloke I knew. He is no longer with us because he didn't get the nose down and keep the machine flying and therefore under control.

Are you ready for yours?

[phiggsbroadband]

I think it is common practice NOT to Sample the tanks after fueling, also NOT to take fuel from a field's supply after that supply has been re-stocked.


This is because, when transferring fuel, it gets all stirred up in the process. So you need to wait for about an hour for the water and contamination to settle, before taking a sample. Most small planes are sampled first thing in the morning, after an overnight stop, in the 'A' test.

[thing]

So you need to wait for about an hour for the water and contamination to settle, before taking a sample.

Which is why it's always best if possible to top up the tanks with the fuel you need the night before, rather than wait until morning and realise you need another 100 litres.

[skyhighfallguy]

First off, ROBERT A "BOB" HOOVER lost BOTH engines in his Shrike Commander because it had been fueled with Jet A. He landed safely.

A device, fitted to the filler cap, was supposed to work in conjunction with fuel nozzles so as to NOT allow JET A fuel nozzle to enter an AVGAS filler.

I guess that didn't happen here.

All the planes I have flown that use AVGAS have a placcard around the filler cap with fuel requirement like: 100LL ONLY and is quite noticeable.

AS far as EFATO, I guess we do things differently on this side of the pond. An engine failure at anytime requires heading towards your PRE SELECTED emergency landing field, ESTABLISHING and trimming for BEst GLIDE SPEED, and then using any restart procedures like: mixture rich, fuel pump on,carb heat on, alternate air select, select another fuel tank, etc.

Now if it happens at 40', you probably don't have time for more than the first 2. And Best rate of climb is usually close enough to best glide speed as to be almost satisfactory. ( a warrior for example, best glide is: 73 and best rate is 79).

AS far as the headline, I ask you all this. When the lawsuit happens (and it will), what will the jury find? That this crash was avoidable if the proper fuel had been used.

Certainly a pilot should always check the fuel by the known methods, but firstly by looking at the fuel truck and seeing what is written on the side: 100LL or JET A.


BACKPACKER, I wrote the post at night and had not just awoken. AS I mentioned above, you should be close to best glide speed if you are trimmed for best rate of climb. And anyone that hasn't taken the time to examine possible landing sites prior to takeoff hasn't done his homework.



It would be nice if someone would post what happens to mixed fuel , but if memory serves, if the fuel looks clear there is danger.

[maxred]

My understanding, from reading about this incident just after it happened on a US forum, was that the aircraft was in transit back to Canada. The airfield he took off from was very urban, and he actually impacted a bridge parapet. He had limited options. That is my understanding. I think he was also in his early seventies, and had a long transit prior to his fuel stop.

So, a number of things, starting with the wrong fuel being put in whilst he grabbed a coffee. Take it from there.....I assume most of us may not think, Christ, an idiot put the wrong fuel in the plane. But wait, it was a Malibu, the fueler may have looked at it and thought, that is a turbine, and so it goes on. Tired pilot, jumps in, and the engine quits on climb out. Very limited options in front. Bad luck he hit the bridge.....

[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, without that, all the other factors, ie: tired pilot, long trip, etc etc are irrelevant. As no accident would have occurred.

This is based on the headline cause for the crash and nothing else...

[maxred]

PA28, not sure anyone is actually argueing with that, are they????

That IS the cause of the accident.

[PA28181]

I was getting the impression from previous posts that the engine failure, the pilots failure to check prior to flight, how tired he might have been, and the subsequent fatal was more of a factor as to the cause than the mis-fuelling.

you could have a small vote to see which of theses factors were the cause,
1: mis-fueling.
2: Failing to supervise the re-fueling?

[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?


http://www.skywaycafe.com/images/felts2.jpg

http://www.supercub.org/photopost/data//500/medium/KSFF.JPG


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-history-nostalgia/2979-bandeirante-crash-leeds-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......:ugh:

[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]

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]

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. :ouch:

Neither the first nor last time, unfortunately.

[Piltdown Man]

How about a little substitution? Let us just say this aircraft had carb icing or an ignition switch failure. Would these have been to responsible for the crash? In this case, I feel each would have lead to the same outcome. That therefore means we should elsewhere for a solution - ie. an attempt to prevent reoccurence.

That doen't mean to say we should do all we can to prevent the wrong fuel from getting in the tanks. What we must do is invest in training to ensure engine failures in singles are more surviable than they are at the moment.

PM

[cockney steve]

@ Avturboy....I absolutely agree with you , prevention is better than cure, however, you say yourself, it continues in your 25 years experience.
All pilots hope never to have a power-failure at takeoff (see what I did there! even covered the snapped glider tow cable) but they continually train for that event. there are many other scenarios where , although one hopes "it'll never happen to me", the scenario is, nevertheless, rehearsed and a mitigating strategy practised.
My post was in the same spirit, IE- Is there anything a pil;ot could do to increase the possibility of keeping the donk turning and burning on the wrong / contaminated fuel. I am well aware that a turbine can run on just about any combustible liquid, though this may seriously foreshorten operating life.

[nonsense]

I don't see mis-fueling as the root cause of this incident. That's not going deep enough.

I see the physical possibility to mis-fuel as the root cause -it is physically possible to put the wrong fuel in an aircraft.

The only measures preventing misfueling are administrative; that is, training of pilots and refuelers and marking of aircraft, pumps, tankers, etc, to attempt to ensure that the correct fuel comes out of the correctly marked pump or tanker and goes into the correctly marked aircraft filler.

In the hierarchy of hazard controls, administrative controls, which rely upon humans not to make mistakes, are a poor substitute for engineering controls which make it physically impossible to make the mistake in question.

Think about it: cars the world over which run on unleaded petrol (gasoline) have special smaller filler necks and a physical flap in the filler (https://www.infrastructure.gov.au/roads/motor/design/pdf/41.pdf) - and that's just to prevent even small amounts of leaded fuel contaminating the tank and poisoning the oxygen sensor and the exhaust catalyst.

This is standardised across hundreds of millions of cars, in a world where leaded petrol was eliminated by 2011 (http://www.unep.org/transport/pcfv/PDF/Hatfield_Global_Benefits_Unleaded.pdf). If the car industry can achieve this, why can't aviation come up with an engineering control preventing mis-fueling?

Now one response would be to point out that petrol cars, which cannot tolerate lead, but can tolerate misfueling with diesel fuel without damage, have the limiting filler, while diesel cars, which are readily damaged by fueling with petrol, and are probably more likely to be misfueled by drivers familiar with petrol cars, are not protected. This is correct, and is a consequence of the need to retain backward compatibility with existing vehicles and bowsers, as well as high volume diesel pumps.

But for aircraft, this is potentially a matter of life and death. The numbers of fillers and bowsers is far smaller, and the ratio of the cost of the fillers to the value of the aircraft is probably lower. Aircraft are regularly subject to regulatory requirements to make modifications as design issues come to light.

Would it really be that difficult to develop special shaped bowser nozzles and filler orifices to physically prevent misfuelling?



As a side note, about 20 years ago, I helped a friend fit a small turbo diesel motor to a Suzuki Sierra "jeep" style 4wd, previously fitted with a (leaded) petrol motor. He often got comments from service station operators.
On one occasion he arrived at a remote roadhouse (Australia), stopped, looked around for the diesel bowsers, finally found them in the section with lots of room for road trains, and went and filled. When he went in to pay, the usual discussion about diesel into a Suzuki ensued, and the cashier commented "I was going to get on the PA and warn you that you were filling with diesel, but you looked very determined to use diesel..."

[avturboy]

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. :ouch:

Neither the first nor last time, unfortunately.

This is one of the well known ambiguities which can lead to misfueling, for that reason in training that I have been involved the issue is highlighted and then fuelling operators are told to ignore such wording.

The only wording to be concerned with is clear, unambiguous grade placard/decal situated at the fuelling orifice.

[avturboy]

I don't see mis-fueling as the root cause of this incident. That's not going deep enough.


That is exactly the point I was trying to make, the cause of the misfuelling activity itself must be subject to root cause investigation.

As a result of such investigations then procedures are refined to the point where a robust fuelling procedure is in place, which "providing" it is followed will control the risk. However, as you point out, an administrative control is still open to poor human performance and that is the limiting factor in controlling misfuels.

I agree that mechanical/engineering controls are the only way to give the guaranteed performance we are looking for. For whatever reason the ongoing nature of this problem (even with continuing loss of life) does not seem to provide the industry/manufacturers/regulators with the incentive to get on do something about it.

My comments reflect my involvement in fuelling operations where we have to work with what we are given, which is a global fleet of aircraft requiring overwing/open line/gravity (or whatever anyone wants to call it) fuelling, without the necessary standardization in fuelling equipment.

There are many proactive folks in the fuelling industry who have tried hard to make it as fool proof as possible. Having worked in locations around the world I am not naive and I realize that in some places the rigor applied to fuelling operations is not be ideal and therefore problems will occur.

In too many places fuelling is seen as an inconvenience, something that everyone knows has to be done but sometimes its just not taken seriously enough. With such attitudes and a reliance on procedure to prevent misfuelling then it's almost a given that it will happen.

I'd like to see the engineering route to a solution explored, in truth I don't think it'll ever happen.

[phiggsbroadband]

Nobody has yet mentioned that in this case the two pumps were in the same metal cabinet and shared a common Apron. Surely airfield design was a factor in this accident.
If the two fuels have separate Pumps on different Aprons, then this accident would be less likely... Also more aircraft could be re-fuelled at once.