Convair 340 (C-131D) ZS-BRV crash Pretoria, South Africa
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Here's a Martin 404 crash on takeoff after servicing with Jet-A:
libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR70-25.pdf
The FO supervised the fueling, the truck was marked 'Turbo Fuel' and 'JET-A' in big letters. He signed a receipt for 200 gallons of Jet-A and 57 quarts of recip oil for the R2800's.
From the NTSB analysis:
It's been a long time but I remember stopping to drop off a passenger in a bizjet in Quincy, Illinois. The airport was small, not sure if it had a tower and the FBO was the Heetco Jet Center. I bought some fuel (it was indeed Jet-A) and one of the motors was a little low on oil so I ordered a quart. 'Sir, we don't normally stock that turbine oil here at the Jet Center' was the reply.
It seems improbable that the wrong fuel could be put into ZS-BRV with so many aviation types onboard and presumably present at the preflight operations. However, it appears that the plane may have come out of the paint shop a couple of days earlier with the new livery. Was the wrong fuel put on late the night before by a line crew with the Jet-A truck? Or, was the Jet-A inadvertently loaded as ballast fuel before going to the paint shop?
libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR70-25.pdf
The FO supervised the fueling, the truck was marked 'Turbo Fuel' and 'JET-A' in big letters. He signed a receipt for 200 gallons of Jet-A and 57 quarts of recip oil for the R2800's.
From the NTSB analysis:
While engine operation was adequate to accomplish a successful take-off with the utilization of the water injection system, the termination of water supply to the engine subsequent to takeoff resulted in immediate manifestation of the detonation and/or preignition conditions. The apparent inability of the flightcrew to recognize immediately the symptoms of detonation, or to assess the cause for this condition, prompted the application of carburetor heat which further elevated induction temperature and contributed to even more adverse detonation condition. Cylinder head temperatures of both engines attained the 300' C. gage limit as a result of the detonation and/or preignition. Again the action taken in opening the cowl flaps, in an effort to rectify this indication, was responsible for increasing drag which adversely affected the critical thrust/drag configuration of the aircraft.
It seems improbable that the wrong fuel could be put into ZS-BRV with so many aviation types onboard and presumably present at the preflight operations. However, it appears that the plane may have come out of the paint shop a couple of days earlier with the new livery. Was the wrong fuel put on late the night before by a line crew with the Jet-A truck? Or, was the Jet-A inadvertently loaded as ballast fuel before going to the paint shop?
While mankind has their "sticky little fingers" on anything, mistakes cannot be ruled out. We are a creater of habit and complacency.
This is where computers are superior. Not perfect of course.
When people demand to know, "how can that happen"? Humans.
if the speculation about misfuelling comes to fruition, then it should have been picked up on a pre flight, depending on the mixture of course. Jet fuel would be at the bottom of the tank, would it not? However I appreciate a lot of fuel would need to be drained, into a clear vessel to have any hope of detecting Jet fuel. How often is the sample smelt?
Could have been a catalogue or errors.
This is where computers are superior. Not perfect of course.
When people demand to know, "how can that happen"? Humans.
if the speculation about misfuelling comes to fruition, then it should have been picked up on a pre flight, depending on the mixture of course. Jet fuel would be at the bottom of the tank, would it not? However I appreciate a lot of fuel would need to be drained, into a clear vessel to have any hope of detecting Jet fuel. How often is the sample smelt?
Could have been a catalogue or errors.
Last edited by Dan_Brown; 9th Aug 2018 at 08:02.
Correct me if I'm wrong, but AFAIK there is no suggestion of R/H engine malfunction. Is it being suggested that jet fuel may have been loaded into the L/H wing tank, but not the R/H?
Seems highly unlikely, unless one bowser ran out and then another was deployed.
Seems highly unlikely, unless one bowser ran out and then another was deployed.
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Maybe they did run the L/H engine a lot during maintenance? An then topped up with Jetfuel?
Enough to cause knocking, not enough to be detected until too late in the takeoff run. Initial issues attributed to water injection by the pilots, but symptoms did not disappear after switching it off?
Normally each engine is fed from one tank only (by regulation), crossfeed is to be used in specific cases only.
Enough to cause knocking, not enough to be detected until too late in the takeoff run. Initial issues attributed to water injection by the pilots, but symptoms did not disappear after switching it off?
Normally each engine is fed from one tank only (by regulation), crossfeed is to be used in specific cases only.
Maybe they did run the L/H engine a lot during maintenance? An then topped up with Jetfuel?
Enough to cause knocking, not enough to be detected until too late in the takeoff run. Initial issues attributed to water injection by the pilots, but symptoms did not disappear after switching it off?
Normally each engine is fed from one tank only (by regulation), crossfeed is to be used in specific cases only.
Enough to cause knocking, not enough to be detected until too late in the takeoff run. Initial issues attributed to water injection by the pilots, but symptoms did not disappear after switching it off?
Normally each engine is fed from one tank only (by regulation), crossfeed is to be used in specific cases only.
You're right to point out that recently-introduced contaminants take some time to reach the engine. One of my company's DC-10s received seriously-contaminated jet fuel at Lagos in the 1980s. Fortunately, one of the engines started to run down just before they turned on to the runway.
In an ideal world, the water drains at the bottom of the wing tanks are dripped before the first flight of the day, and - as Dan_Brown points out - any kerosene would sink below the gasoline and sit on any water, given the time.
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Well, no, not really. Water settles out because water and gasoline are imiscible. Gasoline and jet fuel mix just fine, and have no tendency to separate from each other. Depending on how much jet fuel was added, and how how much it was agitated as it was added, you might find that the mixture in the bottom of the tank had a greater percentage of Jet fuel than the top, but you aren't going to find a nice clear division, like you will with water and gas that has sat undisturbed overnight.
Good point, A Squared.
Do they predate the CV-340? Presumably not. Is the aircraft only refuelled over-wing, or does it have a refuelling gallery for pressure refuelling?
I still don't understand, however, why we are discussing a possible refuelling error in this case.
I still don't understand, however, why we are discussing a possible refuelling error in this case.
I still don't understand, however, why we are discussing a possible refuelling error in this case.
The refuelling error will go away soon as someone comes up with yet another theory!
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Good point, A Squared.
Do they predate the CV-340? Presumably not. Is the aircraft only refuelled over-wing, or does it have a refuelling gallery for pressure refuelling?
I still don't understand, however, why we are discussing a possible refuelling error in this case.
Do they predate the CV-340? Presumably not. Is the aircraft only refuelled over-wing, or does it have a refuelling gallery for pressure refuelling?
I still don't understand, however, why we are discussing a possible refuelling error in this case.
Unfortunately, Jet / AvGas fuelling errors have been happening since the dawn of the jet age, and many accidents have happened as a result over the years. There have been measures put in place to minimize risk, but it's still there....and an awful lot of the fuellers don't know one airplane or fuel type from another.
Here are two reports (of much smaller aircraft) misfuelled in Canada in just the last few years:
Aviation Investigation Report A15C0134 - Transportation Safety Board of Canada
Transportation Safety Board of Canada - Aviation Investigation Report A11Q0036
With large piston aircraft as rare as they are becoming, the risk of a fueller that has never encountered the type thinking Jet A is required is fairly high. Now, that should be addressed by ordering the correct fuel, placards, hoover rings, vigilant crew, fuel sampling, checking fuel slip, etc. But misfuelling does still happen, and not as infrequently as one might hope.
This may very well not have had any part in this accident at all, until additional information is released, it remains a real possibility.
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The facts are simple, EFATO and bitten by density altitude, there may be other contributing factors..
Only one engine failed and no white smoke so misfuelling is a daft theory.
Expect SACAA to release an interim report soon.
Only one engine failed and no white smoke so misfuelling is a daft theory.
Expect SACAA to release an interim report soon.
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Fuel type
As I posted earlier (see below) and with all prune type focus (including film from within and external to aircraft) being on the Left Engine smoke/fire = presumed failure, it is now separately in question, yet will be part of any investigation anyway, that kerosene may have been mis-fuelled. We will know from the investigation soon enough.
Further, from external (eye witness report referenced below, who saw Right Engine on fire before impact) and now from one passenger on board (this from a chat at Wonderboom a week ago), it seems the Right Engine was failing/failed also, before impact.
Together, a double eng failure is a horrible day at the office! How it happened C O U L D be explained by fuel Octane rating, Water injection or other reasons unknown. However, that a separate suggestion of missfuelling is now in play, it is plausible that this may be involved. I’m trying to choose my words carefully, for we all know that we don’t know what we don’t know and that this .......... is a rumour mill.........
The fuel type (Avgas v Kerosene) actually pumped into wing during refuelling prior to this flight, is now in question.
It will of course be critical to see what the investigation finds from fuel samples taken.
I mention this because it now appears that both engines were failing / had failed, meaning the right engine was also seen on fire, before impact. That report from an experienced pilot eye witness on ground, close to the crash.
Further, from external (eye witness report referenced below, who saw Right Engine on fire before impact) and now from one passenger on board (this from a chat at Wonderboom a week ago), it seems the Right Engine was failing/failed also, before impact.
Together, a double eng failure is a horrible day at the office! How it happened C O U L D be explained by fuel Octane rating, Water injection or other reasons unknown. However, that a separate suggestion of missfuelling is now in play, it is plausible that this may be involved. I’m trying to choose my words carefully, for we all know that we don’t know what we don’t know and that this .......... is a rumour mill.........
The fuel type (Avgas v Kerosene) actually pumped into wing during refuelling prior to this flight, is now in question.
It will of course be critical to see what the investigation finds from fuel samples taken.
I mention this because it now appears that both engines were failing / had failed, meaning the right engine was also seen on fire, before impact. That report from an experienced pilot eye witness on ground, close to the crash.
Last edited by Runnymede; 10th Aug 2018 at 12:22.
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Well, I guess we can contact the SA aviation authorities and tell them they can cancel thier investigation, you have it all figured out.
Last edited by A Squared; 11th Aug 2018 at 17:22.
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- They were incredibly lucky to have such a low casualty. This was not an emergency landing, just an uncontrolled crash into a dairy factory !
- Some admin / paperwork / licensing issues that don't reflect too well on the operation but probably not contributing factor.
- No evidence that the right hand engine developed any issue - we are still on the dark as of why they could not maintain altitude. No performance calculation provided.
- Nice add for GOPRO...
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From the preliminary report:
They had an engine fire but never did the engine fire checklist? 
2. Preliminary Findings
2.1 The captain had a valid Australian Air Transport, Commercial and Private Licence and he was type rated on the aircraft (Convair 340/440). However the validation issued by SACAA was for Private Pilot License under visual flight rules (VFR) which was valid until 5th May 2021.
2.2 The FO had a valid Australian Air Transport, Commercial and Private Pilot Licence, however he was not type rated on the aircraft (Convair 340/440). 2.3 The FO’s validation of his foreign license was only limited to Single Engine Landing aircraft with the following aircraft types (C150, C172, C182 PA 28 A/B) this is based on his foreign license validation application and skill test report dated 9th of May 2016 and the validation was valid until 05 May 2021.
2.4 The LAME had been issued with aircraft maintenance licence, with the appropriate rating endorsed and was valid at the time of the accident.
2.5 The aircraft is certified for two crew operation, however the engine controls were also operated by LAME who is not part of the crew according to the aircraft flight manual and he is not rated on the aircraft as a pilot.
2.6 The Crew resource management (CRM) in the cockpit was found lacking
2.7 The Aircraft Flight Manual requires two pilots to operate the aircraft and both need to be rated on the aircraft, however the documents and licenses made available to Investigation team indicates only Captain rated on the aircraft (Convair 330/440).
2.8 The aircraft had 2 pilots and 17 passengers on board. Both pilots and two passengers were seriously injured; one passenger (LAME) was fatally injured with 14 other passengers sustaining minor injuries.
2.9 Four (4) persons on the ground sustained serious injuries and another four (4) had minor injuries.
2.10 The owner had sold the aircraft to a Museum in the Netherlands and the aircraft was to be exported to the Netherland on 12 July 2018.
2.11 According to the maintenance records presented to the investigation team, the last maintenance performed on the aircraft was A, B & C maintenance checks on 06 July 2018 at 18115.1 hours, and it was during this maintenance event when the manifold pressure gauge was removed, repaired and refitted to the aircraft. No maintenance test flight was performed after the completion of the scheduled maintenance.
2.12 The aircraft Type Certificate (TC) is held by Transport Canada.
2.13 The crew filed a flight plan of FAWB-FAPN-FAWB and it was granted, however the investigation revealed that the FAPN was closed for maintenance and landing of fixed wing aircraft was prohibited.
2.14 After the e50kts call, the captain indicated that the left manifold pressure appeared to be low.
2.15 The crew were informed of the left engine fire and the master caution light illuminated, however the engine fire extinguishing system was not activated.
2.16 The emergency procedures were not followed after the crew were made aware that number 1 engine caught fire.
2.17 The ATC reported that the aircraft reached 800ft but could not sustain its altitude, and started losing height.
2.16 The Number one engine pressure manifold gauge was defective prior to the accident (on the 26/02/2018 and 05/05/2018) and during take-off roll the pilot reported that the manifold pressure was low.
2.1 The captain had a valid Australian Air Transport, Commercial and Private Licence and he was type rated on the aircraft (Convair 340/440). However the validation issued by SACAA was for Private Pilot License under visual flight rules (VFR) which was valid until 5th May 2021.
2.2 The FO had a valid Australian Air Transport, Commercial and Private Pilot Licence, however he was not type rated on the aircraft (Convair 340/440). 2.3 The FO’s validation of his foreign license was only limited to Single Engine Landing aircraft with the following aircraft types (C150, C172, C182 PA 28 A/B) this is based on his foreign license validation application and skill test report dated 9th of May 2016 and the validation was valid until 05 May 2021.
2.4 The LAME had been issued with aircraft maintenance licence, with the appropriate rating endorsed and was valid at the time of the accident.
2.5 The aircraft is certified for two crew operation, however the engine controls were also operated by LAME who is not part of the crew according to the aircraft flight manual and he is not rated on the aircraft as a pilot.
2.6 The Crew resource management (CRM) in the cockpit was found lacking
2.7 The Aircraft Flight Manual requires two pilots to operate the aircraft and both need to be rated on the aircraft, however the documents and licenses made available to Investigation team indicates only Captain rated on the aircraft (Convair 330/440).
2.8 The aircraft had 2 pilots and 17 passengers on board. Both pilots and two passengers were seriously injured; one passenger (LAME) was fatally injured with 14 other passengers sustaining minor injuries.
2.9 Four (4) persons on the ground sustained serious injuries and another four (4) had minor injuries.
2.10 The owner had sold the aircraft to a Museum in the Netherlands and the aircraft was to be exported to the Netherland on 12 July 2018.
2.11 According to the maintenance records presented to the investigation team, the last maintenance performed on the aircraft was A, B & C maintenance checks on 06 July 2018 at 18115.1 hours, and it was during this maintenance event when the manifold pressure gauge was removed, repaired and refitted to the aircraft. No maintenance test flight was performed after the completion of the scheduled maintenance.
2.12 The aircraft Type Certificate (TC) is held by Transport Canada.
2.13 The crew filed a flight plan of FAWB-FAPN-FAWB and it was granted, however the investigation revealed that the FAPN was closed for maintenance and landing of fixed wing aircraft was prohibited.
2.14 After the e50kts call, the captain indicated that the left manifold pressure appeared to be low.
2.15 The crew were informed of the left engine fire and the master caution light illuminated, however the engine fire extinguishing system was not activated.
2.16 The emergency procedures were not followed after the crew were made aware that number 1 engine caught fire.
2.17 The ATC reported that the aircraft reached 800ft but could not sustain its altitude, and started losing height.
2.16 The Number one engine pressure manifold gauge was defective prior to the accident (on the 26/02/2018 and 05/05/2018) and during take-off roll the pilot reported that the manifold pressure was low.
1.1.17 The GOPRO also shows that the pilots were not sure if they had retracted the landing gears, as they can be heard asking each other whether the gears are out or not. It also shows that though the pilots and LAME were informed of the left engine fire, they were asking each other which engine was on fire. At no stage did the pilots or the LAME discuss or attempt to extinguish the left engine fire, as the left engine fire extinguishing system was never activated.
The following is the procedure which the pilots were required to follow after identifying the engine which was on fire, as extracted from the inflight checklist contained in the aircraft flight manual (AFM):
i. Feather the propeller.
ii. Pull the appropriate fluid shut-off “T” handle.
iii. Close the heat source valves of the burning nacelle with the emergency heat valve disconnect switch.
iv. Place the cowl doors switch of the burning nacelle to the CLOSE position.
v. Place the fuel shut-off valve switch of failed engine to the CLOSED position.
vi. Place boost pump switch of the inoperative engine to OFF position.
vii. With fire extinguisher selector on main, operate the appropriate fire switch; the main CB supply out light, on the fire control panel, should come on.
viii. If fire persists, place the fire extinguisher selector to reserve and operate the appropriate fire switch.
Based on the wreckage examination including the propeller and cockpit GOPRO recording the above procedures were not followed by the crew when the left engine caught fire.
The following is the procedure which the pilots were required to follow after identifying the engine which was on fire, as extracted from the inflight checklist contained in the aircraft flight manual (AFM):
i. Feather the propeller.
ii. Pull the appropriate fluid shut-off “T” handle.
iii. Close the heat source valves of the burning nacelle with the emergency heat valve disconnect switch.
iv. Place the cowl doors switch of the burning nacelle to the CLOSE position.
v. Place the fuel shut-off valve switch of failed engine to the CLOSED position.
vi. Place boost pump switch of the inoperative engine to OFF position.
vii. With fire extinguisher selector on main, operate the appropriate fire switch; the main CB supply out light, on the fire control panel, should come on.
viii. If fire persists, place the fire extinguisher selector to reserve and operate the appropriate fire switch.
Based on the wreckage examination including the propeller and cockpit GOPRO recording the above procedures were not followed by the crew when the left engine caught fire.
As they were having a hard time (and eventually failed) to maintain altitude I'd say you try to run both engine as long as possible. Even a failing engine can still produce thrust.
Not sure that was their plan all along but could explain it.
Not sure that was their plan all along but could explain it.
Last edited by atakacs; 11th Aug 2018 at 20:46. Reason: typo