IN: Tampa plastic surgeon dies after jet fuel put in prop plane

[ELB]

Picture of (prior to) mishap aircraft:

[ELB]

I just re-read the NTSB report and something caught my eye:

The mishap pilot flew to Kokomo, arriving about 1030, in the mishap aircraft. The mishap aircraft was fueled upon landing. The mishap pilot then provided recurrent training to another pilot...in a different type of aircraft.

When instruction finished several hours later, pilot receiving training drove the mishap pilot to the mishap aircraft and saw the mishap pilot check the fuel tanks and give a thumbs up, but didn't stay for the entire pre-flight. The mishap pilot took off and crashed shortly afterward.

The type of aircraft that the mishap pilot provided training for: PA-42 Cheyenne II. The NTSB report doesn't mention something at the moment, but I bet it will in the final, which is the PA-42 Cheyenne III is a turboprop. Takes Jet-A fuel.


Pic of PA-42

[03Lightningrocks]

The "pilot said" story is just that. A story from the only guy still alive from the mistake. Putting Jet A in a plane that requires avgas is just stupid beyond all imagination. The fueler should have refused to put Jet A in the airplane. He would have simply needed to say, Your aircraft requires AvGas and this right here is Kero(jetA). The pilot would have then said, Oh my, thanks for catching that for me. The fueler is responsible for the incident and that is that. If the guy is a brainless moron, the company hiring him should be addressed. But it takes a brainless moron to force Jet A into an aircraft that takes AVGAS. I don't give a darn what the pilot says. Pilots don't typically check to see what kind of fuel was pumped into the aircraft. They check fuel levels.They also check that the fuel cap is on securely. But they don't take the cap off and sniff the fuel to see if the guy who fueled it was an idiot. Should the guy be punished... I don't know. But he sure as heck needs a new career and should be fired.

[ELB]

NTSB Safety Alert: Pilots: Fueling Mistakes Learn how to detect if your aircraft has been misfueled

• While fuel nozzles and fuel fillers are designed to prevent misfueling, our investigations have found numerous modifications that can allow misfueling to occur. For example, aviation gasoline (avgas) nozzles are small and round and fit into smaller opening fuel filler ports while jet fuel nozzles are larger and flattened like a duck’s bill, requiring a larger fuel filler port (see figures 1 and 2). However, our investigations have shown that some fixed base operators (FBOs) are modifying their jet fuel nozzles with the smaller avgas nozzle or other smaller type nozzle, such as the round jet spout nozzle, to more easily fuel smaller turbine helicopters. These non-standard jet fuel nozzles can easily fit into the smaller filler ports of aircraft that require avgas and allow for misfueling to occur.

• When an aircraft is modified from using a reciprocating engine (avgas) to a turbine engine (jet fuel), some supplemental type certificates (STCs) have not required that the fuel filler port size be changed accordingly. As a result, line personnel have had to make accommodations such as installing an avgas fuel nozzle or round jet nozzle on a jet fuel truck to allow jet fuel into the smaller SA-050 March 2016 avgas fuel filler port. These STC modifications can lead to fueling confusion because the same model or similar looking aircraft may now have different fuel requirements.

• Once the wrong fuel is pumped into an aircraft, identifying that misfueling has occurred can be difficult, if not impossible, to detect.

…

What can pilots do?
• Always tell line personnel your aircraft’s registration number, what type of fuel your aircraft requires, and which tanks to fuel. Then verify that the correct fuel is being provided.

At the link four incidents are listed as examples of where the wrong fuel was added. In at least one case, at that FBO standard Jet-A nozzles were routinely used to dispense Jet-A into Avgas type fuel filler spouts on airplanes that had been modified with turbine engines.

More at the link.

[03Lightningrocks]

NTSB Safety Alert: Pilots: Fueling Mistakes Learn how to detect if your aircraft has been misfueled

• While fuel nozzles and fuel fillers are designed to prevent misfueling, our investigations have found numerous modifications that can allow misfueling to occur. For example, aviation gasoline (avgas) nozzles are small and round and fit into smaller opening fuel filler ports while jet fuel nozzles are larger and flattened like a duck’s bill, requiring a larger fuel filler port (see figures 1 and 2). However, our investigations have shown that some fixed base operators (FBOs) are modifying their jet fuel nozzles with the smaller avgas nozzle or other smaller type nozzle, such as the round jet spout nozzle, to more easily fuel smaller turbine helicopters. These non-standard jet fuel nozzles can easily fit into the smaller filler ports of aircraft that require avgas and allow for misfueling to occur.

• When an aircraft is modified from using a reciprocating engine (avgas) to a turbine engine (jet fuel), some supplemental type certificates (STCs) have not required that the fuel filler port size be changed accordingly. As a result, line personnel have had to make accommodations such as installing an avgas fuel nozzle or round jet nozzle on a jet fuel truck to allow jet fuel into the smaller SA-050 March 2016 avgas fuel filler port. These STC modifications can lead to fueling confusion because the same model or similar looking aircraft may now have different fuel requirements.

• Once the wrong fuel is pumped into an aircraft, identifying that misfueling has occurred can be difficult, if not impossible, to detect.

…

What can pilots do?
• Always tell line personnel your aircraft’s registration number, what type of fuel your aircraft requires, and which tanks to fuel. Then verify that the correct fuel is being provided.

At the link four incidents are listed as examples of where the wrong fuel was added. In at least one case, at that FBO standard Jet-A nozzles were routinely used to dispense Jet-A into Avgas type fuel filler spouts on airplanes that had been modified with turbine engines.

More at the link.

Nice find. It would be something to find out that situation applied here. It has been 2 months and nothing yet. Maybe it will come out eventually.

[Keith B]

Piper Aerostar



Twin engine prop driven aircraft that closely resembles many aircraft that are turbine powered.

Theoretically it could have been converted to turboprop which would burn Jet A fuel, and not have had the fuel inlets resized for the Jet A nozzle. The line person DID question the PIC and he confirmed multiple times it needed Jet A. The line person is not required to know all of the requirements of every version of aircraft, just follow the PIC’s direction.

Bottom line, PIC screwed up and ended up paying the price for his negligence.

[6L105]

Per 14 CFR 91.3(a), "The pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft."

[ELB]

...

Nice find. It would be something to find out that situation applied here. It has been 2 months and nothing yet. Maybe it will come out eventually.

Thanks.

NTSB final reports sometimes take awhile to come out. There are a couple dozen incidents from early October in the NTSB database and the only two of them have progressed beyond "preliminary report" to "factual", and none of them have made it to "final report." One of the "factual" reports was a non-fatal groundloop with not much damage where the pilot basically said "I screwed up the landing roll out". I expect fatality incidents get more scrutiny and take more time.

[ELB]

... The line person DID question the PIC and he confirmed multiple times it needed Jet A.

At least one of the fueler's requests to the pilot was during pilot's approach to the airport, presumably by radio, so that may be on a recording. Also the pilot likely signed paperwork to account for the amount and type of fuel dispensed, so probably there are two independent verifications that the mishap pilot was getting Jet-A . Also the truck was apparently a Jet A fuel truck only, because the NTSB notes the truck was marked on three sides with big letters "JET-A". It's unfortunate but the pilot did have more than one chance to correct things. I wonder if the fact that he was giving instruction in a different, Jet-A fueled aircraft subtly blinded him to the error.

[dhoobler]

The "pilot said" story is just that. A story from the only guy still alive from the mistake. Putting Jet A in a plane that requires avgas is just stupid beyond all imagination. The fueler should have refused to put Jet A in the airplane. He would have simply needed to say, Your aircraft requires AvGas and this right here is Kero(jetA). The pilot would have then said, Oh my, thanks for catching that for me. The fueler is responsible for the incident and that is that. If the guy is a brainless moron, the company hiring him should be addressed. But it takes a brainless moron to force Jet A into an aircraft that takes AVGAS. I don't give a darn what the pilot says. Pilots don't typically check to see what kind of fuel was pumped into the aircraft. They check fuel levels.They also check that the fuel cap is on securely. But they don't take the cap off and sniff the fuel to see if the guy who fueled it was an idiot. Should the guy be punished... I don't know. But he sure as heck needs a new career and should be fired.

While I agree with what you said about the guy who pumped the fuel, I have to disagree with the text in red.

Aviation fuel is color coded. Jet fuel is clear or straw colored. The most common aviation gasoline, 100LL, is blue. It is standard procedure during pre-flight and after each refueling to pull a fuel sample and visually inspect it. Airplanes have fuel sample cups on board for this purpose like this one:


A carburated single engine airplane has at least three sample points. Fuel injected aircraft have more. I have no idea how many sample points this twin engine aircraft has.

The pilot should have pulled multiple fuel samples after refueling and visually inspected it. He should have noticed a color discrepancy.

[03Lightningrocks]

The "pilot said" story is just that. A story from the only guy still alive from the mistake. Putting Jet A in a plane that requires avgas is just stupid beyond all imagination. The fueler should have refused to put Jet A in the airplane. He would have simply needed to say, Your aircraft requires AvGas and this right here is Kero(jetA). The pilot would have then said, Oh my, thanks for catching that for me. The fueler is responsible for the incident and that is that. If the guy is a brainless moron, the company hiring him should be addressed. But it takes a brainless moron to force Jet A into an aircraft that takes AVGAS. I don't give a darn what the pilot says. Pilots don't typically check to see what kind of fuel was pumped into the aircraft. They check fuel levels.They also check that the fuel cap is on securely. But they don't take the cap off and sniff the fuel to see if the guy who fueled it was an idiot. Should the guy be punished... I don't know. But he sure as heck needs a new career and should be fired.

While I agree with what you said about the guy who pumped the fuel, I have to disagree with the text in red.

Aviation fuel is color coded. Jet fuel is clear or straw colored. The most common aviation gasoline, 100LL, is blue. It is standard procedure during pre-flight and after each refueling to pull a fuel sample and visually inspect it. Airplanes have fuel sample cups on board for this purpose like this one:


A carburated single engine airplane has at least three sample points. Fuel injected aircraft have more. I have no idea how many sample points this twin engine aircraft has.

The pilot should have pulled multiple fuel samples after refueling and visually inspected it. He should have noticed a color discrepancy.

If you read the NTSB report that ELB posted above, it says that once the fuels are mixed it is near impossible to tell. I only have that to go on.

[03Lightningrocks]

...

Nice find. It would be something to find out that situation applied here. It has been 2 months and nothing yet. Maybe it will come out eventually.

Thanks.

NTSB final reports sometimes take awhile to come out. There are a couple dozen incidents from early October in the NTSB database and the only two of them have progressed beyond "preliminary report" to "factual", and none of them have made it to "final report." One of the "factual" reports was a non-fatal groundloop with not much damage where the pilot basically said "I screwed up the landing roll out". I expect fatality incidents get more scrutiny and take more time.

I mentioned earlier that I worked for Allied fueling at DFW airport in the early to mid 80's. Allied had the contract for the fueling of all airlines and private aircraft. We did not have the confusion issues with fueling back in those days. If the nozzle did not fit...Quit..attempting to fuel and report that the wrong fuel had been ordered. It rarely if ever happened. I suppose we did not have the issues with conversions they have now. After reading that it is easier to understand how something so critical can be confused. If the pilot had followed the recommendations in the article you posted, he likely would have caught the issue. I am somewhat surprised the plane ran long enough to take off. It was a tragedy. Flying is the safest of all forms of transportation but dumb mistakes are often fatal.

[ELB]

Yes the NTSB safety alert notes that if you fill a partially full tank with the wrong fuel it can be difficult or impossible to tell just by color and odor that the right fuel has been contaminated with the wrong fuel. Looks like there might be a market niche for a pocket-sized not overly expensive (ha!) fuel test gadget that can tell you if Avgas has Jet-A in it or vice versa.

[03Lightningrocks]

I am somewhat surprised the plane ran long enough to take off. It was a tragedy.

Fuel systems have sumps, long lines, more sumps, accumulator tanks etc. It takes a while for the wrong fuel to get from the tanks to the cylinders. It really depends on each specific model and its fuel system design. Losing an engine on the takeoff roll might be better but I don't think the fuel system engineers have that goal in mind.

Flying is the safest of all forms of transportation ...

True, we never left one up there!
(bad joke to lighten up the mood)