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Avgas vs Jet A: Wrong Fuel Caused Alaska Forestry Plane Crash

Enviado hace 7 meses

In May, 2020, three firefighters and one pilot took off from the Aniak runway in an Aero Commander 500 Shrike. They crash landed in a pond right off the runway. All four survived. According to the National Transportation Safety Board’s preliminary report, the culprit was the wrong fuel. The report says that a vendor tasked with filling up the plane was unclear which kind of fuel to use for the type of airplane, and filled it up with the wrong kind. The fuel vendor asked the pilot if he wanted… (www.kyuk.org) Más...

Rebecca Shaffer

60 comentarios de miembros

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Jonathan Huls hace 7 meses 38

I love the Monday morning quarterbacking that goes on here. Shows the true maturity of us pilots and aviation “enthusiasts.”

If you are a pilot, the only appropriate takeaway from any accident involving pilot error is to conclude that this can happen to me if I let it. Dumb mistakes are made by brilliant people every day...but aviation shows little tolerance for this. We must learn from each other. We don’t each have time to find every limit on our own. This is why SOP’s, best practices, and written checklists exist. They are written in blood folks.

So here is a suggestion...extend a smidgeon of grace, because tomorrow it might be your turn to be smart and act dumb. It happens to all of us, and sometimes we don’t get away with it, and we will not grow out of it. But it is the duty of every Captain to spend a career trying their absolute best to do so.

I hope we all give the fuel truck a hard look before we allow a drop of fuel into our ships. That is the point of this forum. To learn...not to judge...because it will happen again to those of us who have forgotten how to learn.

J (ATP, Check Airman)

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ben walldroff hace 7 meses 11

fantastic response above.
you nailed it

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SmittySmithsonite hace 7 meses 4

Well said. I'm not a pilot, but the same goes for ANY and EVERY industry. I've been working on automobiles for as long as I can remember, and every so often I'll forget to tighten something. That's why nothing leaves here without a test drive. I've come up with routines that make this very rare, but it is always possible! I lose tools at an alarming rate - that problem I have never seemed to been able to fix ...

The one Perfect Man that walked this Earth was born Christmas Day. Everyone else, no matter who you are, is flawed.

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Jonathan Huls hace 7 meses 1

Amen!

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Markus Wolff hace 7 meses 2

Yours was the 1st response I’ve read so I had to read everybody else’s responses Yours is the best. I appreciated that

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Jayden Hakunti hace 7 meses 1

i read your comment and was so fulfilled that i did not have to scroll down and read anymore.

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James M hace 7 meses 1

Excellent viewpoint. Everyone makes mistakes. I will never forget my 3 leg 100 mile trip, a requirement for a pilot license (1980s). I failed to lock the prime pump. This caused the engine to run rich, therefore I couldn't fly the plane and lean it out. What a simple mistake, that anyone can make. I never did that again! Thank God, I knew enough about engines at didn't push that little Piper 160.

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K R hace 7 meses 1

There are mistakes and then there is incompetence - in the sense "why does this guy have a pilots license"? This category of mistake (a fundamental error which can lead to death and destruction) is one that any professional would feel should never be made, but if made (mistakes do happen as you say) then it should only be in training and before a license is issued. Calling this an "acceptable" mistake demeans the license. Why bother to license pilots if you allow them to make such fundamental errors? I used to make jet and avgas for a living - the properties are quite different: including smell? Where is the smell test? The fuel loader apparently even told him - I am loading jet.

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Ehud Gavron hace 7 meses -1

Respectfully, what it says on the side of the truck is the FBO's problem.

Failure to sample the fuel is the PIC's problem and renders the aircraft not airworthy.
See 14 CFR 91.7, 9.407 and many other references.

They could write "MACHINE DIESEL" on the truck. That's certainly not helpful, but not unlawful either. The pilot who doesn't check the fuel for proper color, consistency, fluidity, and lack of contaminants is the one person who IS responsible.

As I said earlier, I'm loathe to judge... but the message needs to be made clear to ALL PICs. If you're going to fly it, YOU'RE RESPONSIBLE for determining airworthiness, and if ANY of the checks fail YOU'RE NOT FLYING. One of those checks is fuel sampling. EVERY SINGLE TIME YOU FUEL. EVERY SINGLE TIME THE AIRCRAFT SAT AROUND. EVERY SINGLE TIME IT RAINED BEFORE YOU CAME OUT THERE. (or snowed, or dust, or whatever).

So yeah, in this case the NTSB has already judged. We're just discussing what we learn from this and how the rest of us can avoid this. Don't be lazy once... or ever. If you can't sample the fuel THAT'S FINE and YOU'RE NOT FLYING TODAY.

E
CPL-H

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Jonathan Huls hace 7 meses 8

Thank you Sir.

You missed my point, but have also illustrated it most eloquently. You have perfect fuel discipline and understand the rules and guidance on the subject. You are a smart and disciplined pilot no doubt...good for you. Your council on others' fuel discipline is also good, and not really in dispute, but...

Does your perfect knowledge and discipline regarding fueling apply to every risk generating aspect of your flying?

Have you never...not ever...been distracted by workload, confusion, pressure, or fatigue... and then failed to perceive a hazard that became ridiculously obvious in hindsight. As a smart pilot are you dumb mistake free to this point? Are you immune to a dumb mistake tomorrow?

You say..."don't be lazy once...or ever." How about tired, hungry, distracted, externally stressed...how about human? That is a naive and fanciful standard to apply to others, when it is simply impossible to apply it to yourself.

Hence my suggestion for a little grace...and perhaps a little humility to season it. If you can't make that dumb mistake...believe me you CAN make another one. And if you survive it, will you read this board and savor the considerable wisdom of those who were not there?

My very best wishes for continued safe and mistake-free flying...please just continue to learn.

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Jesse Carroll hace 7 meses 2

Had a lot of respect for your comment 2 days ago! Not so much for berating EHUD, not so much!
Everybody makes mistakes, just try to live and learn from them. However, Ehud is totally correct for the PIC is the boss of his machine just as Captains are of their ships!

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Ehud Gavron hace 7 meses 2

Well said. None of us are perfect. There's a reason the checklist(s) are there... and yes I do strive to get my fellow pilots to always ("there's no always/never except in flying") follow them :)

V/r

Ehud

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ben walldroff hace 7 meses 1

Just curious...
Fuel color sampling..visual check ..
What color is clear + blue (assuming some residual remained from AV)
???????
Don’t make me ask my 3rd grade daughter either...

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Jesse Carroll hace 7 meses 0

Won't know, being I'm color blind!

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Richard Orgill hace 7 meses 11

>>>>>The report says that a vendor tasked with filling up the plane was unclear which kind of fuel to use for the type of airplane, and filled it up with the wrong kind. The Forestry airplane is an Aero Commander 500 Shrike, and only uses a certain type of fuel. The fuel vendor asked the pilot if he wanted “prist with your jet.” Prist is a type of chemical that prevents fuel from gelling in planes that fly higher altitudes; "jet" refers to Jet A fuel. The pilot said no. The fuel vender filled it up with Jet A fuel, and wrote that down on a receipt that he then handed the pilot, who signed it.<<<<<

>>>>>"Like with any accident or incident, you know, we conducted an after action review of the incident to try to pull any lessons learned out of it that we could, you know, to see if there needs to be any policy changes or anything that we can do to make for a safer aviation program," said Tim Mowry, spokesperson for the Alaska Division of Forestry.<<<<

Now let me think how we can make this better.....does he mean like COMMUNICATE CLEARLY?

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silverio califano hace 7 meses 9

What happened to the placard near the fuel tank opening or pressure fill port? It should have been there.

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john doe hace 7 meses 2

It was, according to the NTSB report.

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Highflyer1950 hace 7 meses 7

Didn’t there used to be different size fuel nozzles for Jet, Jet A-1 and Avgas? Also colour coded as well? I thought that the Jet nozzle was bigger and would not go into an avgas filler port. Memory could be shot as well?

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gil graham hace 7 meses 1

Don't rely on the smaller nozzle! My pilot friend caught a lineman grabbing a funnel to fill his plane once.

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Ehud Gavron hace 7 meses 10

1. The NTSB report https://app.ntsb.gov/pdfgenerator/ReportGeneratorFile.ashx?EventID=20200529X64359&AKey=1&RType=Prelim&IType=LA

2. It indicates the placard WAS ON THE FUEL PORT showing 100LL

3. The Lycoming IO-540 (same as in the helicopter I fly) uses low-lead aviation fuel ("avgas"). IT CAN'T BE POWERED BY JET A

4. Where do we point fingers, IF WE HAVE TO, it's the pilot that didn't sample the fuel from all tanks and the lowest point in the fuel system (water drain area).

So as a commercial helicopter pilot I'm loathe to blame another pilot. However, had the fuel been sampled, the color would NOT have been blue (AVGas) and the aircraft would be considered NON-airworthy.

If I upset someone calling it like I see it... well, I called it like I see it. PIC is responsible to ensure the aircraft is airworthy prior to takeoff... and fuel sampling would have failed.

E

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justin chavez hace 7 meses 4

I fly a shrike (different company) and know this pilot personally. There is only one sump on the AC50, it is essentially a two person procedure if you want to sample fuel and given how the fuel system works it takes significant time for fuel in the wings to contaminate fuel in the drain. Call it like you see it all you want, I see it in the POH for the aircraft.

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lyn williams hace 7 meses 4

I understand the 'loath to blame another pilot'...but doing the preflight is essential...and not just the parts you want to. I've flown early in the morning and gotten fuel only to find that I had GALLONS of water in the tank...because the new fuel truck jockey didn't bother to drain the water from their large tank. I've walked away from a flight where the PIC couldn't be bothered to take a sample after refueling...and watched the aftermath when the engine quit on take off. Thats one checklist item you cannot afford to miss. Just do it. Live to fly another day.

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themold hace 7 meses 7

I'm a CFII and I agree 100% with you. FARs make the PIC the final authority and responsible for the operation of the aircraft. That's a rule not to be taken lightly. My personal philosophy that I teach is that the purpose of the preflight inspection is to find a reason not to fly that particular aircraft. If you can't find anything unairworthy, then go flying.

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msongy hace 7 meses 4

A similar thing happened to Bob Hoover in 1978. A lineman put 60 gallons of Jet A into his Commander and he and 2 passengers crashed. The aircraft ran fine through taxi and runup, but lost power during climbout after the 100LL left in the fuel lines ran out.

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Warren Craycroft hace 7 meses 3

Great example of Mr. Huls' point above. My Dad flew Mustangs with Bob in the fifties. Bob was a true pilot's pilot. But even airmen of Bob Hoover's calibre and experience can make a mistake.

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William L. Pickett Jr. hace 7 meses 1

That's how Bob Hoover came up with the Hoover Nozzle.

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linbb hace 7 meses 0

Oh sorry didnt see your post. Darn.

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Tom Wilson hace 7 meses 4

Back in the 80's we had to put redtrictors and new fuel caps in all ports on the 421 I used to fly.Also an AD came out mandating anything referencing "Turbo" be removed from the ceilings,etc. so as to lessen the chance a fueled would think it was a turbine aircraft. 40 years later and we still see the same thing happening. Ultimately it's the pilots responsibility.

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Robert Winterstein hace 7 meses 3

I guess the tanker was not equipped with a "Hoover Nozzle". But it's still the PIC responsibility.

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Tom Zaidman hace 7 meses 3

The Shrike Commander looks very much like the Newer Turbo Commander. ONE uses Avgas the other Jet A fuel.its always the pilots responsibility which fuel is served.

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William Robertson hace 7 meses 3

One of my fears when I intermittently fly a malibu and a meridian. I observe fueling when possible and double check the ticket and confirm with the lineman.

Avgas and jet blend together. The only way to tell by dumping is the “napkin test” to check for a halo.

The PT6 can run on avgas, the piston can’t run the kerosene.

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jbird17 hace 7 meses 2

To all Pilots and Fuelers,

Make sure your product is what is dedicated. Double check, triple check. It is all our responsibility. The Fuel supplier, the FBO, the Lineman, the pilot. 90% of pilots could not tell me how to check if Avgas is contaminated by JetA.

Read up on it. It takes a copious amount of JetA to change the color of 100LL. I mean a lot of it. A simple fuel sump would never show unless your tanks had 0 avgas in them. Have your FBO show you. I bet they will even be surprised if they have some knowledge of how to check contaminated Avgas. Most FBO's lack the knowledge of quality control.

Pilots please double check and understand contaminated fueling. Wish you all safe flying.

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Craig Good hace 7 meses 2

I thought that the Bob Hoover filler ring/wide Jet A nozzle system, born of exactly this problem in his Shrike, was supposed to prevent this. Why were they relying on just a placard?

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Kara Ottewell hace 7 meses 2

I'm not a pilot, just a person interested in aviation, but I'm surprised that there isn't a color-coded ring around the fill ports indicating the type of fuel required.

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Tim Dyck hace 7 meses 1

I am also not a pilot but in the mining industry every tank is color coded as to what goes in and often labeled. Labels do wear and wash off but colour coded tanks and filler caps are hard to screw up.

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Shane Adair hace 7 meses 1

There is a requirement for a color ring label Kara. It was installed on this aircraft as well. Makes it even more baffling...

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Dubslow hace 7 meses 3

They least they could do is link to the NTSB report... damn media these days

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SFRobert hace 7 meses 1

The article said not out yet.

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SFRobert hace 7 meses 2

But Mike Hanninen linked a preliminary: https://app.ntsb.gov/pdfgenerator/ReportGeneratorFile.ashx?EventID=20200529X64359&AKey=1&RType=HTML&IType=LA

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linbb hace 7 meses 2

Same thing happened to Bob Hoover years back he wrote about it in a publication. He also had company management from Rockwell on board. No injuries due to his skill when he crashed. Its all on the pilot to pay attention he said as some people were talking to him during the fueling. Nothing new here happens every year due to linemen who dont do there job. And the pilot not checking there fuel smell.

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linbb hace 7 meses 0

Oh and it was the same type of AC.

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Jesse Carroll hace 7 meses 2

Why does it take 6 months to write a one page letter showing 3 people screwed up? Luckily no one was killed.
Just saying!

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lyn williams hace 7 meses 4

not to mention yet another of the ever dwindling inventory of AeroCommander 500 series lost to idiocy.

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Scott Skylane hace 7 meses 5

Surprisingly, it seems the NTSB is in the habit of doing complete investigations, before it publishes any accident information. In other shocking news, the NTSB is apparently engaged in *several* other accident investigations, at any one time, and is forced to operate within a finite *budget* to accomplish all of this.

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iflyfla hace 7 meses 1

That wording indicates that the person writing the article has little or no knowledge of aviation. The media probably put one of their ace political reporters on the incident.

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nascarco hace 7 meses 1

Great points Jonathan Huls! Thank you.

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James Radcliffe hace 7 meses 1

Always sample the fuel. Jet fuel might have been off loaded into 100LL tank at the airport. Someone might have tampered with the plane overnight and taken out Avgas and put water in its place. The fuel caps can leak as well if it rains. Make it a habit before the first flight of the day and after refueling.

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Jeff Brenton hace 7 meses 1

I thought there was an airworthiness directive on the piston commanders to install a restrictor on the fuel inlet, to prevent a Jet A nozzle from being inserted.

Of course, that isn't 100% - there have been crashes where the fuel truck operator filled the tanks with Jet A despite the restrictor...

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ImperialEagle hace 7 meses 1

Not the first time this has happened. Years ago, back in Atlanta, a Martin 404 chartered by real estate investors was fueled with JetA at PDX. It took off and immediately had trouble. The Captain figured out that if the engines were at full power he could keep them going. He declared an emergency and tried to get into the westbound pattern of arrivals headed to ATL. He almost made it but the engines were so fouled and overheated he had to put it down on I-285 (which was brand new at the time and nobody used it!). He skipped over a bridge (at Snapfinger? Lakewood?) and came down in opposing traffic on the other side of the bridge. I think a car got hit head-on with fatalities and some people were killed on the plane. But, most survived.

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ImperialEagle hace 7 meses 1

Correction:
The departure airport was PDK!

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Chris B hace 7 meses 1

And it happens all the time.
Then there were the jets that was refueled with JetA contaminated with DeF fluid not Prist.....The engines cut out.

Thankfully it was within gliding range of an airport

https://www.aopa.org/news-and-media/all-news/2019/may/22/new-def-fuel-contamination-incidents-reported

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Randy Barron hace 7 meses 1

I'm not a pilot, but I love learning from you all on these boards.

Agreed that the pilot is the "buck stops here" person, but can we spare a few thoughts about training for fuel vendors?

It seems to me that airports should insist that anyone putting fuel into an airplane should know which types of fuel go into which airplanes, regardless of special nozzles, placards, what have you.

They should also be trained to then double-check against the placards, and triple-check with the pilot, without using "ain't I cool for a ground guy" jargon. In other words, they can assist the overworked, hungry, distractedly busy pilots with a critical task: putting the correct fuel (without neglected water accumulation, thank you) into the plane in the first place.

I also agree that the pilot still has to check to be sure that's what actually happened. But it seems to me the origin of the near-fatal problem was with an under-trained (and mostly likely underpaid) fuel vendor.

Am I way off here?

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A Frank hace 7 meses 1

situational awareness --GUESS NOT

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john doe hace 7 meses 1

Aside from failure of the PIC to sample fuel, sounds like imprecise language was a problem. Not to mention a lax attitude and/or inadequate training on the part of the refueler.

Lesson here is same as always: there's no place for casual flying. Whether the means is a hang glider or a wide-body, the price of safety is constant vigilance.

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PBADC3 hace 7 meses 1

Flying a Turbo Lance, I'm paranoid about getting Jet-A instead of Avgas, since the big turbo inlet scoop on the front sometimes confuses the ramp into thinking it's a turboprop. We've removed the "Turbo" labels from the cowling, and put big labels on both fuel caps and inlets saying "100LL or 110LL only".

I always make a point of visually confirming what fuel is going in. If the ramp refuels while I'm gone, then I make sure to check the receipt carefully, verbally confirm with the ramp that they re-fuelled with Avgas, and then drain twice as much fuel as normal when checking the sumps. Finally, I open both fuel caps and look for that telltale blue color and smell-test it for Jet-A. (As for why I smell-test, this article is very informative: https://blog.aopa.org/aopa/2016/01/11/misfueled/).

But I can totally understand why, under normal circumstances, most pilots wouldn't be as paranoid about the fuel type. These mistakes are rare, but they usually cause EFATO, which is almost always fatal, which should remind all of us to be more careful, not just those of us flying a turbocharged piston.

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Etienne Daniels hace 7 meses -1

All this could have been avoided by a 1 $ sticker. The FAA has a whole range and rules about them for small airplanes. But no sticker that tells you what kind of fuel the aircraft is allowed to fly with. My Japanese car has one with "Diesel" my Kawasaki has one with 91 octane minimum and 10% ethanol max. Even my parachute made in de US (Raven II) had a warning "skydiving is dangerous" Yet a multi million $ aircraft does not have a 1 $ sticker that really makes sense.

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mike hanninen hace 7 meses 6

The airplane had a placard. See the picture in the NTSB report.

https://app.ntsb.gov/pdfgenerator/ReportGeneratorFile.ashx?EventID=20200529X64359&AKey=1&RType=HTML&IType=LA

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John Rumble hace 7 meses 3

Doesn't do much good if the guy fueling is illiterate or has not been trained to the minimums

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william baker hace 7 meses -3

Someone has been watching Emergency to much.

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Ronald Pogatchnik hace 7 meses -1

Fault of the PIC PERIOD>

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