A really dumb accident

RotaryWingBob

RotaryWingBob

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http://www.ntsb.gov/ntsb/brief2.asp?ev_id=20001212X22299&ntsbno=LAX01LA033&akey=1

I don't make a habit of commenting on accidents, but this one strikes me as so dumb that I wonder if I'm missing something.

Basically the PIC of a Cherokee 140, in the middle of an ILS approach tried to switch fuel tanks and managed to move the fuel selector to off.

Which raises some questions...

1. Why would anybody want to switch tanks in the middle of an instrument approach?

2. Why didn't the pilot familiarize himself with something as important as the fuel selector?

3. Why didn't he glance down at the selector before turning it?

4. How did he manage to switch the selector off without pressing the release button which (AFIK) all PA28's have?

5. Why was he unable to switch back to the left tank, since that doesn't require the release button to be pressed?
 
crainalrectitis
 
RotaryWingBob said:
1. Why would anybody want to switch tanks in the middle of an instrument approach?
Click to expand...
GUMPS
G - Gas - on Fullest Tank (or in most Cessna's, on Both)

As to the rest? Dunno...
 
I don't make a habit of commenting on accidents, but this one strikes me as so dumb that I wonder if I'm missing something.

Basically the PIC of a Cherokee 140, in the middle of an ILS approach tried to switch fuel tanks and managed to move the fuel selector to off.

Which raises some questions...

1. Why would anybody want to switch tanks in the middle of an instrument approach?

>>>>GUMPS, realized he hadn't switched tanks yet.

2. Why didn't the pilot familiarize himself with something as important as the fuel selector?

>>>>Unknown

3. Why didn't he glance down at the selector before turning it?

>>>>Moving the head in IMC can induce vertigo.

4. How did he manage to switch the selector off without pressing the release button which (AFIK) all PA28's have?

>>>>Unknown. Maybe it was stuck in the "in" position. Another thing to add to my preflight check list.

5. Why was he unable to switch back to the left tank, since that doesn't require the release button to be pressed?

>>>>Silence induced Panic.

These are all just guesses, but I think they are reasonable ones....

-Skip
 
Greebo said:
GUMPS
G - Gas - on Fullest Tank (or in most Cessna's, on Both)

As to the rest? Dunno...
Click to expand...

Reading the report, it isn't clear if the guy was inside the FAF or not. Our SOP is to have the prelanding checklist complete before the FAF, with the exception of gear and flaps (which helps you down). My feeling is that if he was past the FAF, he ought to have just left the tanks as they were, but outside, he was OK to switch. I'm not sure why he didn't try switching it back.

The other option is to switch tanks sometime before, as in when over the airport if flying outbound on a PT from an on-field VOR, or when over a nearby airport. You can glide if you lose power, and the other pilot can troubleshoot.
 
We switch tanks for the last time just as we're cleared out of our cruise alititude. If there is so little fuel that I need to switch one more time, I've committed a judgement error and have extended the flight too far. You want to be able to say, "well, it's running isn't it?" and just leave it alone when one doesn't have the cushion of thousands of feet below....
 
I actually plan an instrument flight in IMC conditions so the FAATS (Fuel is the first F)is complete 50 to 75 miles out. If there is a problem, I have enough altitude to accomplish basic trouble shooting. I don't look at the fuel tank indicators in the two birds I fly; just know by rote where they are to be switched to. When switching tanks, I monitor the fuel flow gauge for 4 or 5 seconds with my hand ready to put the boost pump on if the engine stumbles.
On long flights when I am sure fuel will be at minimums, I burn a tank dry (or until the fuel gauge is where I know it's empty backed up by computations of burn enroute. There is only fuel left in one tank; no changing of one's mind in conditions such as these is possible--it's only in one place!!

Best,

Dave
A-36TN ADS
 
RotaryWingBob said:
4. How did he manage to switch the selector off without pressing the release button which (AFIK) all PA28's have?
Click to expand...

What release button? Mine, nor any of the other PA-28's I've flown have a release button.
 
N2212R said:
What release button? Mine, nor any of the other PA-28's I've flown have a release button.
Click to expand...

There's a button above the selector that has to be pressed in before the selector will rotate to the off position. You can switch it from off to left or left to right without pushing it.

From the PA28-181 POH:

"The fuel selector control (Figure 7-7) is located on the left side-panel, forward opf the pilot's seat. The button on the selector cover must be depressed and held while the handle is moved to the OFF position."
 
Not all PA28's have the fuel selector button - it was added later as a safety measure.
 
MSmith said:
Not all PA28's have the fuel selector button - it was added later as a safety measure.
Click to expand...

That's very true. Here's a lesson for those filling up the experience bucket before the luck bucket runs out. Years, ago in a 1965 Cherokee 180, that I had just been checked out in:

I switched tanks prior to start-up. The fuel selector markings were old and worn. I thought I had put the switch exactly on the proper spot (L or R, I don't remember which). I had plenty of time to do this as I was on the ground with the engine stopped. No pressure at all. I did my run-up which is always thorough and the engine started, ran for a while then died. Some guy in another plane on the ground keyed his mike, and laughed at me for pulling the mixture instead of the carb heat. I had done neither. What I had done was not put the fuel selector switch in the exact correct position to allow fuel flow. If I had not done a proper run-up, I would have had an engine failure on take-off.

People (mostly non-pilots) ask me what my closest call in an airplane was and I just have to laugh, because this was it, but nobody will pay attention to the story long enough and its not very exciting. Scared the hell out of me. Later when I bought my own Cherokee 140, I made double sure the fuel was on either L or R exactly. These full switches are also in an odd place where you have to crane your head and/or bend down to switch them. Sometimes you can't really feel them go into the proper position. They are also a potential IMC, vertigo nightmare waiting to happen.

I like the position and design of the Tiger's fuel selector A LOT BETTER.
 
MSmith said:
Not all PA28's have the fuel selector button - it was added later as a safety measure.
Click to expand...

I didn't know that. Or maybe I did -- I'm not sure a PA28-180 I used to occasionally fly had one. But... the NTSB report states that the button on the accident aircraft was operational.
 
I suspect you mean 5148S - I'm a member at Kenmarson now. I don't think it has the button. I didn't think the club's Warriors do either, except maybe the newer one that you've probably never seen.
 
Greebo said:
New acronym - please define?
Click to expand...

K.

At Recurrent Training Center couple years ago, they taught a check as one approached the airport environment--generally far enough out to get everything set up before beginning the approach. For me, about 50 miles out seems to work well.

Fuel
Selector in Detent; on fullest tank; Boost pump as required

Altimeter
Altimeter set (ATIS/AWOS); weather received.

Approach
Approach reviewed: MSA; Altitudes; Course; FAF; MAP; DH; or MDA; missed

Tune
Tune and identify navaids; set annunciator; marker beacon; GPS

Special
Safety or special items to check such as alternate; hold; STAR if not already on one.

I use this without fail when IMC approaching the airport environment.


Dave;)
A-36TN ADS
 
MSmith said:
I suspect you mean 5148S - I'm a member at Kenmarson now. I don't think it has the button. I didn't think the club's Warriors do either, except maybe the newer one that you've probably never seen.
Click to expand...

5148S and 6639J (which I think got sold). It's been a long time since I flew one of those Warriors, so I really can't say. I'm pretty sure 8126X, which was my favorite Cherokee (Archer II) there had the button.

Still, the point made in the NTSB report was that the aircraft had the button and that it functioned properly. I still stand by my point that it's pretty lame to fly an aircraft without being familiar with the fuel system.

Check out Crew Dawg aviation there in the FBO building at VAY. The owners are friends of mine, and they're trying to put together a class for instruction and rentals!
 
What is Crew Dawg aviation? Kenmarson is currently running as "Crew Dawg Aviation, t/a Kenmarson Aero Club"?
 
MSmith said:
What is Crew Dawg aviation? Kenmarson is currently running as "Crew Dawg Aviation, t/a Kenmarson Aero Club"?
Click to expand...

The name Crew Dawg, AFIK, belongs to Bob Cameron. When he and Frank took over from Ken, they used the Crew Dawg name. Around the first of the year, Bob and Carl Bubnoski split off and started what is now Crew Dawg Aviation. Carl runs the flight instruction end and Bob runs the maintenance end (in addition to Bob, there's at least one other A&P/IA). For my money, Carl and Roland Arthur (who is an independent CFI) are the two best instructors at VAY.

When you're 61 the memory really starts to go :mad:

Did I really steer you to Kenmarson? When was that?
 
Your website steered me to Kenmarson. I started there July 2003.

I have more questions and insights at VAY, but I'll take it offline.
 
RotaryWingBob said:
I didn't know that. Or maybe I did -- I'm not sure a PA28-180 I used to occasionally fly had one.
Click to expand...

Our 1966 Cherokee 180C didn't have one. The detent was obvious though. I always took the extra second verifying it wasn't between positions and there was no switching when closer than 5 minutes out just in case. If it stops, put it back where you found it.

IMHO: Know your critical systems by touch or don't go.
 
fgcason said:
Our 1966 Cherokee 180C didn't have one. The detent was obvious though. I always took the extra second verifying it wasn't between positions and there was no switching when closer than 5 minutes out just in case. If it stops, put it back where you found it.

IMHO: Know your critical systems by touch or don't go.
Click to expand...

Can't argue with any of that, Frank... That's why I find this accident so disturbing.
 
My 1965 Cherokee 180C did not come equipped with the fuel selector with a lockout. The early Cherokees did not have the lock out button or the fuel selector with a positive stop at each detent. The early ones just have a flat plate with 4 positions, L, R, off, off. The valves on those early ones are subject to getting stiff and difficult to feel the detents. They can be lubricated, but like all things, they don't last forever.

Piper SB 355 covers the lubrication and/or replacement of the valve itself. SB840 announces the availability of the updated cover kit with the lockout and positive detents.

Guess how I know all of this?

The 140 in this case would not have the lockout type fuel selector cover as factory equipment. Obviously, it was added on. They may or may not have done something about the valve. If the valve was old, it is likely that it was quite hard to turn, inspite of the new cover, could be inadvertently set to off. The NTSB report does indicate the valve was hard to turn. I could see it happening.

But not to me, I have both the new cover and a brand new valve. The new valve is MUCH better than the old ones. It's actually an Allen 6S122, which has ball bearings to make the detents click. The new cover also helps by providing positive stops and the lock out.

I can tell you, the old valve made me uncomfortable. You really had to be careful setting it into a detent.
 
The PA-28-180B that I used to own years ago (1963 model) did not have a button that needed to be pushed in. Must be something that showed up in later models.
 
Chuck:

I hope I'm not too late on this response...

And NOT to pick on you. But, I have to agree with Bob. I was also taught GUMPS. But! G to me means verify not switch. Not switch UNLESS necessary. And this is done miles out, not on final. I asked this question to many a CFI: Why Switch? The answer I always received was: 'That is what is taught.' No real definitive answer. If you are on a tank that you KNOW has gas, the engine is running, all is well! Why switch?
I pity the fool in a Cessna that runs on BOTH tanks. They never learn fuel management and when they are OUT... They are OUT - OUT OF LUCK! Hello GROUND!

Piper! Well, dumb location to put a Fuel Valve! YEA! You can't beat a Grumman! Smack dab in front of BOTH the Pilot & Co-Pilot. Kind of difficult to teach a student how to switch tanks on a Piper when the student/pilot can't see the valve AND the Co-Pilot/Instructor CAN'T reach the valve.

G - Gas - Verify
U - Undercarriage - down and locked, 3 Queens whoops! Have to be PC - 3 Greens
M - Mixture - Full Rich - Dependent on DA
P - Prop - Full Forward - Is the prop still on the plane?
S - Systems - OMG! There are dozens to chose from: Seat belts, A/P, Cowl Flaps, Canopy Un-Locked <-- Real planes have canopies, Boost Pump, Tail Hook, etc.

Barry
 
First post and necro-wow.... Grand entry!

Were you searching for some thing specific?
 
I have a 1970 Cherokee 140 and it doesn't have any button release to turn the fuel off.
 
bbchien said:
We switch tanks for the last time just as we're cleared out of our cruise alititude. If there is so little fuel that I need to switch one more time, I've committed a judgement error and have extended the flight too far. You want to be able to say, "well, it's running isn't it?" and just leave it alone when one doesn't have the cushion of thousands of feet below....
Click to expand...

I have yet to fly IFR so I'm not sure if it changes anything but I know that in my 182, the POH has you switch from both tanks during takeoff to the right tank for cruise flight then back to both for landing. If this aircraft is the same, then the POH tells you to switch to both tanks, so that's just something you add to your landing checklist. I wonder since "BOTH" and "OFF" are usually directly across from each other, maybe he got the pointer end of the selector confused with the tail end.
 
Bob sadly died several years ago. Great guy and missed by those that knew him. Never too late to talk safety though.
 
AdamZ said:
Bob sadly died several years ago. Great guy and missed by those that knew him. Never too late to talk safety though.
Click to expand...

Which Bob are you referring to? Bob from CrewDawg?

If that Bob, you are HAPPILY MISTAKEN!
He is alive and well and Grumpy as ever.

Barry
 
FLYADIVE said:
Which Bob are you referring to? Bob from CrewDawg?

If that Bob, you are HAPPILY MISTAKEN!
He is alive and well and Grumpy as ever.

Barry
Click to expand...

The person that started this thread ELEVEN years ago, died of cancer nearly EIGHT years ago - his name was Bob.
 
FLYADIVE said:
Chuck:

I hope I'm not too late on this response...

And NOT to pick on you. But, I have to agree with Bob. I was also taught GUMPS. But! G to me means verify not switch. Not switch UNLESS necessary. And this is done miles out, not on final. I asked this question to many a CFI: Why Switch? The answer I always received was: 'That is what is taught.' No real definitive answer. If you are on a tank that you KNOW has gas, the engine is running, all is well! Why switch?
I pity the fool in a Cessna that runs on BOTH tanks. They never learn fuel management and when they are OUT... They are OUT - OUT OF LUCK! Hello GROUND!

Piper! Well, dumb location to put a Fuel Valve! YEA! You can't beat a Grumman! Smack dab in front of BOTH the Pilot & Co-Pilot. Kind of difficult to teach a student how to switch tanks on a Piper when the student/pilot can't see the valve AND the Co-Pilot/Instructor CAN'T reach the valve.

G - Gas - Verify
U - Undercarriage - down and locked, 3 Queens whoops! Have to be PC - 3 Greens
M - Mixture - Full Rich - Dependent on DA
P - Prop - Full Forward - Is the prop still on the plane?
S - Systems - OMG! There are dozens to chose from: Seat belts, A/P, Cowl Flaps, Canopy Un-Locked <-- Real planes have canopies, Boost Pump, Tail Hook, etc.

Barry
Click to expand...

That drives me up the wall. Instructors quite often know nothing more than what they learned from their instructors, who have very possibly have been wrong. Doesn't anyone do original research these days? (Note my sig)

Bob Gardner
 
Still silently BEGGING for an automatic change in post color, for when they are resurrected like this.
So one can immediately know something is up. I realize it must come from the site developers, not the moderators/owners of POA. But it would seem so simple to have any threads >1 year old appear in...green or orange. Does vBulletin have a suggestion box?
 
Hey! I just noticed on another vBulletin forum I attend, that each original post has a "time started" stamp, on the list of posts. This is v. 4.2.2.
It says for example;

Go to first new post Coupled HSI
Started by DCarter, Today 05:37 AM

Is that a software update (ie $$)? or a switch available on 3.8.6 (ours).
Hoping......
 
Why do people complain about old threads being resurrected?

There's really nothing new under the sun. Well, really rarely. If folks only spoke when they had something truly new and exciting to say, most of us would never speak.

I fly a PA-28 occasionally and had never given much thought to the fuel selector other than putting it on L or R. This thread was informative for me.

Edit to add.... The one I rent has a ?button? that has to be pressed to move it to the off position. So I understand 3 positions. What is new (to me) is that the switch isn't always precise and there are some extra OFF positions lurking in there. Like false neutrals on a motorcycle. :D
 
Last edited:
noobJohn said:
Why do people complain about old threads being resurrected?
Click to expand...

It's context, John. (and not a complaint about old threads.)
I find, that in general, a response to something that happened a decade ago can appear completely inappropriate due to the passage of time.
 
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