Las Cruces Cessna 421 crash - wrong fuel

[overdrive148]

From the Phillips 66 SDS:

100LL:
Relative Density (water=1): 0.71 @ 15°C
Evaporation Rate (nBuAc=1): N/D
Viscosity: N/D
Odor: Gasoline

Jet A (with Prist, an anti-icing additive in our fuel)
Specific Gravity (water=1): 0.775-0.840 @ 68ºF (20ºC)
Evaporation Rate (nBuAc=1): <1
Viscosity: 1.5-2.5 cSt typical @ 68ºF (20ºC) / 8 max cSt @ -4°F (-20°C)
Odor: Kerosene


I wonder why the units and measurements are different between the SDS's anyway, pretty sure that relative density and specific gravity are the same. The temps aren't though 5*C difference between the two.

 

[PaulS]

Next you'll be asking me to light a match!

We could call this the eyebrow test...... strike a match, apply to sample, if you still have your eyebrows Jet A, if they are gone, 100LL

 

[alfadog]

I wonder why the units and measurements are different between the SDS's anyway, pretty sure that relative density and specific gravity are the same. The temps aren't though 5*C difference between the two.

No, JetA is denser, 6.8 lb/gal vs 6.0.

 

[overdrive148]

No, JetA is denser, 6.8 lb/gal vs 6.0.

I figured Jet A was more dense (else how would it cause problems until the tanks were close to empty?) but the terms themselves for measuring density were different between the SDS sheets. I was saying I think the terms were the same measurement - not the measurements themselves.

We could call this the eyebrow test...... strike a match, apply to sample, if you still have your eyebrows Jet A, if they are gone, 100LL

 

[alfadog]

I figured Jet A was more dense (else how would it cause problems until the tanks were close to empty?) but the terms themselves for measuring density were different between the SDS sheets. I was saying I think the terms were the same measurement - not the measurements themselves.

LOL. I see your point now

 

[Henning]

That's probably true, but the other 3 that died didn't have brain cancer.

Nope, but one failed and died for his failure and took 2 with him, but they took the job and accepted the risk. Either one of them could have looked at the fuel truck/pump as well. Just because you're not the pilot doesn't mean you shouldn't educate yourself on your work environment. Bet the ramper feels like crap.

 

[Henning]

I do not allow anyone to put fuel in my planes. I must be there to see what it is they are doing. I was at Davenport, IA a couple of years ago and they tried to fuel my RV-10 with Jet A.

I'm the exact same, I either fuel or supervise the fueling.

 

[Henning]

Plane built in 1974. Hoover Ring/Nozzle (SAE AS 1852) didn't come around until 1984, I believe.

Isn't there an SB for a retrofit though?

 

[Henning]

The pilot was a good friend of mine. I am positive Freddy did not forget to sump. I hope that if you all have an accident, you don't get the Monday morning QBing that is going on here. God speed Freddy ... you're sorely missed already.

Yep, we all make mistakes, some have consequences greater than others, this was a big mistake.

 

[alfadog]

Isn't there an SB for a retrofit though?

AD, as above.

 

[Henning]

How would a sniff test work??

At the tank, depends on the concentration of kero, I'm guessing it was a C model since wit 20 gallons in 50 they probably wouldn't have made it off the ground without noticing a problem. 20 gallons to top off a big tank in a C model probably wouldn't smell. It's always a habit of mine from fueling boats to smell the nozzle when I get it, that's the best way I've found to keep from using the wrong fuel.

 

[kenjr]

very sad RIP. I find it a little difficult to see the blue in my tube when I'm testing in a noon high sun. I took a trip with my boys out to El Paso a few weeks ago and allowed them to fuel the plane without my supervision (first time ever for that) because they were running a fuel special at .60/gal cheaper over the weekend. So, I authorized them to go ahead and top the tanks and save me the $$. I was super anal about testing the fuel though when we arrived to leave on tuesday. The fuel in my test tube looked white so I even walked it over to the hangar so i could get some shade to see if it was really blue. I could tell by the smell it was familiar and I knew it wasn't Jet-A (I spent 4 years in the Navy as an aircrewman...I know Jet-A/JP5) but was more worried that since the plane had sat for a few days with low tanks in a hot climate that maybe there was a lot of condensation and the tube was so full of water that there was only a trace of 100LL.

Better safe than sorry I guess - especially with my 3 young boys in the plane with me.

 

[Henning]

Doesn't beat living, though.

Conclusion not founded in evidence, only fear and supposition.

 

[overdrive148]

Conclusion not founded in evidence, only fear and supposition.

Beats dying of brain cancer.

Wouldn't the same be true of your comment

 

[Henning]

Good catch. I didn't think to look at the NTSB report.



So we know about PIC responsibility, however will the ground crew share some of this responsibility?

Responsibility as in moral responsibility depends on the level of training they have received. Since a 421 airframe is also available as a 425 turboprop, and is at the top of the range for AvGas burners (most planes that size and Genre will run Jet A), if it's a new employee, no.

Responsibility as in criminal legal responsibility absolutely not. It's the captain's job to get the plane fueled properly. You can delegate the duty but not the responsibility.

Responsibility as in civil liability, no two ways. First the Air Ambulance will be on a 135 certificate which means they operate under Strict Liability rules. It doesn't matter why it happened, they are responsible. The other is that he protected through the principle of Respondeat Superior, Let the Master Answer; his employer is liable for his actions when acting on the employer's behalf.

 

[danhagan]

Sorry to hear about your friend.

Thanks Ren ...

Yep, we all make mistakes, some have consequences greater than others, this was a big mistake.

Was it? If you're single pilot 421 MED EVAC and you've got W&B, Fuel, Flight Plan, etc. all occuring at the same time and you sumped ... you're single mistake (if it even is that) was depending on the sump test. He had 2 opportunities to catch the problem at the receipt or the side of the truck if he wasn't filing a flight plan in the cockpit.

Failing a GUMPS on downwind, base and final would be bigger in my book.

 

[Henning]

Wouldn't the same be true of your comment

No, not at all. Dying of brain cancer is a long and suffering way of dying, I know three people who died of it, one closely, it's not pleasant in the slightest. Crashing a high energy plane like a 421 is quick low suffering way to go. If it was his good karma to be spared that, then the other three are doing well.

 

[docmirror]

Thanks Ren ...



Was it? If you're single pilot 421 MED EVAC and you've got W&B, Fuel, Flight Plan, etc. all occuring at the same time and you sumped ... you're single mistake (if it even is that) was depending on the sump test. He had 2 opportunities to catch the problem at the receipt or the side of the truck if he wasn't filing a flight plan in the cockpit.

Failing a GUMPS on downwind, base and final would be bigger in my book.

I'm sorry you lost a friend as well. It's sad the way this happened, but not only did the pilot sign the fuel receipt with Jet-A listed, he was at the fuel cap securing it. I believe he had a min of three, maybe four bites at this apple, and he missed them all. Fuel truck/hose; Standing over gas filler; sign receipt with Jet-A listed; fuel sump.

RIP. I hope it never gets me, but we are all only human.

 

[Henning]

Thanks Ren ...



Was it? If you're single pilot 421 MED EVAC and you've got W&B, Fuel, Flight Plan, etc. all occuring at the same time and you sumped ... you're single mistake (if it even is that) was depending on the sump test. He had 2 opportunities to catch the problem at the receipt or the side of the truck if he wasn't filing a flight plan in the cockpit.

Failing a GUMPS on downwind, base and final would be bigger in my book.

Yep, it was a big mistake not to check the fuel supply before it went into the plane. I'm not ****ting on him, it may be what was meant to karmically happen for his Pax and he just got caught up in it. If it wouldn't have been the fuel it would have been something else.

You won't get me to argue or defend my gear up, I ****ed up a whole long line of **** ups, not just a GUMPS check.

If we don't realize and accept that not checking the fuel supply (like I said, I sniff the nozzle before it flows) was a mistake, then we learn nothing making his death a karmic tragedy rather than relief.

 

[petrolero]

Fuel Testers that detect water and Jet A?

This accident has me somewhat spooked. You know the age and relative mental capacity of *some* of the nitwits who fuel your plane. This accident chain is easy to imagine even if the pilot correctly sumped the tanks.

So...

What about fuel testers that claim to test for the presence of water and Jet A?

I found a reference in this AOPA article from 1990 on fueling problems to a "ClearSight" fuel tester by a For-Mar Aviation Specialties. I find nothing about this product in a google search - only references back to the AOPA article. This device supposedly used the density difference between Jet A, water and 100LL to float a ball or balls of density greater than 100LL but less than either water or Jet A. This seems like a sensible idea. What product available today does this?

Then there is the GATS jar which claims to "detect" Jet A although I don't have one so I don't know how it accomplishes that. It also claims to strain out water and dirt. I do understand how it accomplishes that bit.

Are there other products that make detection of mixed fuels more evident than just a color check? Numerous articles online mention that color check is not reliable with mixed fuels and in varying light conditions. So density would seem to be a good crosscheck. However...

Both Avgas and Jet A are petroleum products. My question is to what extent one is soluble in the other and one might act as a diluent. Yes they have different densities, but anyone who's ever used gasoline as a solvent knows that... well... it is a solvent and can dilute heavier hydrocarbons. Can it not dilute Jet A such that the combined mixture is neither 6.0 ppg nor 6.8 ppg but some volume-weighted average of the two? And this wouldn't need to happen for the entire tank, just the portion you test. I would imagine a large amount of Jet A would sink to the bottom immediately and it might get diluted at the interface and perhaps never be completely diluted. But if it only takes 10% to cause a problem I wonder if that Jet A would get heavily diluted by the 100LL making it less detectable by either color *or* by density. Shirley someone has tested all this over the past fitty-odd years.

I may have to do some tests unless someone has references to tests already done by others.

 

[James331]

No one has fueled my aircraft but me. In fact, I have only used 100LL once in 200 hours. I still sump check before each flight. My autogas is wheat colored, like JetA.

I am not trying to be mean about the pilot missing this, but the fuel is dyed for a reason and he should have been both checking it, and being able to tell when it's diluted. The main reason to check fuel is to look for color and water.

Self fueling is not always an option, landing at larger airports often it's only full service fuel.

Still I watch for the duck bill and verify it's JET A with prist.

No, you do that if you do not like the way the fuel feels or smells. Or you can pay to have the tanks emptied and refilled.. or you can take off with the doubt in your mind because you could not figure out how to find a piece of paper.

Realistically if you add 600lbs of fuel to 1400lbs existing, on a quick turn you're not going to see jack on a fuel sump.

We only sump before the first flight and have fuel quality assurance papers for the airports we use, still, as I said, we supervise all fueling, and verify on the printed receipts which we keep.


The ONLY way to make sure you're good is to fuel the plane yourself (if possible) OR supervise fueling, as that's your responsibility as PIC.

 

[PaulS]

{Snip}



It's always a habit of mine.... to smell the nozzle when I get it, that's the best way


{Snip}

Sorry, it reminded me of Jimmy Kimmel's unnecessary bleeping, couldn't help myself...

 

[warthog1984]

Re: Fuel Testers that detect water and Jet A?

This device supposedly used the density difference between Jet A, water and 100LL to float a ball or balls of density greater than 100LL but less than either water or Jet A. This seems like a sensible idea. What product available today does this?

Any $20 hydrometer off the internet.

 

[Ted]

In this case, does not appear sumping the fuel would have helped.

It can happen to any of us. Remain vigilent. A sad day.

 

[James331]

Thanks Ren ...



Was it? If you're single pilot 421 MED EVAC and you've got W&B, Fuel, Flight Plan, etc. all occuring at the same time and you sumped ... you're single mistake (if it even is that) was depending on the sump test. He had 2 opportunities to catch the problem at the receipt or the side of the truck if he wasn't filing a flight plan in the cockpit.

Did he over see the fueling?

I'll betting it was in his GOM and probably OPSPEC.

I'm in the same line, different airframe, though our bird can burn 100ll (nor happily though), we have to observe the refueling. Normally you take on fuel when the crew is picking up or dropping off the pt. so it's normally not a super rush, also the pt does NOT constitute a emergency.

 

[PaulS]

So the engines stopped running, planes still can fly without engines, we've established that before. Why did this end in a crash?

 

[James331]

Critical phase of flight

 

[Swampfox201]

I remember it happening once when I worked the line back in the 90s. Not our airport but it was close enough that it stuck in my brain. A Navajo topped with jet fuel. Thy went down in a corn field off the end of the runway. Everyone survived that one.


Sent from my iPhone using Tapatalk

 

[Zeldman]

So the engines stopped running, planes still can fly without engines, we've established that before. Why did this end in a crash?

There is a chance that both engines didn't quit at the same time. There could be a possibility that one engine quit and the A/S got slow, and then a VMC proplem as the other engine quit.

Or both engines were losing power at different rates. Awful big props up front acting as speed brakes.

In my C-421s, I do think of engine failure after airborne. I always think that at take off, high density altitude, (DA up to 10k around my home base in summer) high power settings and low airspeed, near max gross weight and one engine quits, there might not be enough time to do anything but expect a quick off airport landing, and hope there is suitable ground in front of the nose. If both engines have significant power loss at different rates and suddenly there is no time. Add a turn and options run really short.

I hate to say it but we can't rule out the possibility of panic then out of time.

So many things could have happened. We will probably never know what the sequence of events was after the engines started losing power.

As an air ambulance pilot I will say I do my very best to ensure the safety of the patient and med crew. Someday my very best might not be enough. That is the risk I understand and take.

 

[Jay Honeck]

very sad RIP. I find it a little difficult to see the blue in my tube when I'm testing in a noon high sun.

This brings up something that has bugged me for years: Color variation in 100LL.

Sometimes it's so blue that it stains whatever it touches. Other times, it's just a hint of blue. This makes definitive testing more of a guessing game than I prefer.

I don't remember this being a problem back when we ran 80 octane avgas. The red was always about the same, or perhaps I was just lucky?

Where in the food chain is the blue dye added?

 

[Kaniki]

Sounds like a(nother) good reason to always keep a pad of 2x2 post-it notes in the console.

 

[Henning]

So the engines stopped running, planes still can fly without engines, we've established that before. Why did this end in a crash?

No direct knowledge of exactly where they went in, but the 421 glides with a lot of energy, and there aren't many smooth places to stick it around there that don't contain big assed rocks that don't move when you hit them.

 

[Dr. O]

We can stand around with a ruler measuring - or we can learn from this.
Both the line boy and the pilot messed up - badly.
The line boy lived.
I do not know any way to protect a pilot from his brain fart.
I am there when my plane is fueled. I am not paranoid.
But I do know that the wrong fuel can be put in their other-marked tank
I do stick a finger in it and smell and rub the finger to see how slick the liquid feels.
It has worked for me up to now (shrug)
Short of having a specific gravity tester it is the best I can do.

 

[Alexb2000]

I'll be the first to admit I don't always supervise my plane being fueled, or sniff the nozzle, or pull our a chemistry kit, or ????. I RARLY see anyone on an FBO ramp sumping their fuel other than students. I do, but I don't think it would have mattered.

The only take away is that if you have an aircraft like a 421 that is easily confused by a ramp newby as a King Air, then put BIG bold Avgas Only stickers around the fuel fillers.

IMO this is an accident that could have happened to anyone. RIP.

 

[Ted]

IMO this is an accident that could have happened to anyone. RIP.

Yep...

 

[Jaybird180]

This brings up something that has bugged me for years: Color variation in 100LL.

Sometimes it's so blue that it stains whatever it touches. Other times, it's just a hint of blue. This makes definitive testing more of a guessing game than I prefer.

I don't remember this being a problem back when we ran 80 octane avgas. The red was always about the same, or perhaps I was just lucky?

Where in the food chain is the blue dye added?

 

[overdrive148]

Hey guys, checking in. Did my sumping and mixing just now. Troubling results. I'll be posting the pics tonight after work.

Visual test did not work at all except for water detection
Smell test worked but not as well as expected
Touch test worked but not quite as well as expected
Paper test worked completely

 

[txflyer]

I've always thought having different nozzle sizes like at the car pumps for diesel and unleaded would stop this kind of mishap.

If you could not fit a jet-A nozzle into a 100LL hole, this would not happen.

 

[overdrive148]

I've always thought having different nozzle sizes like at the car pumps for diesel and unleaded would stop this kind of mishap.

If you could not fit a jet-A nozzle into a 100LL hole, this would not happen.

The nozzles on the jet a truck we have are bigger than the standard small Cessna ports, the avgas nozzle is finger and thumb circle size, the duckbill is middle finger and thumb straight out size. There's a round one on the jet a truck but its bigger. Some planes have big fuel ports though

 

[tonycondon]

In the Wichita accident the line guys had learned how to lay the duckbill nozzle on its side and dribble Jet-A into a Turbine conversion plane (Malibu maybe). They did the same thing when they mistakenly put Jet-A in the 421