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An ogre in your tank?An ogre in your tank?

We’ve noted before that seeing two or three supposedly rare events in quick succession doesn’t always mean they’ve suddenly become more frequent. If the intervals between those events are truly random, some will be longer than others. By chance, a couple of unusually short intervals could occur back to back. But while a sudden flurry isn’t necessarily a cluster, it does attract attention. If the result is hysteria, that’s unfortunate—but if it prompts a closer look at whether something really has changed, and whether existing precautions do everything within reason to minimize risk, that’s not a bad thing at all.

On May 18, 2015, the NTSB released its factual report on the April 17, 2015, forced landing of a Cessna 421B near Diboll, Texas. The one-month turnaround was unusually quick, but that came as no surprise to those who had read the preliminary report. Both engines lost power shortly after takeoff because the turbocharged piston airplane had been refueled with 53 gallons of Jet A.

Fortunately, everyone on board survived with injuries that weren’t life-threatening. That stands in contrast to the Feb. 22, 2015, crash of a Piper Malibu in Spokane and the Aug. 27, 2014, wreck of a Cessna 421C air ambulance near Las Cruces, New Mexico. Everyone on both those aircraft died when they lost power immediately after takeoff, and while official determinations of probable cause have yet to be issued, the NTSB’s preliminary reports make clear that both had also been misfueled.

Three accidents in nine months wouldn’t seem like a big deal—if it weren’t for the fact that it had been five years since pumping Jet A into a piston airplane last caused enough damage to warrant an NTSB report. The most recent fatal accident of this type happened in 1994.

Those facts that have already been established reveal no obvious pattern. The Texas pilot put in a fuel order and left the airport; the next day he signed a credit-card receipt detailing the sale as “Jet A.” The FBO said it hadn’t installed larger nozzles on its Jet A trucks because they service a high volume of military helicopters with turbine engines but smaller filler ports.

Whether the Malibu pilot requested line service or topped his own tanks hasn’t been reported; the self-service fuel station at Felts Field dispenses both avgas and Jet A. The preliminary report on the Las Cruces accident says that the pilot remained in the cockpit while the tanks were topped, “assisted the line service technician with replacing the fuel caps,” and went into the FBO office to sign a ticket for 40 gallons of Jet A.

In retrospect, the Texas pilot would seem to have made the most common mistake. He trusted someone else to fuel his airplane without his supervision. It’s easy to slip into that habit when the FBO and the linemen know your aircraft, but it doesn’t always travel well. It’s worth noting that he took fuel samples before departure and found that they “appeared blue like 100 LL aviation gasoline.” Contamination by jet fuel is hard to detect after it has had time to mix in with the remaining quantity of avgas, and harder still if the pilot has no reason to anticipate a problem. The circumstances of the Spokane accident remain obscure, but the pilot killed in New Mexico was on the scene with every opportunity to observe the proceedings. Why he failed to notice the larger truck, the smell of jet fuel, or the details of the receipt he signed remains a mystery.

What does any of this have to do with running a flight school? Potentially, a couple of things. While none of these accidents happened on instructional flights, hammering in one basic lesson during primary instruction might have helped prevented at least two out of three. Being there while the airplane is fueled is necessary but not sufficient; you also have to pay reasonably close attention to the proceedings. If the markings on the truck don’t match your request, blow the whistle until the discrepancy is resolved.

If you do your own refueling, take those extra 20 seconds to read the prompts on the self-service pump. Yes, errors can and have crept in elsewhere in the chain—inside the refinery, while loading delivery trucks or replenishing airport fuel farms, even when refilling the truck at the airport—but they’re scarce compared to those of simply sending the wrong truck or pumping from the wrong nozzle. Labelling and equipment reforms have made them rarer still. Taking personal charge of the fuel that goes into any aircraft you fly is one of the vital lessons that should be drilled home during primary instruction.

And if your flight school’s instructors benefit from the reminder, so much the better.

ASI Staff

David Jack Kenny

Manager, Safety Analysis
David Jack Kenny analyzes GA accident data to target ASI’s safety education programs while also supporting AOPA’s ongoing initiatives and assisting other departments in responding to breaking developments. David maintains ASI’s accident database and regularly writes articles for ePilot, Flight School Business, Flight Training, CFI-to-CFI, and other publications.

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