The pilot reported that, after a flight the day before the accident, he requested that the FBO top off the tip tanks with fuel.
Before the flight the next morning, he performed a preflight inspection of the airplane. There was no water in the fuel sample, which appeared to be blue, similar to 100LL aviation fuel.
He performed an engine run-up before takeoff, and no anomalies were noted.
During climbout, the airplane vibrated slightly, and the climb performance degraded. The airplane reached 2,100 feet above ground level, and the left engine then sputtered and lost all power.
Shortly after, the right engine also lost all power, and the pilot conducted a forced landing to a highway median near Diboll, Texas, resulting in one serious and two minor injuries.
The smell of JetA fuel was prominent at the accident scene.
A post-accident examination of the reciprocating engines revealed that they exhibited signs of detonation, consistent with having been operated with JetA fuel, and a review of fueling records revealed that the airplane had been serviced with JetA fuel instead of the required 100LL aviation fuel.
Further, the FBO employee who fueled the airplane reported that he mistakenly serviced the airplane with 53 gallons of JetA fuel.
Examination of the fuel tank filler ports revealed placards next to the ports indicating that only 100LL fuel was to be used.
A credit card receipt signed by the pilot also showed that the airplane was serviced with JetA fuel.
The FBO employee also noted that the nozzle on the JetA fuel truck was small and round like the nozzle on the aviation gas fuel truck.
According to the airport manager, the larger JetA nozzle, which was J-shaped with an opening of 2-3/4 inches, had recently been switched to a smaller, round nozzle; switching to a smaller fuel nozzle increased the chances that aircraft that needed 100LL fuel could be misfueled with JetA fuel.
The FAA had issued an airworthiness directive (AD) about 26 years before the accident requiring that the filler ports be equipped with restrictors to preclude misfueling; the restrictors reduced the fuel filler diameter to 1-5/8 inches.
A review of the airplane’s maintenance records indicated that the AD had been accomplished, however, an examination of the airplane revealed that it was not equipped with the required restrictors.
Based on the evidence, the engine likely lost power due to the use of the improper fuel type. Further, the noncompliance with the AD increased the possibility that the airplane could be misfueled with JetA fuel, as occurred before the accident.
Probable cause: The total loss of engine power due to the use of an improper fuel type. Contributing to the accident were the servicing of the airplane with the improper fuel, noncompliance with an airworthiness directive, and the fuel nozzle installed on the fueling truck.
NTSB Identification: CEN15LA199
This April 2015 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.
I fly a DA 42 which burns Jet-A. I have noticed that rampies may not be familiar with this type of plane and may think it uses avgas. To prevent any misfueling, I lock the filler port cap and am always present when fueling. The training of rampies is not consistent and one cannot assume that misfiling will not occur despite placards, nozzles, etc.
This has given me flash back to the time this same problem almost Killed R.A. “Bob” Hoover! ” A perhaps-undesired recognition for the late pilot is the “Hoover Nozzle” used on jet fuel pumps. The Hoover Nozzle is designed with a flattened bell shape. The Hoover Nozzle cannot be inserted in the filler neck of a plane with the “Hoover Ring” installed, thus preventing the tank from accidentally being filled with jet fuel.
This system was given this name following an accident in which Hoover was seriously injured, when both engines on his Shrike Commander failed during takeoff. Investigators found that the plane had just been fueled by line personnel who mistook the piston-engine Shrike for a similar turboprop model, filling the tanks with jet fuel instead of avgas (aviation gasoline). There was enough avgas in the fuel system to taxi to the runway and take off, but then the jet fuel was drawn into the engines, causing them to stop.
Once Hoover recovered, he widely promoted the use of the new type of nozzle with the support and funding of the National Air Transportation Association, General Aviation Manufacturers Association, and various other aviation groups (the nozzle is now required by Federal regulation on jet fuel pumps)”
Bob Hoover was contacted by Shaw Aero Devices, FL the manufacturer of most fuel cap and filler adapters for GA. I told them the story about Hoover’s plane at Brown Field, CA. after they came to Wichita to prototype the change on the Cessna and the Beech fleet. Shaw Aero hired Bob to advertise for them.
Bob Hoover, ‘The Greatest Stick and Rudder Man” ever to fly! Quote by Jimmy Doolittle.
Who switches to a smaller nozzle that allows a goof at the fuel truck to get Jet-A into the tank?. Then ignoring the placards. A no-brainer lawsuit. This FBO should be taken off the field also.
Aren’t the pump handles colored diferent, like the green or yellow handles at the gas station? If not, they SHOULD be!
I guess he didn’t see the placards, because they were covered up by the fueling hose.
Pilot signed for Jet A. Jet A smells distinctly different than avgas. Some shared negligence here. Kudus to the pilot for getting it down without killing anyone. Lawsuit? You must be a lawyer. General aviation is already on fragile ground in this country. A litigious society doesn’t help, especially punitively as you suggest.
The pilot signed for fuel, not Jet-A. A lawsuit is demanded here due to neglegence of the first order. This is a life/death deal, not just some fender bender. The lawsuit needs to drive the FBO off the field and punish them to the extent NOONE else does this again…
I stand by my first comment. Jet A was SPECIFIED on the fuel receipt. Jet fuel looks, feels and smells specifically different than avgas. Contributory negligence at the least on the pilots part. Gen aviation needs to protect itself from those who are all too eager to sue us all into oblivion. Those who use the legal system as a weapon are preditors. I notice you didn’t deny being an attorney.
The damage was done BEFORE he signed the receipt. He does not share liability for this since the plane was placarded and there is nothing in a fuel service that specifies anyone needs to babysit the service…it’s a pure winnable lawsuit aggravated by his engine out.
I am not debating the merits of the “winnable ” lawsuit. I am questioning your eagerness to litigate against aviation businesses. You seem to be out for blood on this one, although I’m sure everyone has learned a valuable lesson. BTW, I have little doubt that plenty of briefcases headed for the sight.
If there EVER was a reason to due someone out of existence it’s when they put you and/or your family in danger of dying. And that’s why this is so serious.
As an attorney, you probably struggle with the concept of a non- litigious society. As a strong defender of general aviation, I stand behind my earlier remarks. Unless this was intended, or if there had been fatalities, I resist your urge for blood. I agree that medical bills, repairs or replacement of the aircraft are in order. But putting them out of business or and losing their jobs is just throwing chum to the sharks. You and I sir will never share the same tank.
I am not a lawyer. But you seem to fail to grasp the scenario.
1. if, as you say, it was intentional then that is far worse than doing it accidentally since then you would have attempted murder or at best attempted manslaughter or criminal negligence.
2. Since it was an accident that caused an aviation engine to die in flight then it is a malicious act with full liability.
3. People suing for no reason is a tort reform issue. People suing due to negligence that could have led to death or dismembership is reasonable and the party should sue.
By winning the lawsuit this person would send a solid signal to others that if you put the wrong fuel in an aircraft as a service provider you will pay a crippling price.
How many pilots to you ever see signing the fuel ticket at the plane. No, they are inside the office or terminal. As for the smell of Jet A, yes, you correct however, that was at the crash site I believe.
Be present at the airplane when it is fueled. With so many models and conversions, this is an error which can occur but is easily prevented by monitoring the fueling service. At least verify the correct fuel truck stops in front of the airplane.
And you sir fail to grasp my point. Litigation is destroying general aviation. Period. Gotta go now as I have some preflight responsibilities to take care of before I go flying. BTW, are you a pilot?
GA is not being affected by litigation. If anything harms aviation it is crashes. Especially ones that result in death. People who know nothing of the sport get upset with each report and do not understand the difference between a stall and the failure to follow GUMPS and get the gear down.
Yes. I am a 1000 hour instrument rated pilot and Cirrus owner.
I think you meant this for gbigs, correct?
And I am a 75 year old 30,000 + hour professional pilot who has owned 9 airplanes and paid thousands upon thousands of dollars for liability insurance to protect myself from people like you. I can no longer afford to do that.
Ah. So you think it’s a peeing contest. We all pay insurance for our aviation sport, especially we who own. My plane costs over $1m bucks. And my next plane will cost over $2m. My rates are lower because I am a good pilot and have had no accidents or incidences. At 75 maybe you have been flying too long and not well enough to keep your premiums down. That is not an industry issue….it’s your issue.
OUR issue! My God man you seethe with arrogance. Learn from it. No more posts from me. You get the last word.
He will always have the last word, you are dealing with a 1000hr instrument rated, 1 million dollar airplane owner…..a SKY GOD!
Yes. Sorry. Thanks
The lesson? Presence ( in mind as well as body) is a good idea when anyone else fuels my plane. If not possible do four tests a few minutes after rocking the wings: 1. Draw 8 oz from each quick drain on the aircraft, plus (if possibe) the gascolator). At each quickdrain look for blue color while holding the fuel testor against a white background, also look for water or sediment; 2. Drizzle a few drops of fuel from each tank onto a piece of white paper then set the paper where the fuel can evaporate. If the fuel evaporates leaving an oily residue I’ve got Jet-A in my tank 🙁 3. If mogas is in any tank near wher I might refuel check for ethanol. 4. Climb up and look in each tank. Dip ’em if less than full. Do what it takes to confirm BOTH quality AND quantity.