Monday, February 22, 2016

Piper PA-46-350P Malibu Mirage, C-GVZW: Fatal accident occurred February 22, 2015 near Felts Field Airport (KSFF), Spokane, Washington

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

NTSB Identification: WPR15LA111
14 CFR Part 91: General Aviation
Accident occurred Sunday, February 22, 2015 in Spokane, WA
Probable Cause Approval Date: 09/06/2017
Aircraft: PIPER PA46 - 350P, registration: CGVZW
Injuries: 1 Fatal.

NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

The pilot was conducting a cross-country flight from Canada to California and had landed to clear customs into the United States and to refuel his airplane. The pilot then departed to continue the flight. During the initial climb after takeoff, the engine experienced a total loss of power, and the pilot attempted to make an off-airport forced landing. The right wing struck railroad tracks at the top of a hill, and the airplane continued down an embankment, where it came to rest adjacent to the bottom of a railroad bridge. 

Postaccident interviews revealed that, when requesting fuel from the fixed-base operator (FBO), the pilot did not specify a grade of fuel to be used to service the airplane. The refueler mistakenly identified the airplane as requiring Jet A fuel, even though the fuel filler ports were placarded “AVGAS (aviation gasoline) ONLY.” The fueler subsequently fueled the airplane with Jet A instead of aviation gasoline. Additionally, the fueling nozzle installed on the fuel truck at the time of the refueling was not the proper type of nozzle. Jet A and AvGas fueling nozzles are different designs in order to prevent fueling an airplane with the wrong type of fuel. 

Following the fueling, the pilot returned to the FBO and signed a receipt, which indicated that the airplane had been serviced with Jet A. There were no witnesses to the pilot’s preflight activities, and it is unknown if the pilot visually inspected or obtained a fuel sample before takeoff; however, had the pilot done this, it would have been apparent that the airplane had been improperly fueled. 

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
A total loss of engine power due to the refueler’s incorrect refueling of the airplane. Contributing to the accident was the fixed-base operator’s improper fueling nozzle, which facilitated the use of an incorrect fuel, and the pilot’s inadequate preflight inspection.

HISTORY OF FLIGHT

On February 22, 2015, at 1405 Pacific standard time, a Piper Aircraft, Inc., PA-46-350P airplane, Canadian registration C-GVZW, was destroyed during a forced landing following a total loss of engine power after takeoff from Felts Field Airport (SFF), Spokane, Washington. The pilot, was fatally injured. Visual meteorological conditions prevailed for the instrument flight rules (IFR) flight, which was originating at the time of the accident. The flight was destined for the Stockton Metropolitan Airport (SCK), Stockton, California.

According to family members, the pilot was traveling to SCK from Canada to participate in recurrent flight training. He had called his wife prior to departure from SFF; he said that his flight to SFF was great, and that he was in good spirits. She could hear the engine in the background as she spoke to her husband, and nothing sounded abnormal.

Air traffic control voice communication information proved by the Federal Aviation Administration (FAA) indicated that the airplane was cleared for takeoff from runway 22R, and the pilot was instructed to turn to a heading of 190° after takeoff. When the controller observed on radar that the airplane had not turned to the 190° heading, he queried the pilot. The pilot responded that he was having engine trouble. The controller cleared the pilot to return to the airport and land on any runway. The pilot stated that he was not going to make it back to the runway, and asked if the controller had any suggestions for an alternate landing site. No further radio transmissions were received from the pilot.

One set of witnesses heard the airplane engine sputtering. They saw the left-wing drop, and the nose pitch up, the right wing dropped, and they lost sight of the airplane as it passed behind a building. The second set of witnesses reported that the right wing struck a railroad track at the top of a hill and subsequently traveled down an embankment. The airplane slid across a road and came to rest inverted adjacent to the bottom of a railroad bridge.

WITNESS INFORMATION

The fixed-base operator (FBO) employee who serviced the airplane with fuel stated that the pilot contacted him on the day of the accident and requested to have his airplane fueled. The pilot did not specify what type of fuel was required, but only that he had cleared customs; he also told the fueler where his airplane was located. The fueler stated that the pilot was not present when he arrived to fuel the airplane. He stated that the majority of the Piper Malibu airplanes that he had serviced required Jet A fuel, so he fueled the accident airplane with Jet A. Once the fueling was complete, he returned to the FBO, and waited for the pilot to return to pay for the fuel. Both the written receipt and credit card receipt provided to the pilot specified that the airplane had been serviced with Jet A. The pilot paid for the fuel and left.

There were no witnesses to the pilot's preflight activities, and it is unknown if the pilot visually inspected or sumped the fuel before departing. Following the accident, an FAA inspector obtained the fueling log from the FBO; the log indicated that the accident airplane had been fueled with 52 gallons of Jet A.

PERSONNEL INFORMATION

The pilot held a Transport Canada single-engine and multiengine land certificate with night ratings. He held a third-class medical with the limitation that glasses must be worn. The pilot had received training in the accident make/model airplane, and was endorsed for proficiency in its operation in March 2012.

AIRCRAFT INFORMATION

The airplane was powered by a Lycoming TIO-540-AE2A 350-horsepower, turbocharged, reciprocating engine. According to the journey record (aircraft logbook), the last annual inspection was performed on July 23, 2014, at an airframe total time of 2,324.0 hours. The last maintenance performed included an oil and filter change on January 15, 2015, at a total airframe time of 2,388.9 hours. There were no recorded flights between January 15, and February 22, 2015.

WRECKAGE AND IMPACT INFORMATION

The airplane crashed in a commercial area near a railroad yard.

The majority of the airplane came to rest at the accident site, with additional wreckage strewn throughout the debris path. Both wings had separated from the airplane fuselage; however, they remained near the main wreckage. The fuel tanks had been ruptured during the accident sequence; however, a strong smell of Jet A fuel was present at the accident site. As a result of the ruptured fuel tanks, a fuel sample was not obtained.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed by the Spokane County Office of the Medical Examiner. The cause of death was determined to be blunt impact to the head, and the manner of death was an accident.

The FAA Bioaeronautical Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens from the pilot. The results were negative for volatiles. The pilot initially survived the accident; as a result, there was positive test results for drugs that were administered to the pilot while he was in the hospital, including ephedrine detected in urine, but not detected in blood, and etomidate, lidocaine, pseudoephedrine, and salicylate detected in blood.

TEST AND RESEARCH

The airplane was equipped with its original fuel equipment, and was appropriately marked with an "AVGAS (aviation gasoline) ONLY" placard at each wings fuel port, which indicated that the airplane operated on aviation gasoline. Both fuel ports were checked by an FAA inspector, and identified as having the appropriately-sized fuel collar for AVGAS.

There were no other malfunctions that would have precluded normal operation of the airplane.
Inspection of the fuel truck after the accident revealed that the fuel hose nozzle was the round type, typically used to service helicopters with smaller fuel filler ports. When the FAA returned the next day to inspect the truck, the smaller rounder fuel nozzle that had been on the fuel truck the night before had been replaced with a flat duck-bill fuel nozzle. When the owner of the FBO was questioned about the switch, he stated that it was for safety reasons, and that he was making sure the appropriate nozzle was attached.

ADDITIONAL INFORMATION

According to the airplane's pilot operating handbook, while performing the preflight checklist, one of the items called out is for the pilot to do a visual check of the fuel supply for both wings, and assure that the fuel cap is secured.

Located at the airport is an FBO that performs turbine conversions on the accident make and model airplane.


 


The National Transportation Safety Board did not travel to the scene of this accident. 

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Spokane, Washington
Piper Aircraft, Inc.; Vero Beach, Florida
Transportation Safety Board of Canada; Edmonton, AB

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

Aviation Accident Factual Report - National Transportation Safety Board:  https://app.ntsb.gov/pdf

NTSB Identification: WPR15LA111 
14 CFR Part 91: General Aviation
Accident occurred Sunday, February 22, 2015 in Spokane, WA
Aircraft: PIPER PA46 - 350P, registration: CGVZW
Injuries: 1 Fatal.

NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

HISTORY OF FLIGHT

On February 22, 2015, at 1405 Pacific standard time, a Piper Aircraft, Inc., PA-46-350P airplane, Canadian registration C-GVZW, was destroyed during a forced landing following a total loss of engine power after takeoff from Felts Field Airport (SFF), Spokane, Washington. The pilot, was fatally injured. Visual meteorological conditions prevailed for the instrument flight rules (IFR) flight, which was originating at the time of the accident. The flight was destined for the Stockton Metropolitan Airport (SCK), Stockton, California.

According to family members, the pilot was traveling to SCK from Canada to participate in recurrent flight training. He had called his wife prior to departure from SFF; he said that his flight to SFF was great, and that he was in good spirits. She could hear the engine in the background as she spoke to her husband, and nothing sounded abnormal.

Air traffic control voice communication information proved by the Federal Aviation Administration (FAA) indicated that the airplane was cleared for takeoff from runway 22R, and the pilot was instructed to turn to a heading of 190° after takeoff. When the controller observed on radar that the airplane had not turned to the 190° heading, he queried the pilot. The pilot responded that he was having engine trouble. The controller cleared the pilot to return to the airport and land on any runway. The pilot stated that he was not going to make it back to the runway, and asked if the controller had any suggestions for an alternate landing site. No further radio transmissions were received from the pilot.

One set of witnesses heard the airplane engine sputtering. They saw the left-wing drop, and the nose pitch up, the right wing dropped, and they lost sight of the airplane as it passed behind a building. The second set of witnesses reported that the right wing struck a railroad track at the top of a hill and subsequently traveled down an embankment. The airplane slid across a road and came to rest inverted adjacent to the bottom of a railroad bridge.

WITNESS INFORMATION

The fixed-base operator (FBO) employee who serviced the airplane with fuel stated that the pilot contacted him on the day of the accident and requested to have his airplane fueled. The pilot did not specify what type of fuel was required, but only that he had cleared customs; he also told the fueler where his airplane was located. The fueler stated that the pilot was not present when he arrived to fuel the airplane. He stated that the majority of the Piper Malibu airplanes that he had serviced required Jet A fuel, so he fueled the accident airplane with Jet A. Once the fueling was complete, he returned to the FBO, and waited for the pilot to return to pay for the fuel. Both the written receipt and credit card receipt provided to the pilot specified that the airplane had been serviced with Jet A. The pilot paid for the fuel and left.

There were no witnesses to the pilot's preflight activities, and it is unknown if the pilot visually inspected or sumped the fuel before departing. Following the accident, an FAA inspector obtained the fueling log from the FBO; the log indicated that the accident airplane had been fueled with 52 gallons of Jet A.

PERSONNEL INFORMATION

The pilot held a Transport Canada single-engine and multiengine land certificate with night ratings. He held a third-class medical with the limitation that glasses must be worn. The pilot had received training in the accident make/model airplane, and was endorsed for proficiency in its operation in March 2012.

AIRCRAFT INFORMATION

The airplane was powered by a Lycoming TIO-540-AE2A 350-horsepower, turbocharged, reciprocating engine. According to the journey record (aircraft logbook), the last annual inspection was performed on July 23, 2014, at an airframe total time of 2,324.0 hours. The last maintenance performed included an oil and filter change on January 15, 2015, at a total airframe time of 2,388.9 hours. There were no recorded flights between January 15, and February 22, 2015.

WRECKAGE AND IMPACT INFORMATION

The airplane crashed in a commercial area near a railroad yard.

The majority of the airplane came to rest at the accident site, with additional wreckage strewn throughout the debris path. Both wings had separated from the airplane fuselage; however, they remained near the main wreckage. The fuel tanks had been ruptured during the accident sequence; however, a strong smell of Jet A fuel was present at the accident site. As a result of the ruptured fuel tanks, a fuel sample was not obtained.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed by the Spokane County Office of the Medical Examiner. The cause of death was determined to be blunt impact to the head, and the manner of death was an accident.

The FAA Bioaeronautical Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens from the pilot. The results were negative for volatiles. The pilot initially survived the accident; as a result, there was positive test results for drugs that were administered to the pilot while he was in the hospital, including ephedrine detected in urine, but not detected in blood, and etomidate, lidocaine, pseudoephedrine, and salicylate detected in blood.

TEST AND RESEARCH

The airplane was equipped with its original fuel equipment, and was appropriately marked with an "AVGAS (aviation gasoline) ONLY" placard at each wings fuel port, which indicated that the airplane operated on aviation gasoline. Both fuel ports were checked by an FAA inspector, and identified as having the appropriately-sized fuel collar for AVGAS.

There were no other malfunctions that would have precluded normal operation of the airplane.
Inspection of the fuel truck after the accident revealed that the fuel hose nozzle was the round type, typically used to service helicopters with smaller fuel filler ports. When the FAA returned the next day to inspect the truck, the smaller rounder fuel nozzle that had been on the fuel truck the night before had been replaced with a flat duck-bill fuel nozzle. When the owner of the FBO was questioned about the switch, he stated that it was for safety reasons, and that he was making sure the appropriate nozzle was attached.

ADDITIONAL INFORMATION

According to the airplane's pilot operating handbook, while performing the preflight checklist, one of the items called out is for the pilot to do a visual check of the fuel supply for both wings, and assure that the fuel cap is secured.

Located at the airport is an FBO that performs turbine conversions on the accident make and model airplane.























NTSB Identification: WPR15LA111 
14 CFR Part 91: General Aviation
Accident occurred Sunday, February 22, 2015 in Spokane, WA
Aircraft: PIPER PA46 - 350P, registration: CGVZW
Injuries: 1 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On February 22, 2015, at 1405 Pacific standard time, a Piper Aircraft, Inc., PA46-350P airplane, Canadian registry CGVZW, experienced a loss of engine power during climb out from runway 22R at Felts Field Airport (SFF), Spokane, Washington. The Canadian certificated pilot, the sole occupant, succumbed to his injuries on February 24, 2015. The airplane was destroyed during the attempted emergency landing after it struck a railroad track. Visual meteorological conditions prevailed for the instrument flight rules (IFR) flight that originated shortly before the accident. The flight was destined for the Stockton Metropolitan Airport (SCK) Stockton, California. 

A National Transportation Safety Board (NTSB) investigator and a Federal Aviation Administration (FAA) inspector responded to the accident site and identified two different groups of witnesses. The first set of witnesses observed the airplane with the engine sputtering. They observed the left wing drop and the nose pitch up. The right wing then dropped, and the witnesses lost sight of the airplane as it passed behind a building. The second set of witnesses reported that the right wing struck a railroad track at the top of a hill and subsequently traveled down an embankment. The witnesses reported that the airplane slid across a road and came to rest inverted adjacent to the bottom of a railroad bridge. 

Responding investigators stated that the majority of the airplane came to rest at the accident site, with additional wreckage strewn throughout the debris path. Both of the wings had separated from the airplane fuselage; however, they remained near the main wreckage. The investigators stated that the fuel tanks ruptured during the accident sequence, and there was a strong smell of Jet fuel present. 

The FAA inspector obtained the fueling log from Western Aviation at SFF; the fuel log indicated that the accident airplane had been refueled with 52 gallons of Jet fuel prior to takeoff. SPOKANE, Wash. – The family of a pilot who died from his injuries in a Spokane plane crash after the wrong fuel was filled into his plane has filed a wrongful death lawsuit against the refueling company.

Monday marked one year since the crash at Spokane's Hamilton Street overpass.

Michael Clements, 61, from Alberta was on his way to California and stopped at Felts Field to refuel.

His plane crashed shortly after takeoff.  He died at the hospital two days later from severe injuries.

The NTSB investigation later confirmed his Piper Malibu was filled with Jet A fuel, instead of the AV gas the aircraft required.

The lawsuit claimed it was a Western Aviation employee who filled the plane full of the wrong fuel, pumping 52 gallons of Jet A into the two tanks over the wings.

The lawsuit also claimed that employee ignored and disregarded numerous safety measures designed to avoid that type of error.

Aviation experts said pump nozzles for the two types of fuel are supposed to be different, but in this case, the lawsuit stated the fuel attendant used a "rogue nozzle," allowing the plane to be filled with the wrong fuel.

The lawsuit also stated the employee ignored labels on the aircraft itself that warned to only fill the plane with AV gas.

The attorney handling the case for Clements family said the family is deeply saddened on the one year anniversary of his death.

The attorney added the family’s experts continue to independently and thoroughly investigate the accident and identify the responsible parties.

Western Aviation did not return calls seeking comment on whether the company had changed its refueling regulations.

The FAA and NTSB said the investigation into what happened is still in the preliminary stage.  Neither agency said when it expected to complete the investigation.

Original article can be found here:  http://www.krem.com

NTSB Identification: WPR15LA111
14 CFR Part 91: General Aviation
Accident occurred Sunday, February 22, 2015 in Spokane, WA
Aircraft: PIPER PA46 - 350P, registration: CGVZW
Injuries: 1 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On February 22, 2015, at 1405 Pacific standard time, a Piper Aircraft, Inc., PA46-350P airplane, Canadian registry CGVZW, experienced a loss of engine power during climb out from runway 22R at Felts Field Airport (SFF), Spokane, Washington. The Canadian certificated pilot, the sole occupant, succumbed to his injuries on February 24, 2015. The airplane was destroyed during the attempted emergency landing after it struck a railroad track. Visual meteorological conditions prevailed for the instrument flight rules (IFR) flight that originated shortly before the accident. The flight was destined for the Stockton Metropolitan Airport (SCK) Stockton, California. 

A National Transportation Safety Board (NTSB) investigator and a Federal Aviation Administration (FAA) inspector responded to the accident site and identified two different groups of witnesses. The first set of witnesses observed the airplane with the engine sputtering. They observed the left wing drop and the nose pitch up. The right wing then dropped, and the witnesses lost sight of the airplane as it passed behind a building. The second set of witnesses reported that the right wing struck a railroad track at the top of a hill and subsequently traveled down an embankment. The witnesses reported that the airplane slid across a road and came to rest inverted adjacent to the bottom of a railroad bridge. 

Responding investigators stated that the majority of the airplane came to rest at the accident site, with additional wreckage strewn throughout the debris path. Both of the wings had separated from the airplane fuselage; however, they remained near the main wreckage. The investigators stated that the fuel tanks ruptured during the accident sequence, and there was a strong smell of Jet fuel present. 

The FAA inspector obtained the fueling log from Western Aviation at SFF; the fuel log indicated that the accident airplane had been refueled with 52 gallons of Jet fuel prior to takeoff.