The National Transportation Safety Board did not travel to the scene of this incident.
Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Burlington, Massachusetts
Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Burlington, Massachusetts
Investigation Docket - National Transportation Safety Board:
Location: Savannah, Georgia
Incident Number: ERA19IA178
Date & Time: May 9, 2019, 12:28 Local
Registration: N744AT
Aircraft: Cessna 550
Aircraft Damage: None
Defining Event: Fuel contamination
Injuries: 7 None
Flight Conducted Under: Part 135: Air taxi & commuter - Non-scheduled - Air Medical (Discretionary)
Analysis
The crew of the air medical flight reported that, while in cruise flight at 35,000 ft mean sea level, the left engine began losing power. The crew requested a lower altitude from air traffic control, shut down and secured the left engine, and diverted. While descending, the right engine lost all power, and the crew performed an uneventful forced landing to the diversion airport.
Several days after the incident, the lineman who worked at the fixed-base operator (FBO) where the airplane was most recently fueled realized that he had inadvertently combined the contents of an unmarked, partially empty container of fuel system icing inhibitor (FSII) with a partially-empty container of diesel exhaust fluid (DEF), assuming that both containers contained FSII. The container of DEF was co-located with the container of FSII, which was contrary to the FBO's policy of isolating DEF off-airfield. The lineman then serviced the fuel truck FSII reservoir with the DEF/FSII combination. The following day, the incident airplane was fueled with Jet A fuel from the truck, and FSII additive from the truck was mixed at the time of fueling. Postincident testing revealed the presence of urea, one of the primary components of DEF, in the incident airplane's fuel system samples.
When combined with hydrocarbon jet fuels, urea forms a solid precipitate, or clathrate, that is known to interfere with fuel filtering and fuel system operation. The presence of DEF in the incident airplane's fuel system resulted in a blockage, which led to the total loss of engine power.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this incident to be:
The lineman's inadvertent introduction of diesel exhaust fluid (DEF) to the fuel truck fuel system icing inhibitor reservoir, which resulted in fuel contamination and a total loss of engine power. Contributing to the accident was the fixed-base operator's failure to ensure that DEF was stored off-airfield in accordance with their own policy.
Findings
Personnel issues Incorrect action selection - Airport personnel
Environmental issues Ground vehicle - Contributed to outcome
Personnel issues Incorrect action performance - Airport personnel
Aircraft (general) - Fluid type
Aircraft (general) - Incorrect service/maintenance
Personnel issues (general) - Airport personnel
Factual Information
On May 9, 2019, at 1228 eastern daylight time, a Cessna C550, N744AT, experienced a total loss of engine power inflight and landed in Savannah, Georgia, without further incident. The two airline transport pilots, two medical crew, and three passengers onboard were not injured. The flight was operated as a Title 14 Code of Federal Regulations Part 135 air medical flight.
The airplane was based at Punta Gorda Airport (PGD), Punta Gorda, Florida. According to fueling records from PGD, on the morning of the incident, the airplane was fueled with 480 gallons of Jet A fuel with a fuel system icing inhibitor (FSII) additive mixed at the time of fueling. The flight crew completed the 47-nautical-mile flight from PGD to Naples Municipal Airport (APF), Naples, Florida, without anomaly.
According to the pilots, about 1 hour 20 minutes into the subsequent flight, from APF to Niagara Falls International Airport (IAG), Niagara Falls, New York, while cruising at 35,000 ft mean sea level (msl), the pilot-in-command (PIC) adjusted the left engine N1 speed to about 103%. Moments after adjusting power, the N1 speed decreased. This occurred "a few times" before the left engine began to "spool down very slowly." After unsuccessfully attempting to restore engine power, the crew requested a lower altitude from air traffic control and began a descent with the left engine at idle power. The PIC then noticed that the left engine displayed no oil pressure, and he subsequently shut it down.
Several minutes passed as the airplane descended with the right engine at 65% fan speed, and while the crew prepared to perform a single-engine approach to Savannah/Hilton Head International Airport (SAV), Savannah, Georgia, about 8,000 ft msl, the right engine became unresponsive and then began "spooling down." The captain declared an emergency and the crew performed a straight-in approach to runway 19, where they landed the airplane without incident; the airplane was subsequently towed to the ramp.
The second-in-command noted that the left fuel filter bypass light did not illuminate, but the right fuel filter bypass light did illuminate.
A lineman who worked for the fixed based operator (FBO) at PGD stated that, the evening before the incident, he noticed that the FSII was low on a fuel truck and he intended to refill it. He went to a shed where the FSII was located and noted that the unmarked FSII container was partially filled, and another bottle next to it that was also partially filled. He combined the two containers and then refilled the fuel truck FSII reservoir. Several days after the incident, the lineman realized that he had inadvertently combined the contents of a 5-gallon FSII container and a 2.5-gallon diesel exhaust fluid (DEF) container instead of two partially empty containers of FSII. He could not recall if the DEF container was marked.
Fuel samples, fuel system filters, and fuel screens from the incident airplane were obtained and sent for laboratory testing. Analysis of the fuel indicated the presence of urea; DEF is a solution comprised of about 33% urea and 67% water. Although urea is soluble in both water and FSII, when added to hydrocarbon jet fuels, it forms a solid precipitate (known as a "clathrate") that is known to interfere with fuel filtering and fuel system operation.
Review of the lineman's training records indicated that he completed National Air Transportation Association (NATA) Fuel Service Supervisor training in July 2018, Professional Line Service training in September 2018, and Line Fuel Service training in September 2018. His training records did not specifically include the DEF Contamination Prevention training released by the NATA in December 2017; however, the lineman did state that he had received DEF training and cross-contamination training in June 2018.
The FBO policies in place to mitigate the hazard of DEF contamination before the incident included isolating FSII to the self-serve shed, isolating DEF off-airfield in the vehicle maintenance shop, conducting mandatory training on DEF contamination, and reviewing cross contamination with staff. After the incident, the FBO made multiple changes to their policies, including retraining line personnel, limiting DEF servicing to vehicle maintenance personnel, removing all unmarked containers from storage areas, and creating a monthly inspection program to review all storage facilities for properly stored and labeled inventory.
On July 24, 2019, the NTSB issued Safety Alert SA-079 warning providers of jet fuel to take measures to prevent contamination of jet fuel by diesel exhaust fluid.
History of Flight
Prior to flight Fuel contamination
Enroute-cruise Fuel contamination (Defining event)
Enroute-cruise Loss of engine power (total)
Approach Loss of engine power (total)
Pilot Information
Certificate: Airline transport; Commercial; Flight instructor
Age: 41, Male
Airplane Rating(s): Single-engine land; Multi-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Unknown
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane single-engine; Instrument airplane
Toxicology Performed: No
Medical Certification: Class 1 Without waivers/limitations
Last FAA Medical Exam: May 1, 2019
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time:
Pilot Information
Certificate: Airline transport; Commercial; Flight instructor
Age: 66, Male
Airplane Rating(s): Single-engine land; Single-engine sea; Multi-engine land
Seat Occupied: Right
Other Aircraft Rating(s): Glider; Gyroplane; Helicopter
Restraint Used: Unknown
Instrument Rating(s): Airplane; Helicopter
Second Pilot Present: Yes
Instructor Rating(s): Airplane multi-engine; Airplane single-engine; Glider; Gyroplane; Helicopter; Instrument airplane; Instrument helicopter
Toxicology Performed: No
Medical Certification: Class 1 With waivers/limitations
Last FAA Medical Exam: September 1, 2018
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time:
Aircraft and Owner/Operator Information
Aircraft Make: Cessna
Registration: N744AT
Model/Series: 550 No Series
Aircraft Category: Airplane
Year of Manufacture: 1983
Amateur Built: No
Airworthiness Certificate: Transport
Serial Number: 550-0017
Landing Gear Type: Retractable - Tricycle
Seats:
Date/Type of Last Inspection:
Certified Max Gross Wt.: 15100 lbs
Time Since Last Inspection:
Engines: 2 Turbo jet
Airframe Total Time:
Engine Manufacturer: Pratt & Whitney
ELT: Installed, not activated
Engine Model/Series: JT15D-4
Registered Owner:
Rated Power: 2500 Lbs thrust
Operator:
Operating Certificate(s) Held: On-demand air taxi (135)
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual (VMC)
Condition of Light: Day
Observation Facility, Elevation: SAV,51 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 16:53 Local
Direction from Accident Site: 276°
Lowest Cloud Condition: Few / 2700 ft AGL
Visibility: 10 miles
Lowest Ceiling: Broken / 3200 ft
AGL Visibility (RVR):
Wind Speed/Gusts: 12 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 120°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.1 inches Hg
Temperature/Dew Point: 26°C / 19°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Naples, FL (APF)
Type of Flight Plan Filed: IFR
Destination: Niagara Falls, NY (IAG)
Type of Clearance: IFR
Departure Time: 11:00 Local
Type of Airspace:
Airport Information
Airport: Savannah/Hilton Head Intl SAV
Runway Surface Type: Concrete
Airport Elevation: 50 ft msl
Runway Surface Condition: Dry
Runway Used: 19
IFR Approach: Visual
Runway Length/Width: 7002 ft / 150 ft
VFR Approach/Landing: Forced landing; Full stop; Straight-in
Wreckage and Impact Information
Crew Injuries: 4 None
Aircraft Damage: None
Passenger Injuries: 3 None
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 7 None
Latitude, Longitude: 32.129165,-81.200836(est)
A serious error which turned out OK. I admire the lineman for admitting his mistake, but, man, that should never happen.
ReplyDeleteLuckily there were a couple of old pros running the plane. They handled it very nicely.