Aviation Accident Final Report - National Transportation Safety Board
The National Transportation Safety Board traveled to the scene of this accident.
Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Indianapolis, Indiana
Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Indianapolis, Indiana
Investigation Docket - National Transportation Safety Board:
Location: Kokomo, Indiana
Accident Number: CEN20FA002
Date & Time: October 5, 2019, 16:37 Local
Registration: N326CW
Aircraft: Piper AEROSTAR 602P
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General aviation
Analysis
The airline transport pilot arrived at the departure airport in the reciprocating engine-powered airplane where it was fueled with Jet A jet fuel by an airport employee/line service technician. A witness stated that she saw a "low flying" airplane flying from north to south. The airplane made a "sharp left turn" to the east. The left wing "dipped low" and she then lost sight of the airplane, but when she approached the intersection near the accident site, she saw the airplane on the ground. The airpane impacted a field that had dry, level, and hard features conducive for an off-airport landing, and the airplane was destroyed.
The wreckage path length and impact damage to the airplane were consistent with an accelerated stall.
Postaccident examination of the airplane found Jet A jet fuel in the airplane fuel system and evidence of detonation in both engines from the use of Jet A and not the required 100 low lead fuel. Use of Jet A rather than 100 low lead fuel in an engine would result in detonation in the cylinders and lead to damage and a catastrophic engine failure. According to the Airplane Flying Handbook, the pilot should witness refueling to ensure that the correct fuel and quantity is dispensed into the airplane and that any caps and cowls are properly secured after refueling.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's exceedance of the airplane’s critical angle of attack following a dual engine power loss caused by the line service technician fueling the airplane with the wrong fuel, which resulted in an aerodynamic stall and subsequent loss of control. Contributing was the pilot's inadequate supervision of the fuel servicing.
Findings
Personnel issues Incorrect action performance - Ground crew
Aircraft Fuel - Incorrect use/operation
Personnel issues Lack of action - Pilot
Personnel issues Aircraft control - Pilot
Aircraft Angle of attack - Capability exceeded
Factual Information
History of Flight
Prior to flight Fuel contamination
Maneuvering Fuel contamination
Maneuvering Loss of control in flight (Defining event)
Maneuvering Aerodynamic stall/spin
Uncontrolled descent Collision with terr/obj (non-CFIT)
On October 5, 2019, about 1637 eastern daylight time, a Piper Aerostar 602P, N326CW, was destroyed when it was involved in an accident near Kokomo, Indiana. The airline transport pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight.
According to the airport employee who fueled the airplane, during the pilot’s approach to the Kokomo Municipal Airport (OKK), Kokomo, Indiana, he asked if the pilot wanted jet fuel, and the pilot said "yes." He said that the airplane looked like a jet airplane. When the airplane arrived, the employee parked the Jet A fuel truck in front of the airplane while the pilot was still inside the airplane. The employee said that he asked the pilot again if he was wanted jet fuel, and the pilot said "yes."
The employee fueled the airplane with about 163 gallons of Jet A from the fuel truck. The employee said that he was able to orient the different-shaped nozzle (relative to the 100 low lead fuel truck nozzle) from the Jet A fuel truck by positioning it 90° over the wing fuel tank filler necks and about 45° over the fuselage filler necks. He said that he initially spilled about 1 gallon of fuel during refueling and adjusted his technique so subsequent fuel spillage was minimal.
The student pilot, who received recurrent training from the accident pilot, said that when she arrived in her vehicle to meet the accident pilot, he was walking between the fuel truck that was parked by the airplane and her vehicle. She said that the accident pilot began training right away about 1045. They completed training, and after 1630, the student pilot drove the accident pilot to the airplane. The student pilot said the accident pilot visually checked the fuel tanks of the airplane to ensure they were fueled up and gave a "thumbs-up" to the student pilot. The student pilot did not stay for the rest of the accident pilot's preflight inspection and drove off. The student pilot heard the engines start and "they sounded normal." The student pilot did not see the takeoff. The student pilot said the winds favored runway 14, which was in use on the day of the accident.
A witness, on a nearby road, stated that she saw a "low flying" airplane flying from north to south. The airplane made a "sharp left turn" to the east. The left wing "dipped low" and she then lost sight of the airplane, but when she approached the intersection near the accident site, she saw the airplane on the ground.
The airport employee said that he was inside the fixed base operator building about 1620 when he heard the engines start. After the engines started, the engines sounded "typical." He said that he did not hear any radio transmissions from the pilot during his departure and did not hear an engine runup.
Pilot Information
Certificate: Airline transport; Commercial; Flight instructor
Age: 59,Male
Airplane Rating(s): Single-engine land; Single-engine sea; Multi-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): Airplane multi-engine; Airplane single-engine; Instrument airplane
Toxicology Performed: Yes
Medical Certification: Class 2 With waivers/limitations
Last FAA Medical Exam: November 9, 2018
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: 7500 hours (Total, all aircraft)
There were no pilot records provided to the National Transportation Safety Board (NTSB) Investigator-in-Charge (IIC) indicating the pilot's flight experience and a recent flight review as required under Part 61.56 received from the accident pilot's wife after two requests were made to her.
On November 28, 2008, the pilot was involved in an aviation accident that was investigated under NTSB accident identification number: ERA09CA073.
On December 2, 2016, the Federal Aviation Administration terminated the pilot's designation as a pilot examiner due to sub-standard performance while conducting examinations.
On November 9, 2018, the pilot reported his flight experience that included 7,500 total hours and 200 hours in last six months as of his last airman medical exam.
Aircraft and Owner/Operator Information
Aircraft Make: Piper
Registration: N326CW
Model/Series: AEROSTAR 602P
Aircraft Category: Airplane
Year of Manufacture: 1981
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 62P08698165008
Landing Gear Type: Retractable
Seats: 6
Date/Type of Last Inspection: August 22, 2019 Annual
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: 2 Reciprocating
Airframe Total Time: 3002.3 Hrs as of last inspection
Engine Manufacturer: Lycoming
ELT:
Engine Model/Series: IO-540-AA1A5
Registered Owner:
Rated Power:
Operator:
Operating Certificate(s) Held: None
The owner of the accident airplane stated he was supposed to receive initial training in the airplane from In Flight Review, Inc., but it never happened for "various reasons." He stated that he never gave permission for the accident pilot to fly the airplane. The owner declined to provide more information as who he gave the airplane keys to.
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual (VMC)
Condition of Light: Day
Observation Facility, Elevation: OKK,832 ft msl
Distance from Accident Site: 3 Nautical Miles
Observation Time: 16:56 Local
Direction from Accident Site: 360°
Lowest Cloud Condition: Clear
Visibility: 10 miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 9 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 140°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.01 inches Hg
Temperature/Dew Point: 22°C / 8°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Kokomo, IN (OKK)
Type of Flight Plan Filed: None
Destination: Kokomo, IN
Type of Clearance: None
Departure Time:
Type of Airspace:
Airport Information
Airport: Kokomo Municipal Airport OKK
Runway Surface Type:
Airport Elevation: 832 ft msl
Runway Surface Condition:
Runway Used:
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing:
Wreckage and Impact Information
Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries:
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 40.474998,-86.063331(est)
On-scene examination of the airplane revealed the airplane wreckage path was about 328 ft in length along an approximate heading of 046° on a dry and hard surfaced fallow bean field. The wreckage and the wreckage path displayed features consistent with an accelerated stall.
On-scene examination revealed the presence of a clear liquid consistent in color, viscosity, oiliness, and odor with that of Jet A jet fuel in a fuselage tank and in the fuel lines leading to the fuel manifolds of both engines. Several of the engine spark plugs exhibited damage consistent with detonation. Flight control continuity was confirmed. The landing gear was in the retracted position.
Additional Information
The Airplane Flying Handbook (FAA-H-8083-38), Chapter 2, Ground Operations, stated in part:
"Jet fuel has disastrous consequences when introduced into AVGAS burning reciprocating airplane engines. A reciprocating engine operating on jet fuel may start, run, and power the airplane for a time long enough for the airplane to become airborne only to have the engine fail catastrophically after takeoff.
Jet fuel refueling trucks and dispensing equipment are marked with JET-A placards in white characters on a black background. Because of the dire consequences associated with misfueling, fuel nozzles are specific to the type of fuel. AVGAS fuel filler nozzles are straight with a constant diameter. However, jet fuel filler nozzles are flared at the end to prevent insertion into AVGAS fuel tanks.
Using the proper, approved grade of fuel is critical for safe, reliable engine operation. Without the proper fuel quantity, grade, and quality, the engine(s) will likely cease to operate. Therefore, it is imperative that the pilot visually verify that the airplane has the correct quantity for the intended flight plus adequate and legal reserves, as well as inspect that the fuel is of the proper grade and that the quality of the fuel is acceptable. The pilot should always ensure that the fuel caps have been securely replaced following each fueling."
"During refueling operations, it is advisable that the pilot remove all passengers from aircraft during fueling operations and witness the refueling to ensure that the correct fuel and quantity is dispensed into the airplane and that any caps and cowls are properly secured after refueling."
On-scene inspection of the fuel truck used to refuel the airplane revealed that the truck had markings "JET A.".
============
Accident Number: CEN20FA002
Date & Time: 10/05/2019, 1637 EDT
Registration: N326CW
Aircraft: Piper AEROSTAR 602P
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Business
On October 5, 2019, about 1637 eastern daylight time, a Piper Aerostar 602P, N326CW, departed from Kokomo Municipal Airport (OKK), Kokomo, Indiana, and impacted a field about 3.6 miles south of the airport. The airplane was destroyed by impact forces. The airline transport pilot sustained fatal injuries. The airplane was registered to Indiana Paging Network Inc and was operated by the pilot under Title 14 Code of Federal Regulations Part 91 as a business flight that was not operating on a flight plan. Visual meteorological conditions prevailed for the flight while departing from OKK.
On the day of the accident, the flight departed from Peter O Knight Airport (TPF), Tampa, Florida, about 0645 and arrived at OKK about 1027. The purpose of the flight was for the pilot, who was employed by In Flight Review, Inc, based in Tampa, Florida, to provide Piper PA-42 Cheyenne recurrent training to a customer based at OKK.
According to the airport employee who fueled the airplane, he asked the pilot of N326CW, while on approach to the airport, if he wanted jet fuel, and the pilot said "yes." He said the he asked the pilot if he wanted jet fuel because the airplane looked like a jet airplane. When the airplane arrived, the employee pulled the Jet A fuel truck out and parked it in front of the airplane while the pilot was still inside the airplane. The employee said that he asked the pilot again if he was wanted jet fuel, and the pilot said "yes." The employee fueled the airplane with about 163 gallons of Jet A from the fuel truck. The employee said that he was able to orientate the different shaped nozzle (relative to the 100 low lead fuel truck nozzle) from the Jet A fuel truck by positioning it 90 degrees over the wing fuel tank filler necks and about 45 degrees over the fuselage filler necks. He said the he initially spilled about one gallon of fuel during refueling and adjusted his technique so subsequent fuel spillage was minimal.
The Jet A fuel truck had "JET A" on its left, right, and rear sides.
The employee that was inside the fixed base operator building about 1620 heard the engines start. After the engines started, the engines sounded "typical." He said that he did not hear any radio transmissions from the pilot during his departure and did not hear an engine runup.
The pilot, who received recurrent training from the accident pilot, stated the accident pilot began training right away beginning about 1045. They completed training and it was after 1630 when the pilot drove the accident pilot to N326CW. The pilot said the accident pilot visually checked the fuel tanks of the airplane and gave a "thumbs-up" to the pilot. The pilot did not stay for the remainder of the accident pilot's preflight and drove off. The pilot heard the engines start and "they sounded normal." The pilot did not see the takeoff. The pilot said the winds favored runway 14, which was in use on the day of the accident.
A witness stated that she saw a "low flying" airplane flying from north to south. The airplane made a "sharp left turn" to the east. The left wing "dipped low" and she then lost sight of the airplane but when she approached the intersection near the accident site, she saw the airplane on the ground.
Post-accident examination of the airplane revealed the airplane wreckage path was about 328 ft in length along an approximate heading of 046° on a dry and hard surfaced fallow bean field. Components of the left side of the airplane were near the southwestern portion of the wreckage path. The wreckage and the wreckage path displayed features consistent with an accelerated stall.
The examination revealed the presence of a clear liquid consistent in color and order with that of Jet A in a fuselage tank and in the fuel lines leading to the fuel manifolds of both engines. Several of the engine spark plugs exhibited damage consistent with detonation. Flight control continuity was confirmed. The landing gear was in the retracted position.
Aircraft and Owner/Operator Information
Aircraft Make: Piper
Registration: N326CW
Model/Series: AEROSTAR 602P
Aircraft Category: Airplane
Amateur Built: No
Operator: Pilot
Operating Certificate(s) Held: None
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: OKK, 832 ft msl
Observation Time: 1656 EDT
Distance from Accident Site: 3 Nautical Miles
Temperature/Dew Point: 22°C / 8°C
Lowest Cloud Condition: Clear
Wind Speed/Gusts, Direction: 9 knots / , 140°
Lowest Ceiling: None
Visibility: 10 Miles
Altimeter Setting: 30.01 inches Hg
Type of Flight Plan Filed: None
Departure Point: Kokomo, IN (OKK)
Destination:
Wreckage and Impact Information
Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 40.475000, -86.063333 (est)
Dr. Daniel Greenwald
The estate of a Florida plastic surgeon who died when his plane crashed shortly after take off in Howard County has reached a settlement with the city of Kokomo, bringing an end to a lawsuit that alleged negligence by city airport employee and improper training given to Kokomo Municipal Airport employees.
The Estate of Daniel Greenwald will be paid a $700,000 settlement, the max amount allowed under Indiana’s tort claim laws, according to court documents filed last week in Howard County Superior Court IV. The estate and Julia Greenwald, the widow of Daniel Greenwald, have filed a petition asking Judge Hans Pate to accept the settlement agreement, which will be paid the city’s insurance. As of Friday morning, the court has ruled on the request, though settlements are usually accepted.
As a result of the settlement, the wrongful death lawsuit filed by the stated and Julia Greenwald in March of last year will be dismissed with prejudice, meaning it can’t be brought back to court.
An email sent Friday to legal representatives of the estate seeking comment on the settlement and lawsuit were returned as of Friday evening.
Kokomo Mayor Tyler Moore called the incident a “devastating situation” for the Greenwald family.
“Our thoughts and prayers continue to be with the Greenwald family,” he said in an email.
Dr. Daniel P. Greenwald, a plastic surgeon from Tampa, died on Oct. 5, 2019 when his Piper PA-60-602P Aerostar crashed in a field just south of Indiana 22 shortly after takeoff from Kokomo Municipal Airport. He was the only person onboard.
A complaint filed by Julie Greenwald and the estate of Daniel Greenwald alleges that the death was due to an airport employee putting the wrong fuel into Daniel Greenwald’s airplane.
The plane should have been filled up with Avgas, but the complaint alleges the employee put in Jet A fuel instead.
A preliminary investigation report by the National Transportation Safety Board in October focused on the type of fuel given to the plane before it took off from Kokomo Municipal Airport, though it did not list a cause.
According to the report, several of the plane’s engine spark plugs sustained damage that was “consistent with detonation,” and that a clear liquid “consistent in color and order with that of Jet A fuel” was found in the fuel lines and manifolds of both of the plane’s engines.
An employee of the airport, according to the NTSB report, told investigators he asked Daniel Greenwald two separate times if he wanted jet fuel for his twin-engine Piper Aerostar 602P because, according to the employee, the plane “looked like a jet airplane.” Both times, the report states, Greenwald told the airport employee “yes.” The report does not name the airport employee, but the Greenwald lawsuit alleges the employee was John Yount.
The estate’s lawsuit denied that Daniel Greenwald ever told anyone to put in jet fuel in his plane and that there were warnings and fueling instructions on the plane’s fuel tank apertures.
“Dr. Greenwald was a highly experienced pilot and never instructed anyone to fuel this aircraft with Jet A fuel,” the complaint reads.
In its formal response to the lawsuit, the city denied any wrongdoing.
According to the Tampa Bay Times, Daniel Greenwald had been flying airplanes since he was a teenager. According to the Times, he was a “well-known well-known plastic surgeon with a private practice, Bayshore Plastic Surgery, in Tampa’s Channelside district” and was “named one of America’s top surgeons in 2009 and specialized in hand and microvascular surgery, cosmetic plastic surgery and also performed gender reassignment surgeries.”
Tampa plastic surgeon Dr. Daniel Greenwald, seen here with his wife, Julia Robbins Greenwald, died October 5, 2019 when the plane he was piloting crashed shortly after takeoff in Kokomo, Indiana.
Tampa plastic surgeon Dr. Daniel Greenwald (top left), seen here with his family, died October 5, 2019 when the plane he was piloting crashed shortly after takeoff in Kokomo, Indiana.
Tampa plastic surgeon Dr. Daniel Greenwald died October 5, 2019 when the plane he was piloting crashed shortly after takeoff in Kokomo, Indiana. 
Tampa plastic surgeon Dr. Daniel Greenwald, seen here with his wife, Julia Robbins Greenwald, died October 5, 2019 when the plane he was piloting crashed shortly after takeoff in Kokomo, Indiana.
Does the preflight checklist on an Aerostar include a fuel sump?
ReplyDeleteSo sad . Kick the tires light the fires check list could be to blame ...
ReplyDelete