Wednesday, August 25, 2021

Loss of Control in Flight: Piper PA-60-602P Aerostar, N326CW; fatal accident occurred October 05, 2019 near Kokomo Municipal Airport (KOKK), Howard County, Indiana

Dr. Daniel Greenwald
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Piper PA-60-602P Aerostar, N326CW







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

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.".

 Dr. Daniel Greenwald, seen here with his wife, Julia Robbins Greenwald.

 Dr. Daniel Greenwald (top left), seen here with his family.

 Dr. Daniel Greenwald

Tampa plastic surgeon Dr. Daniel Greenwald, seen here with his wife, Julia Robbins Greenwald. 






31 comments:

  1. Statements from line service about what the pilot said and explaining how he managed to defeat the purpose of oversize nozzles to fuel the plane are unbelievable. Owner said he did not have use of the plane? Dead men tell no tales.

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    Replies
    1. Agreed, that statement from the line service technician telling all the steps he had to take, just to override the built in precautions, to prevent misfuelling. I'm just left shaking my head.

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    2. Probably held his cell phone to his head and yammered the whole time. No attention to markings at the fuel ports or anything else.

      Phone obsessed people go about their tasks all the time with no focus on the work. Doesn't get mentioned in these reports.

      Delete
  2. Hard to believe city only had to pay $700,000 in damages

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    Replies
    1. "Negotiations with a view toward settlement of this matter were had and an offer was made on behalf of all Defendants in the amount of Seven Hundred Thousand Dollars ($700,000.00) in compromise of this claim, which is the maximum recovery available to the Plaintiff under the Indiana Tort Claim Act." https://bloximages.chicago2.vip.townnews.com/kokomotribune.com/content/tncms/assets/v3/editorial/b/22/b227b750-bff8-11eb-bc3a-a76edf1df2ce/60b15b8aa3091.pdf.pdf

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    2. The $700,000 limit only applies to claims against Indiana governmental entities, not private individuals or businesses. Kokomo Municipal Airport is a government-owned airport; hence the limitation of liability. I'm sure the estate has some creative lawyers who are pursuing other non-governmental "responsible parties" in order to recover more money.

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    3. non-governmental "responsible parties" apparently do not exist, for the "The Kokomo Municipal Airport and the FBO are owned and operated by the City of Kokomo."

      Delete
  3. From beginning to end, this story has grr to be the most unbelievable due to the series of events. Not much more could be said.

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  4. What a chain of events!
    Unauthorized use of the airplane.
    Failure to notice a single point refueling hose.
    Failure to notice “Jet A” sign.
    Failure to pay attention to an ‘underling’.
    Failure witness the refueling.
    Failure to check fuel quantity and smell.
    Failure to fly the plane as far into the crash as possible!!

    So why does the city have to pay anything?
    To cover the plaintiff’s attorney’s fees for a frivolous lawsuit.

    But then why is the city employing someone that cannot identity aircraft. That doesn’t know the difference between a piston engine and a turboprop by looking at them. That cannot tell the difference between the sound of piston engine firing up and a jet engine spooling up. And that hasn’t been trained on the reason for the flared jet fuel nozzle. Enough negligence to go around but...

    When I was the head of lines services we had a Twin Comanche come roaring back to the ramp and the ‘pilot’ started screaming at our guy that had fueled his plane because he had not replaced the fuel caps. I walked up and asked if he was the pilot. He looked at me somewhat confused and said, “Of course I am the pilot”. I said,”Then of course you preflighted your plane”. He marched off in a huff.
    The company rule was to leave the fuel caps off specifically to avoid liability for an improper cap replacement.
    He was the only ‘pilot’ to ever have a problem with that.


    ReplyDelete
    Replies
    1. What kind of an idiot thought of that "policy"? I have been an aviation professional for over 30 years and the first time of heard of something like this. If they ordered 10 gallons of Avgas did you just leave it in a bucket by the plane also...to avoid liability? Not directing this towards you personally but that sounds like an awful idea

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    2. You are just the kind of person I hated to run into at the airport. Dumb and your brother dumber running the line services? Get off the tarmac you idiot.

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    3. That "policy" story lacks an important detail.

      Carrying out that policy, regardless of whether a pilot is expected to do his preflight properly or not, requires that the pre-fuel conversation by the line crew includes telling the pilot "The caps will be left off for you to re-install", with acknowledgment from the pilot.

      It is obvious that the Twin Comanche pilot in that story was not advised of the "policy". The story seems suspect. What FBO could routinely operate that way and only have caps left off once in the memory of the head of line services?

      Delete
    4. I rarely use a fuel truck, only when the self service is out of order .. twice that I can remember in over 40 years.
      Once using the truck I was flying a 210, the lineman put a red notice on the windscreen, right in my view and unavoidable to miss. It read “ check fuel caps, check for correct fuel type”. I had watched him fill the tanks with 100ll, I climbed the ladder each side to secure the caps. After fueling, and after watching me secure the caps, the red notice went onto the windscreen anyway. At the time I wondered how many pilots didn’t do these steps and thus warranted the notice.
      I’ve never heard of leaving the caps off intentionally, and after reading the mishaps on this website I’d think that might be a very, very bad idea.

      Delete
  5. sad story looked like a big enough field to put it down
    rule # 1 fly the airplane first

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  6. Pilot was an acrobatic instructor who flew an Extra so hard to understand why he did not pitch down and land in field

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    Replies
    1. Perhaps first only one engine failed and he had to deal with a OEO situation while still being slow, close to VMC, and simply got behind or suddenly distracted and overwhelmed when the other engine failed. It's actually quite unlikely they failed at exactly the same time but when they did, probably suddenly/completely due to detonation.

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  7. It looks like the pilot was once a DPE, but lost his designation as such due to poor performance. Given the numerous documented errors and inexplicable occurrences with this accident, I wonder what his professional record as a cosmetic surgeon was like.

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  8. Obituary comments suggests patients loved the doctor which indicates he was a good doctor

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  9. Curious that toxicology was performed, yet there is no statement regarding the results.

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    Replies
    1. The tox results show compounds for managing cholesterol (atorvastatin), blood pressure (losartan), and acid reflux (ranitidine) trade name Zantac.

      Probably did not require a statement because none of those are on the list of compounds that would contribute to LOC. Just a guess, but curiosity made me go look!

      Delete
    2. Thanks! Reports usually mention anything detected, regardless of impairment intentional, so I thought it was curious nothing was noted one way or another. Thanks for looking it up!

      Delete
  10. In the 12 years I worked line, I was constantly being yelled at by the other line guys because I would ALWAYS remove the helicopter nozzle from the rear hose of the Jet A truck and replace it with the required duckbill. They liked the convenience of the straight nozzle because we fueled a lot of helos and Jet-Prop conversions, but I always held that it is far safer to have to chanege the nozzle each time rather than killing someone.

    Everyopne in this incident is stupid. The upside is this jackass didn't kill someone else with his stupid mistake.

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  11. Be a surgeon or be a professional pilot. Never half ass two things - whole ass one thing.

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    Replies
    1. Kenneth, you hit the nail on the head on this one; didn't ya?

      Delete
  12. Stuff you can't make up...

    Does anyone get the back(?)story straight:
    - a guy has a plane that just sits and waits for him at an airport somewhere?/in Tampa to get trained in by In Flght Review
    - an MD ex-DPE (current or former employee at In Flight Review?) just takes the liberty to use this plane to fly half way across the country from FL to IN to give a few hours currency instruction to a student pilot (who and where was the "regular" instructor?) in a different aircraft and then fly back the same day?
    - did the owner go after the estate for his wrecked aircraft?
    - was there any insurance on the aircraft and in whose name?
    - was there anything being transported on the plane either from FL or back from IN
    - what exact type of training did the pilot provide/what did they do those few hours in IN?

    I probably forgot a few things that went through my head. We do have a friend who writes scripts for various types of TV shows on a different continent - I will tell her this story and see what she'll spin out of that...

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    1. Some answers were already there in the docket. The woman and her boss Mr. Davis were both in the plane and her boss had used the training outfit since 2010. The flight was also described.

      The NTSB proof reading mistake that has the trainees in the Doc's lap in the right seat can add to your friends fanciful tale.

      "She said the Mr. Greenwald was seated in the right seat of the airplane the entire time of the training flight and that she and Mr. Davis took turns flying from the right seat of the Piper Cheyenne. She said that Mr. Davis has used In Flight Review for training since 2010. She has been flying with Mr. Davis for about 4 years. She said she is a flight instructor and a Part 91 contract pilot on a Cessna 340 and Piper Cheyenne airplanes."

      "She said the flight portion of training was a flight review and instrument proficiency check that was about an hour in duration. She said they performed a single-engine out on takeoff, a short field takeoff, stalls, and accelerated stalls. She said they did a VMC demonstration “all the way to loss of control.”She said they did not perform a duel engine out to landing. They performed holds, autopilot instrument approaches, and hand flown instrument approaches."


      https://data.ntsb.gov/Docket/Document/docBLOB?ID=8543183&FileExtension=pdf&FileName=RECORD%20OF%20INTERVIEW%20Laura%20Stants-Rel.pdf

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  13. I can think of a few reasons why someone piloting a plane without authorization might attempt a turn back on a power loss rather than the nice big, open field in front of them.

    And I bet the good doctor was giving the other pilot some recurrent instruction! In what subject I can’t hazard a guess, but I’m doubting it was aviation.

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    1. @ Mike - You bet wrong. Defaming the deceased pilot with immorality innuendo is bad enough, but to do so when the documentation shows otherwise is evil.

      As already posted in the comment above your own:

      https://data.ntsb.gov/Docket/Document/docBLOB?ID=8543183&FileExtension=pdf&FileName=RECORD%20OF%20INTERVIEW%20Laura%20Stants-Rel.pdf

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  14. This whole story is unbelievable except for the part that the good doctor killed himself. I'm from Texas and I'm 75 years old and this story takes the cake right out of my mouth. The take away here is "Men are stupid when their ego is running the show". Lawyer JOKE, "You go in to a room where there is a rattle snake, a tiger and a Lawyer; you only have two bullets in the revolver, WHO will you shoot first"? Answer, Two bullets in the Lawyer.

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  15. Similar accident at Cincinnati Lunken Airport in June 1984, Cessna 340A topped off with JetA. Tragic…
    https://www.jvra.com/verdict_trak/article.aspx?id=29353

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