Monday, December 20, 2021

Wrong Fuel: Aero Commander 500S Shrike, N909AK; accident occurred May 28, 2020 near Aniak Airport (PANI), Alaska














Aviation Accident Factual Report - National Transportation Safety Board 

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

Additional Participating Entity: 
Federal Aviation Administration / Flight Standards District Office; Anchorage, Alaska 

Investigation Docket - National Transportation Safety Board:

State of Alaska operated by Division of Forestry

Location: Aniak, Alaska 
Accident Number: ANC20LA050
Date and Time: May 28, 2020, 16:00 Local 
Registration: N909AK
Aircraft: Rockwell 500 
Aircraft Damage: Substantial
Defining Event: Wrong fuel
Injuries: 4 Serious
Flight Conducted Under: Public aircraft

Factual Information

On May 28, 2020, about 1600 Alaska daylight time, an Aero Commander 500S airplane, N909AK sustained substantial damage when it was involved in an accident near Aniak, Alaska. The pilot and three passengers sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 public aircraft flight.

The airplane was owned by the State of Alaska and operated by the Division of Forestry.

According to the pilot, after arriving in Aniak, he had the local fuel vendor's ground service personnel refuel the airplane. He then signed the fuel receipt, and he returned to the airplane's cockpit to complete some paperwork before departure. Once the paperwork was complete, he then loaded his passengers, started the airplane's engines, and taxied to Runway 29 for departure.

The pilot said that shortly after takeoff, and during initial climb, he initially noticed what he thought was mechanical turbulence followed by a reduction in climb performance, and the airplane's engines began to lose power. Unable to maintain altitude and while descending about 400 ft per minute, he selected an area of shallow water covered terrain as an off-airport landing site. The airplane sustained substantial damage during the landing.

The fueler reported that he was unfamiliar with the airplane, so he queried the pilot as to where he should attach the grounding strap and the location of the fuel filler port. Before starting to refuel the airplane, he asked the pilot "do you want Prist® with your Jet" to which the pilot responded that he did not. After completing the refueling process, he returned to his truck, wrote "Jet A" in the meter readings section of the prepared receipt, and presented it to the pilot for his signature. The pilot signed the receipt and was provided a copy. The fueler stated that he later added "no Prist®" to his copy of the receipt, and that he did not see a fuel placard near the fueling port.

A postaccident examination revealed that the reciprocating engine airplane had been inadvertently serviced with Jet A fuel. A slightly degraded placard near the fuel port on the top of the wing stated, in part: "FUEL 100/100LL MINIMUM GRADE AVIATION GASOLINE ONLY CAPACITY 159.6 US GALLONS." 


Pilot Information

Certificate: Airline transport; Commercial; Flight instructor
Age: 53, 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): Airplane 
Second Pilot Present: No
Instructor Rating(s): Airplane single-engine; Instrument airplane
Toxicology Performed: No
Medical Certification: Class 2 With waivers/limitations 
Last FAA Medical Exam: September 5, 2019
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time: 4869 hours (Total, all aircraft), 30 hours (Total, this make and model), 4003 hours (Pilot In Command, all aircraft), 40 hours (Last 90 days, all aircraft), 40 hours (Last 30 days, all aircraft), 4.5 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Rockwell 
Registration: N909AK
Model/Series: 500S
Aircraft Category: Airplane
Year of Manufacture: 1975
Amateur Built:
Airworthiness Certificate: Normal 
Serial Number: 3232
Landing Gear Type: Retractable - Tricycle 
Seats:
Date/Type of Last Inspection: March 5, 2020 Annual Certified 
Max Gross Wt.: 6748 lbs
Time Since Last Inspection: 
Engines: 2 Reciprocating
Airframe Total Time: 6966.4 Hrs as of last inspection
Engine Manufacturer: Lycoming
ELT: C126 installed, not activated
Engine Model/Series: IO-540 SER
Registered Owner: 
Rated Power: 325 Horsepower
Operator: 
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC)
Condition of Light: Day
Observation Facility, Elevation: 
Distance from Accident Site:
Observation Time: 23:56 Local
Direction from Accident Site:
Lowest Cloud Condition: Few / 6500 ft AGL 
Visibility: 10 miles
Lowest Ceiling: Overcast / 12000 ft AGL
Visibility (RVR):
Wind Speed/Gusts: / 
Turbulence Type Forecast/Actual:  /
Wind Direction: 
Turbulence Severity Forecast/Actual:  /
Altimeter Setting: 30.15 inches Hg
Temperature/Dew Point: 15°C / 2°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Aniak, AK
Type of Flight Plan Filed: Company VFR
Destination: Soldotna, AK
Type of Clearance: None
Departure Time:
Type of Airspace: Class E

Wreckage and Impact Information

Crew Injuries: 1 Serious 
Aircraft Damage: Substantial
Passenger Injuries: 3 Serious 
Aircraft Fire: None
Ground Injuries: 
Aircraft Explosion: None
Total Injuries: 4 Serious
Latitude, Longitude: 61.581665,-159.54306(est)



5 comments:

  1. Oh my God...this is pathetic. I don't know who I want to slap more, the clueless ramp guy who, for obvious reasons, has no business working with aircraft, or the inattentive pilot who can't see "JET A" staring him in the face.

    ReplyDelete
    Replies
    1. I'm with you. What were these guys thinking? Dumb and dumber, I guess?

      Delete
  2. Happens way to often. Minimum wage employees in fuel truck, in FBO office and in airplane cockpit. Nobody paying attention. Sad.

    ReplyDelete
    Replies
    1. The airport manager earns $80,500 plus benefits. That's not too shabby for Aniak, Alaska.
      The Alaska Forest Service pilot salary is $95,000 per year plus benefits.
      Crowley Fuels - Aniak Fuel Delivery
      October, 2021
      If you're in Alaska and are looking for the next chapter in your career as a driver, mechanic, or terminal manager, check our opportunities in shoreside operations and apply today!

      Delete
  3. Need I say this should have been preventable? It is kind of important that the right fuel goes in.
    Don't they have different nozzles so the one for jet won't fit in the other? And different colored handles? Anything to get someone's attention.

    ReplyDelete