The National Transportation Safety Board did not travel to the scene of this accident.
Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; San Jose, California
Investigation Docket - National Transportation Safety Board:
Location: Palo Alto, CA
Accident Number: WPR21LA342
Date & Time: September 13, 2021, 13:50 Local
Registration: N162DF
Aircraft: Beech 58
Injuries: 1 Minor
Flight Conducted Under: Part 91: General aviation - Personal
Aircraft and Owner/Operator Information
Aircraft Make: Beech
Registration: N162DF
Model/Series: 58 P
Aircraft Category: Airplane
Amateur Built:
Operator:
Operating Certificate(s) Held: None
Operator Designator Code:
Meteorological Information and Flight Plan
Conditions at Accident Site: VMC
Condition of Light: Day
Observation Facility, Elevation: KPAO,7 ft msl
Observation Time: 13:47 Local
Distance from Accident Site: 1 Nautical Miles
Temperature/Dew Point: 24°C /15°C
Lowest Cloud Condition: Clear
Wind Speed/Gusts, Direction: 10 knots / , 330°
Lowest Ceiling: None
Visibility: 10 miles
Altimeter Setting: 29.87 inches Hg
Type of Flight Plan Filed:
Departure Point: Palo Alto, CA
Destination: Reno, NV (RNO)
Wreckage and Impact Information
Crew Injuries: 1 Minor
Aircraft Damage: Substantial
Passenger Injuries:
Aircraft Fire: None
Ground Injuries:
Aircraft Explosion: None
Total Injuries: 1 Minor
Latitude, Longitude: 37.457391,-122.10347 (est)
ALWAYS watch the linemen fuel your tanks. ALWAYS !
ReplyDeleteThis, this, a thousand times this! Adding to that, observe the fuel truck and placards. The fuel type is on each side of the vehicle in big letters for this (and HAZMAT) reasons. It’d also be wise to check the fuel receipt. Sumping won’t always catch a mis-fuel.
DeleteThere was ample opportunity for the mistakes to be caught and this incident to be prevented. Thank God it didn’t result in a loss of life…. this time….
It’s disappointing to read the pilot failing to acknowledge their neglect. I don’t have warm fuzzies that this won’t happen to the same pilot again.
KPAO FBO "Rossi Aircraft, Inc. has been serving general aviation and supporting the local community for over 30 years. We share the same enthusiasm for aviation as our customers. We are comprised of highly skilled pilots, mechanics, engineers, and aircraft owners. We understand that keeping aircraft airworthy, and keeping the costs down to a reasonable level, are important ingredients to keeping aviation affordable." @ skyvector
ReplyDeleteI have been a motorcycle enthusiast and corporate Turbine pilot my entire life. I also personally own and fly a piston aircraft.
ReplyDeleteWhen I'm riding the Harley, I simply assume that everyone is trying to kill me, and act accordingly as an alert defensive driver.
During the past 10-15 years, I find this is best survival tactic to use at the airport as well...
must be an alert defensive driver.
I drive my vehicles like you ride your bikes. I expect someone to pull out in front of me at a traffic light where I have the green light just as one example (and that saved four times in 35 years of driving). There are countless other defensive driving assumptions that have saved me (and them) from a potentially bad wreck.
DeleteI also have friends who ride and give you bikers a wide lane to work with when passing on the interstates. I keep a lookout for you too.
I appreciate bikers that stay away from cars and cars should always be on the lookout for bikers. What I have a problem with is bikers that ride the so close to the other lane that your mirror will almost hit them. Why do they do this? It's not a smart way to ride a motorcycle.
DeleteWhy do bikers constantly ride almost on the line next traffic? When I pass them in my lane, my mirror almost hits them. This isn't a smart way to ride a bike.
DeleteRiding on a wheel track away from the center of the lane avoids debris that ends up resting between auto/truck wheel tracks. Also helps for seeing past the vehicle ahead, and for being seen by vehicles behind you. Those two considerations are particularly important when in traffic, where you don't have unlimited distance to observe debris or be seen.
DeleteMost riders are careful not to let their position put the handgrip/mirror over the centerline, but being on the wheel track does leave minimal distance to centerline.
If you think about what would happen if the rider was centered in his/her lane and ran over a semi tread "gator" laying in the lane that was suddenly revealed as the car in front passed over it, you would realize how smart it is to the ride wheel track instead of center. And with people cutting in and out of lanes, being centerline adjacent prevents being run off the road when a car moves up into your space that didn't see you before making their move.
Hoover nozzles, checklists and text markings haven't worked. Time to try something different, implemented in the simplest possible way.
ReplyDeleteThose 1982 port markings reflect an expectation from that time period that all rampers would read text instructions adjacent to a fuel port. Wouldn't it be best to have a marking that is universal in appearance and instantly recognizable without reading?
A red circle/slashbar decal at the port with a jet aircraft under the slashbar could stop some of the misfuels if universally applied to gasoline fueled aircraft fill ports. Make the jet image cartoon style, favoring a superhero or Jay Jay the jet theme if that's what it takes to help the least attentive notice them.
AOPA could raise awareness by sponsoring a prize contest to submit images toward creating a new standardized decal. Crowdfunding could make them free to hand out at FBO's. Would be easy for FBO's to instruct their rampers "don't put Jet-A in ports that have that goofy sticker next to them".
The only pertinent “checklist” is the preflight checklist where the pilot checks the fuel level, fuel smell and fuel cap security. Then there is sumping the fuel to check it for color, smell and impurities. No matter what service is performed, airworthiness is the sole responsibility of the pilot which cannot be relegated.
ReplyDeleteBeing present is the answer. Sumped color can mislead when a mixture is present. Smell test can work, paper evap test is another option. A POA posting includes some visuals and discussion:
Deletehttps://www.pilotsofamerica.com/community/threads/avgas-and-jet-a-contamination-results.74702/
Quite simply -I have never walked away and let someone refuel my aircraft with out being in attendance during the entire operation which includes closing my own cap .
ReplyDeleteMake sure the correct fuel goes in your plane. YOU are the one who will be most sorry if a mistake is made.
ReplyDeleteI worked as a ramp-monkey at multiple small & med size FBO's, and fueled everything from Cubs to military aircraft. I've seen it happen more than a few times, the wrong fuel truck approaching an aircraft, and have personally intervened to alert the fueler to make sure they didn't cross-fuel. I will say MOST FBO's train their personnel adequately, but unfortunately the notoriously low-pay position combined with understaffing allows for some pretty questionable individuals despite FAA regs & background checks. I am not a pilot, but always ALWAYS triple-checked my fuel orders against the aircraft type AND placards- there's too many turbined machines out there that look like they should take 100LL (and still I'd lay awake at night second-guessing myself). I never took it personally when a pilot hovered nearby, watching as I refueled their aircraft just before they put themselves and family into it to fly away. If I were a pilot, you can be sure I would be present at every refueling. Thankful that this pilot lived, but I can hear the lawyers sharpening pencils for a go at the FBO and the employee...
ReplyDeleteNowhere in the docket does it address the elephant in the room. How did a JET-A truck that should have a duckbill hoover nozzle successfully insert itself into an AVGAS hole?
ReplyDeleteA good article to read: https://blog.aopa.org/aopa/2016/01/11/misfueled/
Perhaps the investigation was not documented as thoroughly as the N51RX Cessna 421 air ambulance mis-fuel in 2014 because this one was non-fatal.
DeleteThe duck bill nozzle sounds great, but there is a common circumstance that renders them completely ineffective. That circumstance involves the simple fact that there are turbine helicopters and aircraft with small fuel ports that the duckbill won't fit.
FBO's must have small nozzle Jet-A dispensing capability.
In the N51RX mis-fuel, the Jet-A truck used had two hose reels, one with duckbill and the other with a nozzle about 1 1⁄2-inches in diameter. There is also a slip-on adapter sold to do the same thing - look up "ADAPSJR-1".
From the N51RX docket, here is a long but informative snippet:
"The FBO’s JET-2 jet fuel truck was also equipped with two different hose reels for “over-wing” refueling. The nozzle on one of the hoses was round and about 1 1⁄2-inches in diameter. The nozzle on the other hose was the “duckbill” type and was about 2 1⁄2-inches wide.
When I asked the FBO employees why their jet fuel trucks were equipped with the smaller 1 1⁄2-inch diameter nozzles, they explained that the principal reason was that they had to refuel several turbine engine helicopters with jet fuel and many of those helicopters had refueling ports that were too small and could not accept the 2 1⁄2 inch wide duckbill nozzle.
They then drove one of their FBO jet fuel trucks to a locally based AS-350 helicopter, which was parked on the ramp at LRU. They removed the cap from the refueling port on the AS-350 helicopter and demonstrated that the 2 1⁄2-inch wide, duckbill nozzle could not be inserted into the 2 1⁄4-inch diameter refueling port on the helicopter.
I asked if there were any other turbine engine aircraft that required jet fuel, but had small refueling ports, which could not accept the 2 1⁄2-inch wide duckbill nozzle. The FBO employees said that in addition to the AS-350 helicopters, they had to use the smaller 1 1⁄2-inch round nozzle on some US Customs helicopters, some US Navy T-34 airplanes, and some very small jet airplanes."
Snippet Source: SUMMARY OF FINDINGS AT FBO (NTSB# CEN14FA462)
https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451531&FileExtension=.PDF&FileName=Summary%20of%20Findings%20at%20FBO-Master.PDF
N51RX docket:
https://data.ntsb.gov/Docket?ProjectID=89965
N51RX report:
https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89965/pdf
Another example: The smaller "helicopter nozzle" was always installed on the truck responsible for the non fatal 2015 N421PK misfuel, further illustrating how routine it can be for the hoover nozzle "protection" to be circumvented:
Delete"The nozzle on the Jet-A fuel truck was small and round like the nozzle on the AvGas fuel truck. The round nozzles were always on the Jet-A fuel truck because of the prevalent military helicopter traffic utilizing their services. It was a lot easier to fuel the helicopters with the round nozzle. Mr. McKey did not know who changed the nozzles, but they were always like that. He knew the round nozzles should not be on the Jet-A truck from his AvFuel training."
Snippet Source: Conversation w/line service employee
NTSB# CEN15LA199
https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426621&FileExtension=.PDF&FileName=Record%20of%20Conversation%20and%20Statement%20-%20Line%20Service%20Employee-Redacted.PDF
The Energy Institute youtube video detailing misfuel prevention shows swapping the smaller nozzle, with instruction to not leave it installed on the truck. Fuelers are supposed to put the duckfoot hoover nozzle back on immediately after using the smaller nozzle:
https://youtu.be/rrg--s48NrA?t=198
The duckfoot hoover nozzle can't reliably accomplish it's intended protection until the last turbine airframe that can't be fueled with one is retired to the scrap yard.
If you can't be at the airplane to observe the fueling process for whatever reason, take some tape and cover each port with the large, bold marking "AVGAS/100LL ONLY". This forces the fueler to read the warning before beginning fueling.
ReplyDelete