Misfueling Cited In Alaska Commander Crash


The NTSB cited misfueling in an accident that injured three people aboard a State of Alaska Shrike Commander in late May. The aircraft was being used to deploy firefighting personnel when it was refueled at Aniak, Alaska, on May 28. According to the report, the operation went pretty much by the book, except that Jet A ended up in the tanks instead of the 100LL its thirsty IO-540s need. The pilot noticed trouble shortly after takeoff and aimed for shallow pond in a gravel pit. He was seriously hurt and his two passengers were also injured.

The report says the pilot left the fueling to the ramp attendant, who told the NTSB he was not familiar with the plane and had to ask the pilot where to attach the ground strap and where the filler receptacle was located. He also asked the pilot “do you want Prist (anti-gel chemical) with your Jet?” to which the pilot replied that he did not. The rampy then pumped Jet A into the filler, which is next to a placard that specifies 100LL only. He prepared the receipt specifying jet fuel and the pilot signed it.

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  1. Must not have had the fuel nozzle restriction installed on the fuel tanks. There are not many FBO fuelers who are familiar with fueling the Aerostar I fly. I always, always supervise fueling of my airplane, even when flying a jet. At least on two occasions I had to remind the fueler to turn on the prist because they forgot to turn the prist dispenser on. Sounds like the pilot of the Commander did not and almost paid the ultimate price.

    • I agree with the “newbie” fueler theory but suspect the pilot was more experienced. The issues I will speculatively assign to the pilot are being distracted by the operation he was going to fly and not having his head in the game. Pilots and crews operating around forest fires get into some intense operational flows and can easily get “bore-sighted” on a single factor. I doubt that the pilot was even listening to the kids questions and never even read the fuel slip when he signed. I am sure his total attention was focused many airmiles down the road.
      I don’t / didn’t fly many recips after I moved from T-29s (CV-240) to the C-141. In the CV we were always attentive to having a “purple” sticker on any truck that approached us with fueling in mind. In the AF, not too much of a worry though. I can understand some of the understanding issues new ramp drivers have with what fuel goes where. I initially fault the FBO or Fueling Company for that. You can’t simply point someone at a vehicle, show them how to get the pump turned on, point them at an aircraft, and tell them to be sure to get the slip signed legibly. That is not enough, hardly. How about taking them out on the line in the golf cart and showing them a cross section of the aircraft they will service? While doing that, point out and make them “read-back” the differences in how a recip engine looks and a turbine of any kind? Cylinders versus blades when looking in the front. And, until they are 500% comfortable, confirm with the pilot which kind of fuel is required, how much, what additives are necessary, and where to put it? Sounds like overkill but could just save your insurance company a large payout and possibly some pilot his / her life along with those of anyone riding with them.
      Pilots are not blameless either. If you don’t know the truck driver personally, confirm, confirm, confirm. Maybe that driver started out fueling B-17s in England and is insulted when you ask or you might be his first “solo” refuel ever. If he gets testy when you cover a few safety points, well, consider using another FBO at that field or tell your DO and have him/her work it out.

      • David, I need to point out that your statement just isn’t true these days. Yes, obviously a combination of lack of training and circumstances, a very unfortunate incident but to “simply point someone at a vehicle, show them how to get the pump turned on” doesn’t happen anymore. There is MUCH more to it. I ran a smallish FBO for many years and no fuel supplier would be OK with no evidence of training. In my opinion you cannot categorize it the way you do. The human factor will always be there, regardless of training. I thought I had a fueler trained thoroughly and after more than a year on the job she came to me to ask for clarification on an order when a pilot asked for 2000 lbs of Jet-A. Glad she asked instead of pumping 2000 gallons.

  2. Looks like a good emergency landing under the circumstances. Well thought out and good job not stall/spinning on way back to the airport.

    Pretty much everything is always our (the pilot’s fault) and its the pilot passengers and any unfortunates on the ground that have to pay the bill.

    The fueler screwed up also but fortunately he or she does not have a broken leg or concussion or whatever.

  3. The report doesn’t say if there were fuel type stickers or stencils near the filter port but I would have to guess there would be. I had a 500B for 15 years and I put several “AVGAS” stickers around the port so that even if they laid the fueling mat over the port there would still be a sticker visible. You can’t rely on the restrictor on the fueling port that was required by AD because a lot of trucks don’t have the duckbill nozzle as they don’t fit helicopters.

  4. Misfueling accidents almost always follow the same chain of events. Lack of experience on the part of the fuel operator, poor communications with a distracted or otherwise preoccupied pilot, fuel nozzles that lack the correct nozzle tip (for whatever reason) and no one checking the final bill to see what was dispensed. Who’s to blame? Everyone in the chain, but ultimately the pilot whose butt is in the sling when things go bad. Any pilot of a big-bore twin should realize he has the ultimate responsibility to make sure the correct fuel is dispensed, especially at airports that service mostly jet-A burning birds. It only takes a minute or two to observe the start of the refueling to see that things are being done correctly. Tossing the proverbial keys to the line boy and heading to the latrine is a good way to get yourself killed.

  5. When I researched NTSB records relative to the aircraft I flew, statistics from decades of reports revealed a glaring fact. Around 85% of all aircraft accidents and incidents are the results of pilot errors.

  6. Sometimes I try to think of accidents that CAN’T be pilot error. It’s a short list. So far I’ve come up with ‘Hit by meteor’. Also ‘Catastrophic engine failure’ unrelated to maintenance or operational issues in circumstances that prevent safe emergency landing. Maybe midair where the pilot is plowed into from behind.