Misfueling Likely Cause Of Recent Aerostar Crash

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An experienced pilot is said to have requested then watched as a lineman filled his piston-powered Piper Aerostar with Jet A fuel. The pilot, Dr. Daniel Greenwald, a successful Tampa-area plastic surgeon, was killed when the Aerostar crashed shortly after takeoff from the Kokomo, Indiana, airport.

Robert Losurdo, who owns the flight instruction company that Greenwald was working for, told the Tampa Bay Times that he’s convinced that Greenwald would never have intentionally asked the Aerostar to be loaded with Jet A.

According to the NTSB’s preliminary factual report on the accident, “the airport employee who fueled the airplane, [said] he asked the pilot of N326CW, while on approach to the airport, if he wanted jet fuel, and the pilot said ‘yes.’ 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 report noted that the fuel trunk had prominent “Jet A” markings on its sides and back.

The normal checks and balances are bolstered by the design of Jet A fuel nozzles, which are built to not fit into the filler ports of piston aircraft. Nevertheless, according to the NTSB prelim, “The [FBO] 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.”

All of this took place soon after the pilot landed and the airplane sat while he conducted his business on the airport. The NTSB report continues, saying that “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.”

Another pilot, who had received flight training from the accident pilot, said he drove the pilot back to the Aerostar and watched him as he “visually checked the fuel tanks of the airplane and gave a ‘thumbs-up,’” according to the report. This second pilot “heard the engines start and ‘they sounded normal.’”

The Aerostar crashed less than four miles south of the Kokomo airport and, according to the NTSB, post-accident 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.”

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16 COMMENTS

  1. “Surgeon” says it all. Competent, meticulous, and overworked to the point of distraction. Been there. People ask you a question and you just murmur out “sure,” “OK,” without ever having heard or registering the question because your mind’s racing on a dozen other balls you are trying to keep up in the air.

    I’m retired now, but when I was working I always focused intensely on leaving my practice on the ground, and if I couldn’t do that, I didn’t fly.

  2. addendum: What the hell was wrong with the line boy? If he asked the pilot twice, it means he was at least thinking about it. Then, when the nozzle didn’t fit, why didn’t he take the time to look in those two holes in the front of the cowling where the engine lives. Hint: If you see cylinders, don’t put jet fuel in the tanks. Two competent guys missed three opportunities to not goof up, and they didn’t, and one died. Not their finest hour.

  3. A total breakdown of all reasonable thinking; an unusual request by the pilot (the fueler recognized it as usual because he raised the question), placards (not mentioned but required), a nozzle that doesn’t fit the filler port, and a preflight (I often wonder how many would actually catch it in a sample).

    The only one here with common sense was the fueler (briefly), but he let the arrogance of the pilot push it all aside.

  4. (From a different Michael R.)
    My fuel supplier here in Europe is BP. They have a “no decal no fuel” rule. Immediately next to each fueling port on the aircraft to be fueled, a sticker indicating the proper fuel is required. One alternative reads “Avgas” and is red. The second alternative reads “Jet A-1” and is black. If no sticker is present, no fuel will be pumped. BP keeps a supply of free stickers in tankers, available to aircraft operators upon request.

    Air BP’s operators always perform a three-way cross-check before refueling an aircraft:

    1) Confirm the fuel request form
    2) Check the decal
    3) Confirm the fuel grade in the truck or fixed equipment is correct.

    In the case of self-service unattended fueling, the card issued is valid for a particular aircraft and fuel type. They are now developing an app that scans the sticker and compares it with fuel information in the customer’s account. It seems like they really want to avoid the “one in a million” human error that caused the tragedy about which this article reports.

    • Not a bad idea. Shouldn’t be an FAA reg, but it is not a bad idea for a FBO to follow. At a minimum, they get a bonus sale for the placards. Alternatively, no placard, then you have to acknowledge the order in writing before fueling.

  5. There should be a more in-depth simple certification/training process for all line personnel that have the responsibility of fueling aircraft. Some of that responsibility should be on the FBO/management that employs such personnel. Of course the pilot has the primary responsibility of having the correct fuel in their aircraft, but as seen, his error killed him. An added checks and balance could stop this type of deadly error by both pilot and the line servicing personnel.

  6. I have over 1500hrs in pt135 flying in an Aerostar. With the peculiarities with this plane in fueling I am surprised the pilot did not personally supervise the fueling. I always did. The picture in the article looks to me like there was no post crash fire. I wonder why the airplane got balled up in the crash?Just goes to confirm what the check airman told me after my first pt135 checkride. Aerostars are not that difficult to fly as long as you fly them by the numbers, even when gliding. Otherwise it will bite!

  7. The line boy needs to move furniture or mow grass for a living. Obviously fueling aircraft is above his pay level. A round of FAA requirements for lineman won’t solve the problem that a simple IQ test would put to bed. He’s walking into the prop or falling off the ladder next.

    • It looks like the line boy followed the owners instructions exactly.
      Blaming the lowly line boy for the MULTIPLE mistakes of the PIC is ludicrous.
      Pay attention to the fueling before and during; then test quantity and type on the preflight.
      Anything less can put you in a smoking hole.

      I’ve smelled Jet-A from a 100LL truck once and stopped the fueling immediately. Seems mistakes can happen all through the process which is WHY it’s the PIC’s job to trust but verify. I’m still here because I ALWAYS make darn sure that there is enough of the right stuff in the tanks to get me to point B.