PA-31 down at TCL

Believe so. Looked at a schematic a few days ago and I believe I saw filters/heaters for each.

Fuel heaters would be for the Cheyenne, not the Navajos. Fuel temp is a Jet-A issue.
 
Its been over a year since this accident so the final report should be out soon. Having followed this accident closely because it occurred close to home plus personal experience with the PA31 325/350/Colemill Panther it seems to me that several elements of this accident have escaped the attention of proceeding posters. As with all accidents this will boil down to a series mistakes when joined together produced the perfect storm of tragedy.

First link of failure was formal training which according to my sources was non existent as the pilot only received a check out by a local flight instructor, how through this training was I'm sure will be in the final report.

Second link of failure was the pilot might have been fatigued from a working weekend where he conducted several days of training sessions and equipment demonstrations. In addition there might have been as part of this event some social drinking or other after hours activities which reduced his rest, please note that I did not say it was to the point of being intoxicated but if he was fatigued this could be a factor.

Third link in the chain might have been his choice of altitudes in a non pressurized aircraft and not using supplemental oxygen. a planned enroute time of three plus hours at 12000 feet would be hard on pilot and passengers alike, one's cognitive skills would be impaired.

Fourth link in the chain is linked to the first lack of training in that his knowledge of the fuel system was most likely less than sufficient, I'm sure he had basic knowledge of the system after all he had a score of hours in the aircraft and just a few days before made an almost 4 hour flight down to ISM but the fuel system of a Navajo is much different than the Seneca he transitioned from.

Fifth and final link I mention is mismanagement of the emergency, it seems whatever training he had went out the window since the engines were not feathered, cowl flaps left open and his decision to overfly closer airports.

To be fair he had a lot on his plate but unfortunately it will most likely be determined it was he who did the serving. So what did or might have happened? ? ? ?

My guess is based on an unsubstantiated (as of yet) report of a radio transmission he made before the first engine quit. He is rumored to have made this transmission to ATC.

"I've got a LOW FUEL FlOW light" There is an annunciator on the glare shield warning panel that says exactly what he reported LOW FUEL FLOW so he was reading it straight off the panel. However it seems he had no idea what that light meant and to be fair not many Navajo pilots do, do you?? If you don't read on.

The LOW FUEL FLOW light illuminates when a sending unit in the main tank slosh box senses a low fuel level condition. The slosh box traps fuel so that it cannot easily exit the box once it enters thus preventing unporting of the fuel supply line to the engine during uncoordinated flight or in turbulence with low fuel in the main tank. The light is rigged on a timer so that the condition must last at least 10 seconds before the light will illuminate to prevent nuisance warnings in other words when it comes on it stays on. Testing this system is on the pre-start checklist but most pilots I've flown with don't do it or just don't understand why and what they are checking.

Here's what would happen if a pilot ran the main tanks dry. With about 10 to 15 minutes flying time left (about 5 gallons) the LOW FUEL FLOW light would illuminate. The pilot hopefully at this point is on short final, if he's at 12000 feet with no fuel in the AUX tanks he has a problem. He must act quickly and decisively to get the aircraft on a runway in the next 10 minutes this would mean an immediate emergency descent to an airport directly under the aircraft; OR if he has fuel in the AUX tank switch immediately to prevent engine failure.

But lets say that he just looked at the light trying to figure out what is was telling him, it would be natural with a less than thorough understanding of the fuel system that he might think he was losing a fuel pump, but hey the engine is still running he thinks WTF? Now he might get a second LOW FUEL FLOW light on the other side doubling his confusion or perhaps while pondering the first LOW FUEL FLOW and doing nothing he now see's the LOW BOOST light come on followed by and almost immediate engine failure. What just happened? Well when the main tank ran dry the low pressure boost pump pressure dropped below 3 psi and turned on the LOW BOOST light very quickly followed by an engine flame out. IF at this point he hit the EMERGENCY BOOST PUMP the fuel in the pump and line would either momentarily restart the engine OR cause surging before running dry and stopping again so maybe just maybe that lead him to hope the engine might relight at some point and was instrumental in him NOT feathering the engine. Of course a short time later he was busy with the other engine following suit and stopping for exactly the same reasons. The big question is why he didn't think of switching to the other tanks. Perhaps helmet fire with a touch of hypoxia certainly that's a big possibility but this aircraft was modified with a fuel totalizer which would show plenty of fuel but not in which tank he may have been overly relying on it rather than fuel gauges which unless maintained properly may have been in his mind less accurate.

If a pilot see's the LOW FUEL FLOW light what would happen if he switched to the AUX tanks? Well of course the fuel quantity indicators would show whatever fuel was in the AUX tanks and the engine would run until the AUX was empty but be aware once the LOW FUEL FLOW light for the main tanks come on they are going to stay on for the rest of the flight irregardless of fuel selector position. The only thing that will extinguish the LOW FUEL FLOW light is adding fuel to the main tank. IF indeed he did call a LOW FUEL FLOW to ATC then he HAD to be on the main tanks and most likely never utilized the AUX fuel the whole flight and after both engines quit staring him in the face were both LOW BOOST and both LOW FUEL FLOW lights thus reinforcing his false assumption that both or I should say all six fuel pumps had failed.

The main tanks also have two fuel quantity sending units to indicate fuel remaining as presented on the fuel quantity gauges after the signal is modified by the fuel quantity computer, but they have nothing to do with the LOW FUEL FLOW light. There is an STC to eliminate the LOW FUEL FLOW light system since it's expensive to maintain and parts are getting hard to find or get repaired, no other light piston driven twin has this warning system which was intended to be an extra layer of protection to warn the pilot of impending fuel flow interruption to the engine be it low fuel quantity in the main tank or an obstruction blocking the entry of fuel into the slosh box. The AUX tanks do not have unporting protection (i.e. slosh box and float switch) that's why takeoff and landings must be made using the main tanks only.

Most Navajo pilots never see a LOW FUEL FLOW light in flight. It's only those few who screw up fuel management or under estimate required enroute fuel. I have thousands of hours in the Navajo and never had a LOW FUEL FLOW light in flight. I have run the AUX tanks empty to the point of getting a LOW BOOST light it's common practice on max range flights to make sure you've used all the AUX fuel, if within a couple of seconds you turn on the EMER BOOST PUMP and switch back to the main tank the engine never misses a beat.

So when thinking of this aircraft's fuel system remember LOW FUEL FLOW lights are related to main tanks only and indicate impending flow interruption (due to low level in the main tank slosh box) to the engine and have NOTHING to do with fuel pressure. The AUX tanks do not use this system. LOW BOOST lights can come on when the selected tank is empty (or pump has failed) mains or aux.

Regardless it's hard to blame the airplane for lack of pilot training but it won't be the first time that's happened. Proper training has resolved many so called accident prone aircraft's bad rap to name a few, the early Lear Jets, MU2's, Robertson Helicopters, Aerostars, and others All good aircraft but demand standardized training.
 
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That is an entirely plausible scenario. It seems possible that he may have run the aux tanks dry and was just freaking out over the boost pump warning light too, if he ran the aux tanks dry. It seems that the timing was just about right for running the Aux's dry assuming the standard practice of switching to the aux tanks in cruise. However, I think your scenario is probably somewhat more likely.

I am looking forward to the NTSB report as we run a couple of Chieftains and I sense that there is something to be learned here.
 
The timing was right for running the mains dry also especially since the cowl flaps were wide open the whole flight, the aircraft had gamma injectors and was reported by other pilots to be very thrifty on fuel but did this pilot lean properly? I'm most interested in his pre engine failure ATC transmissions did he sound lucid and alert or soporific?
 
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The timing was right for running the mains dry also especially since the cowl flaps were wide open the whole flight, the aircraft had gamma injectors and was reported by other pilots to be very thrifty on fuel but did this pilot lean properly? I'm most interested in his pre engine failure ATC transmissions did he sound lucid and alert or soporific?

I had to re-read everything to reacquaint myself on the subject at hand.

I am inclined to believe fuel mismanagement on the information I have seen, but I am still open minded here. I never thought of possible pilot problems.

The cowl flaps are huge and cause a lot of drag. One engine out emergency checklist calls for both cowl flaps to be closed. If the cowl flaps are open and the plane is set up for cruise, then the cowl flaps are closed, the change in attitude can be felt. With cowl flaps open and improper leaning, range will be shorter.

I am looking forward to the NTSB report as we run a couple of Chieftains and I sense that there is something to be learned here.

Me too. There is always something to learn.
 
I'd tend to agree fuel mismanagement is the most likely cause, and expected that when this crash happened. Cowl flaps are easy to forget in the Navajo if he wasn't using a checklist. Leaning a Navajo properly isn't difficult, but if he wasn't trained on how to lean it, they can be real fuel hogs.

I'd also agree with proper training. Navajos aren't hard to fly by any means, really pretty easy. But the fuel can bite you. I have a few hundred hours in them. Love flying them, miss flying them. But not something that most people transitioning up can just get a couple hours in and be good to go.
 
I had to re-read everything to reacquaint myself on the subject at hand.



Me too. There is always something to learn.

I like your Henry Ford quote, he would be appalled that the problems this country faced in his day have only magnified.
 
In a previous thread about distraction or lack of systems knowledge that turned deadly I posted that years ago a 421 crash killed six parents of my close personal friends. Eight children lost their mothers, and four lost both parents.

An open front baggage door and subsequent decisions made due to haste and confusion resulted in a good aircraft hitting the ground.

Knowing that the crash was preventable made acceptance even more difficult to accept than it was to begin with. Having gone through this experience, I feel empathy with the family members and pray they somehow find solace. What a terrible, terrible tragedy.
I totally agree my heart goes out to the family and friends of these six fine people. The pilot was no doubt much loved and a very intelligent man to err is human and it's something each one of us must guard against every flight and every minute of every flight. The finest legacy to the those who lost their lives will be learning from this event so that it never happens again.
 
a00c0260_AppendixA.gif

Above diagram show right main fuel tank and how water can collect in an area of tank that cannot be drained, this was the cause of an accident in Canada when water froze around the flapper valve and prevented fuel from entering the surge tank (or slosh box if you will) causing the level in the surge tank to drop even though the main tank was 3/4 full. The pilot did get a R LOW FUEL FLOW light prior to the engine quitting. Ice of course had nothing to do with 447SA but it shows that the system works as designed BUT you must get the aircraft on the ground quickly if you get a LOW FUEL FLOW light of course if you have full AUX tanks switch to them but still land as soon as possible.

It was determined in the above accident that:

Findings as to Causes and Contributing Factors
  1. The right inboard fuel tank contained a substantial amount of water, which froze and probably impeded the flow of fuel to the right engine, causing it to stop.
  2. After the right engine stoppage, the pilot did not maintain the aircraft at a safe airspeed and altitude.
  3. The pilot did not fly a stabilized approach, and the airspeed of the aircraft was allowed to decrease below that required for safe flight.
  4. The pilot was task saturated during the approach.
 
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Wow... thanks for the picture of the flapper valve. I have never seen one before.
 
You don't have a toilet? :D

I live in the southwest desert. Just look for the rattlesnakes before squatting....

And if you hit a cactus while squatting.... you really find out who your friends are when you start asking people to remove the thorns.....
 
I live in the southwest desert. Just look for the rattlesnakes before squatting....

And if you hit a cactus while squatting.... you really find out who your friends are when you start asking people to remove the thorns.....

I thought it might be something like that, or an outhouse.
 
A real outhouse does not have walls.

Even in Alaska....

Grandparents had an outhouse when I was a kid. No plumbing but for a well pump. I dropped some kittens down the hatch once when I was very small, and grandpop whipped my ass red!

In the desert "over there" we had a tent and a plywood contraption w/ 4-5 holes so 4-5 could go at once. Man in the afternoons that tent was hot and stunk! Had another smaller tent w/ 4 - 2-3" PVC pipes angled 45* into the ground. You just walked in, stuck it in a pipe, and peed. I don't know what the females used though.
 
Had another smaller tent w/ 4 - 2-3" PVC pipes angled 45* into the ground. You just walked in, stuck it in a pipe, and peed. I don't know what the females used though.

Pizz tubes.... remember those well from military days. Except the ones we had were just out in the open....... when the smell got too bad, plant new ones in another area. :vomit::vomit::vomit:

A friend of mine, as a young boy, tells me about the time he poked all the knot holes out of his grand parents brand new cedar outhouse. He didn't sit down for a week after that as well.....
 
Read the narrative of this accident from Australia here before proceeding : This accident is interesting because the cause was listed as fuel starvation with reported fuel on board sufficient for the flight.

My comments on selected segments are in bold inserted into the accident report.

History of the flight

The Piper Aircraft Corporation PA-31-350 Navajo Chieftain, (N447SA was a PA31-325 but the fuel system except for location and design of fuel selector valves are virtually the same as a PA31-350) registered VH-UBC, departed Albury on a charter flight with a pilot and six passengers on board. About 5 minutes into the flight, as the aircraft climbed through approximately 5,000 ft, the pilot reported that the right fuel flow light illuminated. (if it was the LOW FUEL FLOW light and not the LOW BOOST then the main tank slosh box was about empty) The pilot moved the right engine mixture control lever to full rich and advised the Albury Tower controller that he was returning to Albury. A short time later, (whats a short time?)the right engine started surging. The pilot reported that he changed the right fuel selector from the inboard to the outboard tank selection, although he was aware that there was only a small quantity of fuel in that tank. The engine continued to surge and he reselected the inboard tank. The pilot reported that he did not shut down the engine and feather the propeller because he thought the engine was producing some power. (how did he determine that, fuel flow, MP, control feel?)

The pilot reported that approximately a minute after the onset of the right engine problem, the left fuel flow light (again was he seeing a FUEL FLOW light or FUEL BOOST) illuminated and the left engine also started surging. (OK folks he had two engine out of fuel) He advised the controller that he was diverting to Holbrook. The pilot found a break in the clouds and descended the aircraft, maintaining visual contact with the ground. On levelling out after the descent through cloud, he reported that the engines operated smoothly, but at reduced power. (reduced power really? TOTAL BS something stinks here) He reported that he maintained blue line speed for a short time, before power reduced to a level (the engines were windmilling he was just wishing some power into his situation) which would not allow altitude to be maintained. During the descent, the pilot opened the crossfeed valve (NOT on the engine failure in flight check list that is not an approved procedure) and checked that all fuel pumps were on, mixture controls were rich and the inboard tanks selected. Unable to restore power, the pilot decided to make an emergency landing in an open field below the aircraft (would have been nice to see him run the engine failure in flight checklist at some point) . Before landing, the pilot extended the flaps and the landing gear and instructed the passengers to prepare for an emergency landing.

The aircraft contacted the ground with its right wingtip and slewed for approximately 93 metres while rotating almost 180 degrees to the right. The aircraft was substantially damaged, but there was no fire. Neither the pilot nor the passengers sustained any injuries. (thankfully) The pilot reported that before exiting the aircraft he switched off the fuel pumps, magnetos and master switches. (if he did this is the first time he followed procedures)

Weather

The weather at Albury and the surrounding area was overcast with low cloud and fog patches. Rain and isolated thunderstorms were forecast for the area. Moderate icing was forecast above 10,000 feet. (Icing in the main fuel tank would not have been a issue)

Skipping down to fuel status:

Fuel status

The aircraft had flown during the previous day, returning to Albury late that afternoon. The pilot who flew the aircraft that day reported that the aircraft and its systems operated normally. He refuelled the aircraft for the next day's flying, filling only the inboard tanks. No fuel was added to the outboard tanks and the pilot estimated that about 25 to 35 litres remained in each outboard tank.

The rostered pilot reported that, on the morning of the occurrence, he carried out a preflight check during which he visually inspected the fuel tank contents. The pilot reported that he found both inboard tanks full, but could not see any fuel in the outboard tanks. In accordance with the operator's practice, the pilot started and warmed the engines so that the flight could proceed without delay when the passengers arrived. (Be real careful doing this can lead to taking off on the outboards with almost no fuel in them)

The `Before starting engine' and `Before take off' checklist procedures required the pilot to check that the fuel selector valves were selected to INBOARD tanks. Both the manufacturer's and the operator's `Before taxiing' checklist procedures then required the pilot to check the fuel selector at each detented position. The operator reported that pilots were encouraged to check the operation of the fuel selector valves in all detented positions during the engine warm up run. The pilot reported that in order to conserve the fuel in the inboard tanks for the trip, he preferred to warm the engines using the fuel from the outboard tanks. (Sounds like CYA statements but OK lets give him that)

The departure had been delayed due to fog at the destination. The flight commenced approximately two hours later than planned, when the fog cleared. The pilot reported that he carried out another engine warm up with the passengers aboard and had checked the INBOARD tanks selection before takeoff. (Sounds like more after the fact CYA maybe he did or did he get in a hurry and takeoff on nearly empty outboards?)

Fuel system

(Deleted first part here's whats important) The slenderness of the tanks and the wing dihedral resulted in the fuel accumulating at the inboard end of each tank. That meant that unless the tank was full, or nearly full, it was not possible to assess the quantity of fuel remaining in the tank by visual inspection or by dipping through the filler cap opening. (Will comment on this shortly)

The left and the right wing fuel systems were independent. Two fuel selector valves, one for each wing's fuel system, allowed the pilot to select either OUTBOARD, OFF or INBOARD positions. When a tank was selected, the fuel was fed to the respective engine system. A crossfeed line with a crossfeed valve was the only interconnection between the two wing fuel systems. The crossfeed valve is normally closed. (Yes it's normally closed and is used ONLY to allow an operating engine to use the fuel on the inoperative engine side and for maintaining balance)

Wreckage Examination and Component Testing

The aircraft sustained substantial damage during the emergency landing. The right wing was damaged, the landing gear was torn off and both propellers damaged. Damage to the blades of both propellers was almost identical and was consistent with them rotating at impact. Calculations based on an aircraft speed of about 110 kts, as reported by the pilot, and propeller blade slash marks at the initial point of impact, indicated that both propellers were rotating at approximately 1,830 RPM at impact. (Did not follow procedures to feather inoperative engines just like the Tuscaloosa accident pilot and this was a pro pilot)

continued.....
 
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When visually inspected through the filler caps shortly after the accident, both inboard tanks were full (wait a minute something stinks in Denmark you mean there was approx 12 gallons used and the tank were visibily full at the filler cap? IMPOSIBLE didn't this report say it was a few paragraphs up? heck yes and from experience I can confirm that) , but no fuel could be seen in the outboard tanks. The investigation determined that there were 210 to 211 litres of fuel in each inboard tank. The right outboard tank contained approximately 25 litres and the left outboard tank approximately 1 litre of fuel.

Detailed examination of the tanks and the fuel system found no evidence of flow restriction or the presence of any foreign material inside the system. Fuel samples taken from the aircraft were tested and found to comply with the respective fuel specification. The fuel was of the correct type and grade for the aircraft.

Both engines were removed from the aircraft. When tested, they operated normally in accordance with the manufacturer's test schedule. There was no evidence of any defect that would have accounted for the reported malfunction.

The fuel system and its components were tested in situ, and found to operate normally. The selector valves and the pumps were removed and tested. Operation of all but the left high-pressure fuel pump was normal.

The left high-pressure fuel pump failed to deliver the required pressure and fuel flow and was found to leak at the rate of about 1/4 litre per minute. The test facility specialist reported that the possibility of the fault resulting from damage during the accident could not be excluded.

There was no evidence of any other abnormality of the individual fuel system components and controls. (Well it seems everything was working as designed the big inconsistencies are only the pilots statements of what happened, while I'm thankful that he (and his passengers) survived to tell his tale it seems to be a tall one and leaves more questions unanswered than answered)
,
Fuel consumption

Calculated fuel consumption, based on the manufacturer's Take Off and Climb performance charts, determined that from the time the aircraft commenced take-off to its emergency landing, approximately 32 litres of fuel would have been consumed. In addition 12 litres of fuel was estimated to have been used during the engine warm ups and taxiing.

The descriptions of the loss of engine power and the subsequent engine surging were consistent with fuel starvation, a situation where the fuel to the engine is interrupted, although there is adequate fuel on board the aircraft.

Although the left high-pressure fuel pump failed to deliver the required pressure and fuel flow and was found leaking during subsequent testing, it would have had little effect on the development of the occurrence and its defect may have occurred during the accident sequence.

Analysis (from the web page tab)

The descriptions of the loss of engine power and the subsequent engine surging were consistent with fuel starvation, a situation where the fuel to the engine is interrupted, although there is adequate fuel on board the aircraft.

Although the left high-pressure fuel pump failed to deliver the required pressure and fuel flow and was found leaking during subsequent testing, it would have had little effect on the development of the occurrence and its defect may have occurred during the accident sequence.

The pilot reported that he had selected inboard tanks for the flight. The investigation was unable to reconcile the pilot's reported recollection of inboard tank selection and the evidence of the remaining fuel quantities in the inboard tanks. (well it seems those making the final report on this accident had their doubts to the pilot's recollection of events too!)

My conclusion is that there are too many answers to unasked question to determine what actually occured on this flight. LOW FUEL FLOW lights mean that main tank slosh box is rapidly depleting what fuel remains available to keep the engine running. LOW BOOST lights mean the selected tank is dry right now and the engine will quit in seconds.

1. Know your aircraft systems 2. Follow emergency checklist to the letter 3. Related to number 2 in an emergency don't start making up your own proceedures

I'd add that reading accident reports for the aircraft you fly and discussing them with other pilots and mechanics will take you a long way down the road to safer flights.

Online PA31 training manual
 
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https://aviation-safety.net/wikibase/wiki.php?id=25760

The above link is an report of another PA31 fuel starvation for unknown reasons (pilot thought he had plenty of fuel) it has a good outcome. The last line of the report is below in bold print.

A factor in this accident was the pilot's failure to visual check the airplane's fuel quantity prior to takeoff.

I disagree with with this conclusion in that you cannot visually check or sump a Navajo's fuel tank for quantity. The only way you will know if it's full is fill it up then look at it. After just a few gallons are used the tank won't show full visually and there is no way to sump it. If you fly a Navajo KNOW your fuel gauges compare fuel added to where the needles are, if you fly multiple Navajo's be warned they may all be different.

Over water at night no way I'd have left with anything less than a topped off tank.
 
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Ok, finally, the long awaited report is out. But it's a factual report, not a probable cause. Does that mean they'll not release probable cause? The news headlines are about fuel pumps causing it. But I read the whole report and to me it sounds like 5 of the 6 pumps were working just fine, and still doesn't get the pilot off the hook for (possibly?) failing to switch from the AUX tanks when they were depleted. This theory is augmented by the fact he apparently had no proper transition training in the 2.9 hrs (!!?) dual he received after buying it?

I'm interested in how you Navajo experts read this.

http://media.heartlandtv.com/documents/Northport+Alabama+Plane+Crash.pdf

Thanks,

Chester
 
Seems they are leaning toward empty AUX tanks and the pilots failure to switch to a tank with fuel (MAIN TANKS). Lack of training was apparent from the start nothing new in the factual report on that issue. Previously there was rumored reports of him getting a LOW FUEL FLOW warning light which would mean he was on the mains when the engines quit. I'd like to read the ATC transcript if it becomes available to see if he mentioned the LOW FUEL FLOW warning or not. It could be that this accident is simply the PIC's failure to manage fuel. However he knew how to switch tanks so the minute the first engine ran out of fuel his hand should have lunged for the fuel tank selectors, why didn't he do that. That is the question that needs to be answered.
 
Often the first indication of running an aux tank dry is the fuel boost pump warning light. The engine data in the docket shows that he was likely on the aux tanks for the requisite amount of time to run them dry. I suspect strongly that he ran the aux tanks dry, fixated on the boost pump light and believed he had a pump problem and not a fuel exhaustion problem. Given the prior maintenance on the fuel pumps, he was probably primed to fixate, especially with his completely substandard check out in the aircraft.
 
I'd say his first indication of a problem was when the engine quit. Then he saw the LOW BOOST light the reason being the engine will quit just seconds after that light illuminates, why he didn't switch tanks is the puzzle, he had lots of previous multi experience plus enough time in this aircraft to know that's the first thing you do. His systems knowledge in this aircraft was weak given his lack of formal training but sometime during the desent it seems logical that he would have switched tanks. His overall experience was good enough that running a tank dry would have been embarrassing but not fatal.
 
With the information I have seen so far I am inclined to believe that this might have been a fuel mismanagement accident.

I just hate to think this was a case of running out of fuel with full tanks.
 
Oh man.......


Probable Cause


The National Transportation Safety Board determines the probable cause(s) of this accident to be:

A total loss of power in both engines due to fuel starvation as a result of the pilot's fuel

mismanagement, and his subsequent failure to follow the emergency checklist. Contributing to the

pilot's failure to follow the emergency checklist was his lack of emergency procedures training in the

accident airplane.
 
the instructor definitely should be punished but I can’t help wonder what it was that prevented the good Dr from reading the manual during the 50 hours he was flying with the instructor.
 
the instructor definitely should be punished but I can’t help wonder what it was that prevented the good Dr from reading the manual during the 50 hours he was flying with the instructor.

True but actual repetitions implant the procedures in the mind. At least half a dozen times my CFI reached over and closed a throttle and said "uh oh what are you going to do now?" Even on XC's.
 
Seems to me the CFI is maybe getting a bum rap. The pilot was "qualified" to fly multiengine airplanes and asked the CFI to go along as a safety precaution, it seems. From the interview with the NTSB:

https://dms.ntsb.gov/public/61000-61499/61098/614322.pdf

• Mr. Phillips said that all I did was ride with him on cross countries with people.You can't really do any training, especially single engine training with people in the airplane. He made sure Jason's power settings were good and things like that.
• He had a Seneca too; it had a Garmin 750 on it, too. Jason was highly intelligent and was a very smart man.
• Jason got his multiengine certificate years ago.
• Jason didn't do any multi engine training with Mr. Phillips. No one else trained Jason on the accident airplane that Mr. Phillips knew of. Jason took the airplane Pilot Operating Handbook home and read it. He did good preflights and was thorough.
• Mr. Phillips didn't think Jason had any experience in the Navajo before this
airplane.
• Jason could handle the airplane well and he was an excellent pilot.
• Most of Jason's time was multi time, his dad gave him the Seneca and that's all he had been flying for his pilot career. Jason had about 800-1000 flight hours in multi engine airplanes.
• Mr. Phillips didn't practice any single engine operations or emergency procedures with Jason in the accident airplane. "You can't do any of those things with people in the airplane and we always flew the airplane with people in it. We had plane loads of people all of the time. There was one night we went out and did night takeoffs and landings, that’s the only time we were together alone in that airplane. Otherwise we would go on trips that he had with other people in the airplane."
Judging from the logbook images the owner, not the CFI, made the "dual received" entries (no cert # included):

 
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Seems to me the CFI is maybe getting a bum rap. The pilot was "qualified" to fly multiengine airplanes and asked the CFI to go along as a safety precaution, it seems. From the interview with the NTSB:

https://dms.ntsb.gov/public/61000-61499/61098/614322.pdf

• Mr. Phillips said that all I did was ride with him on cross countries with people.You can't really do any training, especially single engine training with people in the airplane. He made sure Jason's power settings were good and things like that.
• He had a Seneca too; it had a Garmin 750 on it, too. Jason was highly intelligent and was a very smart man.
• Jason got his multiengine certificate years ago.
• Jason didn't do any multi engine training with Mr. Phillips. No one else trained Jason on the accident airplane that Mr. Phillips knew of. Jason took the airplane Pilot Operating Handbook home and read it. He did good preflights and was thorough.
• Mr. Phillips didn't think Jason had any experience in the Navajo before this
airplane.
• Jason could handle the airplane well and he was an excellent pilot.
• Most of Jason's time was multi time, his dad gave him the Seneca and that's all he had been flying for his pilot career. Jason had about 800-1000 flight hours in multi engine airplanes.
• Mr. Phillips didn't practice any single engine operations or emergency procedures with Jason in the accident airplane. "You can't do any of those things with people in the airplane and we always flew the airplane with people in it. We had plane loads of people all of the time. There was one night we went out and did night takeoffs and landings, that’s the only time we were together alone in that airplane. Otherwise we would go on trips that he had with other people in the airplane."
Judging from the logbook images the owner, not the CFI, made the "dual received" entries (no cert # included):unction


I agree with you as far as Phillips providing instruction to the Dr in his plane. The news article is alluding that Phillips provided flight instruction with an expired CFI Certificate AND medical. He didn't provide instruction but rode along as a sort of safety pilot. However, he accepted compensation for this, which he admitted and was convicted of, and I get the impression Phillips may have given actual flight instruction to others unrelated to this incident. It doesn't mention whether his other Certifcate (i.e. Commercial) was suspended prior or not, but perhaps irrelevant anyway without a valid medical.
 
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