Good ADM Saved my Bacon

Discussion in 'Lessons Learned' started by Ted DuPuis, Nov 9, 2013.

  1. Ted DuPuis

    Ted DuPuis Administrator Management Council Member

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    From this thread:

    http://www.pilotsofamerica.com/forum/showthread.php?t=65321

    The discussion came up that, as pilots, we should talk more about experiences when we broke the accident chain. I thought it would be best in the "Lessons Learned" section since some people might be more comfortable posting anonymously.

    Too often, we read about NTSB reports and talk about what we would have done differently. However, that's looking at a situation where the worst has happened. The reality is, that could happen to any of us. While there are varying causes, I suspect that part of it is a typical unwillingness by pilots to deviate from a plan because we tend to want to stick to our plan. After all, the chances are that it will be fine. This part is true. But we also know that very few people in NTSB reports got into a plane with the intent of crashing, which means they were in the same shoes we are. I think if we talk more openly about how we have broken the accident chain, maybe that will keep it more in everyone's minds. So I'll start with a couple of experiences, interestingly on the same trip.

    Last year right after Christmas I had a Cloud Nine flight to Belize and back. This was around 20 hours of flying in 2 days. Long, but not out of the ordinary for me. I do long trips and I'm comfortable with them and make plans accordingly. The trip down was relatively easy.

    On the trip back, winds were predominantly out of the north. Something like out of the northwest, which resulted in me having headwinds from clearing customs in Key West up to Alabama. The trip was expected to be something at around 4 hours. The 310 at the power setting I was using burns 27 GPH with 140 gallons total for a hair over 5 hours of fuel.

    Two issues ended up hurting my range. Headwinds were worse than forecast (to the surprise of no one), and there was a cloud layer that I wanted to stay above for icing purposes, which made the headwinds worse still.

    As I approached the destination, it looked like it would be close on fuel. The instrument approach for the airport (only one) also would have taken me out the wrong direction if I had needed to use it. Clouds were at that borderline point where a visual approach may or may not have been possible.

    I saw the accident chain as follows:

    1) Trip plan getting into last hour of fuel remaining
    2) Headwinds worse than expected
    3) Failed to stop for fuel in time
    4) Fuel exhaustion somewhere with a double engine failure

    I stopped it before 3 happened, and diverted for fuel with under 50 nm remaining on the trip. Although I think there would have been enough fuel to make the rest of the trip, it would have been close.

    Then after the drop off, I had to get back to Ohio from Alabama. I was above the icing layer (easy to climb through - lightweight and cold I was doing 1,500-2k fpm climb). However, it was solidly between me and the ground back at Ohio. My home airport is a north-south runway that is 2800 ft, which is a hair tight for a 310 and does not allow carrying in any extra speed. So on this I would have a night approach that should be easy enough (not that close to mins), but then came the fact that there had been snow while I was gone. Although the runway was reported as clear, the winds were out of the west, meaning that the snow could have drifted onto the runway. If that was the case, I wouldn't know until about over the runway (again, night approach) and then would have a low go-around/missed and then climbing back into the ice to go around and shoot the ILS at the neighboring airport (with an east/west runway).

    I saw the accident chain as:

    1) Aircraft gets iced up on approach to "short" runway, potentially requiring extra speed
    2) Runway covered in snow with crosswind
    3A) Plane skids off side of runway or overruns runway
    3B) Plane ends up back in icing, gets iced up, crashes

    So I stopped all of this before it was an issue. I diverted to the neighboring airport with a 5500 ft east/west runway and an ILS. Then I called a friend of mine for a ride home. The next day, got a ride back and ferried the 310 to its home. A beautiful day.
     
  2. pilot_dude

    pilot_dude En-Route

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    ADM which results in a safe landing is good ADM.
     
  3. Ted DuPuis

    Ted DuPuis Administrator Management Council Member

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    Not true.
     
  4. FORANE

    FORANE Pattern Altitude

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    Headwinds can easily get one in trouble. I almost got in trouble coming home from Philly to Tennessee at midnight one winter a few years back. I was fighting a headwind of around 50 knots above 10k msl. I tried to get slightly better winds by going a little lower but still fought a headwind and fuel burn was higher at the lower altitude. I should have landed for a fuel stop but didn't.
    When I got to my home airport I had very low fuel remaining. I clicked the CTAF but no lights came on. My home airport has mountains in the traffic pattern; they will not leave the lights on pilot control unless you call ahead during the day to request it and you have completed their night checkout to become an authorized night pilot at that field. I had not called ahead.
    I diverted to the closest field with runway length able to accommodate my planes requirements. At that point I was flustered. I noticed while maneuvering for the alternate that the runways lights became fuzzy. I realized that I was looking at runway lights partially obscured by trees. I climbed and managed to get into the alternate but did not have much fuel by the time I landed.
    Numerous links present in retrospect.
     
  5. Alexb2000

    Alexb2000 En-Route

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    Ted-

    Good topic. When I fly in the mountains one of the biggest problems is alternate airports. In my case the nearest IFR airport is 60 miles. The nearest VFR airport has no fuel. It is a constant mental battle to stop for fuel and/or change directions whenever the conditions require it (quite a bit).

    I see the accident chain as:

    1. Arrive at fuel minimums
    2. Airport closed because of disabled aircraft on the runway
    3. Divert to nearest and run out of fuel on the way
    4. POAers post a link to the NTSB report and call me an idiot.
     
  6. pilot_dude

    pilot_dude En-Route

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    Do tell.
     
  7. Skylane81E

    Skylane81E Final Approach

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    Just cuz you got away with it doesn't mean you chose wisely.

    I got away with stud running a single over Lake Michigan in the dark MVFR, yet I don't plan to do it again because it was DUMB
     
  8. denverpilot

    denverpilot Taxi to Parking

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    Stud running, eh? Much money in transporting young males around? LOL
     
  9. GMascelli

    GMascelli En-Route

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    Ted,

    Great topic.

    My flight was a quick turn and burn, Wilmington (KILG) to first flight (KFFA), just under 500 miles round trip. I wanted some flight time and my friend who will fly my plane on occasion wanted to meet up with family on vacation. The plan was to fly down with him and then fly my plane home since he was driving back with them. The flight down was uneventful. We did the intros then I saddled up for home.

    This was back in August 2011, when there were TFR's for the fires south of Virginia Beach and north of Elizabeth City, NC. I had enough fuel on board for the round trip and after picking up my clearance I was heading north. This was one of those trips, riding along fat dumb and happy listening to some tunes while working with approach. I even managed a PIREP for Center when they asked about the smoke.

    I was checking my times as I headed north dealing with headwinds. I actually used my AP (wing leveler) and ran through my calcs once again. I figured on 10-12 gallons on board when landing at ILG. I would be landing just after sunset and if there were problems I wanted more of a safety factor in the tanks. I used the 496 to look up Georgetown's (KGED) hours and they would be closed for fuel so I advised approach I would be diverting to Salisbury (KSBY)for fuel. Approach asked if it was a fuel emergency or minimum fuel, I responded neither, just being safe. I landed, took on enough to bring me to tabs each tank (30 gallons) and launched for home. I enjoyed a great sunset and a nice landing at ILG.

    The potential accident chain:

    1) Getting into to my magic hour of fuel
    2) Headwinds greater than planned for
    3) My go-to fuel stop was closed
    4) Deciding to roll the dice and just get home
    5) Potential for fuel exhaustion and turning into a glider at night

    I made the decision with 40 minutes left to get home to break the chain at 4 and divert for fuel. Tempting maybe for some to continue since the preferred fuel stop was closed but that little voice in my head didn't want to be a statistic.

    http://gmflightlog.blogspot.com/2011/08/first-flight-and-home.html
     
    Last edited: Nov 10, 2013
  10. Geico266

    Geico266 Touchdown! Greaser!

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    I think the FAA mins are too low. 30 mins of fuel is too low IMHO, ditto on the 45mins at night.

    I've had to divert on several flights. My mins are an hour minimum.
     
  11. FORANE

    FORANE Pattern Altitude

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    Yup.
    Same here. I keep 1 hour minimum based on full power down low - not cruise power at altitude fuel consumption. Got too close once and do not wish to get into a situation where I make poor decisions secondary to pressure of low fuel.
     
  12. Unregistered

    Unregistered Guest

    I agree.

    There's this guy I know, can't remember his name, planned a 4hr flight in an Archer, book fuel burn should have averaged 9.25, he planned for 10 to be safe, so he planned to land with just over 45min of fuel. As he passed over the last fuel option until his destination, checked his times, checked destination weather, checked sunset time, checked the gauges - all good, press on. Landed at destination within 4mins of his planned enroute time of 4 hrs. Topped off the tanks and checked his fuel burn rate, which showed that he had 6mins of useable remaining in the tank in use, and 10mins in the other. Had he planned to allow only 30minutes in reserve instead of 45, . . . . .
     
  13. Skylane81E

    Skylane81E Final Approach

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    Damnyouauttocorrect
     
  14. Ted DuPuis

    Ted DuPuis Administrator Management Council Member

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    Duncan pretty well nailed it. We know that bad decisions do not always result in a crash, and in fact they don't result in a crash most of the time. What they do is increase the probability of a crash. Using the fuel examples, we know that most of the time when someone cuts fuel close, they don't usually run out, they just have less than they're comfortable with. When you take a look at the broad database of what causes crashes, you start to see which decisions are better and which are worse. Most people who fly into icing, even a 172 don't end up crashing, they just need new pants. The old way of thinking was "if I had a safe landing, it was good ADM." The reality has shown that to not be the case.

    I knew someone who did very similar, also in an Archer. I think part of this comes down to bad fuel level and fuel flow indications as well, which are common on older aircraft, especially pistons.

    As for the minimums, remember that limits are not goals, they really are limits. But for certain aircraft, you really just don't have good fuel capacity. The tighter your margins, the more important ADM is.
     
  15. Baron2PG

    Baron2PG Pre-takeoff checklist

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    Fuel totalizer error will also get you in trouble. Back in September I was taking my daughter back to college. I was going to take on a bit more fuel but after loading a ridiculous amount of her junk in the plane I was pushing my weight limit for the fuel load the FUEL TOTALIZER said I had on board. The 1st link in the chain is now set. As we cleared the Blue Ridge mountains the XM ATIS in Nashville was reporting off-forecast low ceilings, 2nd link in place. The head winds were also much stronger then forecast; however, the fuel totalizer was telling me that I'd have a bit less then an hours fuel upon arrival; 3rd link.

    Fortunately my SOP is to double check my fuel totalizer whenever I hit 1/4 tank; which is 42 gallons. When I did so I realized that I must have fat fingered my fuel qty during a prior fueling as the fuel totalizer was off by 20 gallons. After correcting I now had less then a 20 minute margin. Error caught and chain broken.

    We quickly detoured to Chattanooga for a quick fueling; surprised at the reasonable gas price and nice FBO, we'll be back. Arrived in Nashville with solid IFR and 400' overcast. No issue on the approach; however, it could have easily been a miss and I'd be on fumes with no out.
     
  16. Ted DuPuis

    Ted DuPuis Administrator Management Council Member

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    One of the scenarios I got handed in the Sim was an approach that suddenly went to below mins on a single engine ILS with icing. My decision was to bust mins and land. I'd do similar if I'd boxed myself in with low fuel, but the good ADM would be to un-box myself.
     
  17. Alexb2000

    Alexb2000 En-Route

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    I believe it's so easy to dismiss this whole conversation by telling yourself you will never get low on fuel. Problem is when you fly to some remote parts of North America, or fly certain aircraft, that isn't an option; like your trips to remote Canada. Couple that with a heavy load of cargo and the decisions get harder. I will admit for example that I have decided to fly heavy vs. take less fuel. Another example is crossing a storm system over open water vs. going around and being fuel critical. These worked out obviously, but those lessor of two evils decisions are never easy. IMO it's the choices we have to make in the grey areas that really challenge us.
     
  18. Skylane81E

    Skylane81E Final Approach

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    It depends for me. I am perfectly willing to blast off for the next airport over with minimum fuel but if I am traveling you best believe I want a solid hour of extra gas.
     
  19. Skylane81E

    Skylane81E Final Approach

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    God bless big gas tanks, they do make making good decisions easier. However as you noted sometimes you just have to make choices. This spring I had to try and haul 900lbs of people to Kelly's island and back. No fuel available on the island and I had to ensure I didn't bust landing weight at arrival. Found that I could make it there and back with an hour to spare so it was gravy. Had the winds not been as forecast I'd have been spring loaded to land short and gas up.


    I have tried to stretch legs out when I had good tail winds too, returning from Lawton OK and seeing that I would hit my minimums very near home I set a hard stop time. If we hit it we were stopping at the nearest field with fuel, even if it meant stopping only a few miles from home (or back tracking a bit.) worked out perfect and our wheels hit payment at home 45 seconds after the expiration of my "land now" time. When I fueled up I found that I had been a little conservative (like I wanted to be) on my fuel judgment and we had about 1.25hrs of fuel still on board.
     
  20. Ken Ibold

    Ken Ibold Final Approach

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    Is that human trafficking of gigolos?
     
  21. Alexb2000

    Alexb2000 En-Route

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    I find that four gold chains and three buttons undone on my polyester dance shirt means I'm stud running at any altitude.:wink2:
     
  22. Dave Siciliano

    Dave Siciliano Final Approach

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    It's important that one sees things ganging up on them that can cumulatively cause an accident like Ted and others on here have; then, one can plan outs. Some folks just don't see it coming.
    My notable experience was just such a case on a Christmas trip a few years ago in the P baron. On the first leg of the two leg trip, a few things went wrong (one the way to Florida). AP went out; one alternator acted up and there was another small instrument issue. When i got to Florida, tower and field were closed and I had to self fuel. I was a bit tired and had to fumble around with self serve I was unfamiliar with, but I did put in plenty of gas. Checked weather one last time and it was fine. I decided to continue but also decided I was pushing a bit and to be prepared to divert and spend the night somewhere if needed.
    On the leg to Greenville, SC I got about 20 minutes from destination and approach gave another plane going in there weather which include low ceilings and ground fog. Tower at destination was closing shortly which meant I wouldn't be able to get ground observations. I decided to continue but also set minimums and if I didn't make the approach, set an alternate that was reported VFR back where I had passed over.
    At destination, I was cleared for the ILS and ceilings were reported just over minimums. The alternator that had acted up, now was out. Hand flying. Had tower been closed, I would have diverted then; but tower reported good visibility under the ceiling and turned up the runway lights.
    Same thoughts as Ted, things are ganging up on me. I'll shoot one approach and go to the alternate if not successful unless it's something I did wrong I could correct. Descended with needles centered and made the approach without difficulty, but felt if anything else had gone wrong, I would have really had my hands full. One thing I stacked in my favor was fuel. I could have flown back to Florida if necessary.
    Wrote to tower chief to thank them for being there when I needed them. After I landed, they shut down the tower for the holiday.

    Best,

    Dave
     
    Last edited: Nov 10, 2013
  23. Palmpilot

    Palmpilot Touchdown! Greaser!

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    I'm guessing you need a pretty good sized cargo plane to transport horses!
     
  24. Palmpilot

    Palmpilot Touchdown! Greaser!

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    I had Flight Watch break the accident chain for me once. I happened to be monitoring their frequency when they called me in the blind to inform me that the Death Valley airport I had filed for my fuel stop was either closed for resurfacing, or did not have fuel available that day, I don't remember which. I had missed the NOTAM when I got my DUAT briefing. :hairraise:

    Fortunately, they reached me while I still had plenty of options. I changed my fuel stop to Lone Pine (O26), which is just past the Sierras.

    So in that case, following my primary flight instructor's advice to monitor Flight Watch enroute was a vital element in breaking the accident chain that day.
     
  25. Baron2PG

    Baron2PG Pre-takeoff checklist

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    Curious - Were you IFR or on a VFR flight plan?
     
  26. txflyer

    txflyer En-Route

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    Fly it like you STOL it ♦
    I took off from 11R enroute to KHRX with 3/4 tanks thinking that would be plenty, but I hit some brutal headwinds.

    Out around Guthrie, fuel was getting critical, so I made the PIC decision to terminate flight following and land on the four sixes ranch private runway. I wasn't going to make it to Plainview.

    The Sheriff had to bring me some car gas to get me out of there. I have a mogas STC so that was o.k. even if it was plain car gas.
     
  27. Arbiter419

    Arbiter419 Cleared for Takeoff

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    Good thread, Ted :)rolleyes:)

    It's always good to reinforce and stimulate this kind of thinking.
     
  28. Palmpilot

    Palmpilot Touchdown! Greaser!

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    I was on a VFR flight plan.
     
  29. Ted DuPuis

    Ted DuPuis Administrator Management Council Member

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    You are correct, and there are other factors in that. One of my "lessons learned" flights was in Canada and also a fuel issue. I think I've talked about that before. It was also my first flight in the Navajo with 8 people total, luggage, and fuel. I had low time in the Navajo at that point.
     
  30. geneseib

    geneseib Line Up and Wait

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    The accident chain is REAL. But for the grace of God I could and should have been a statistic.

    Took off on a dark moonless night across Missouri. Had refueled 20 minutes into my previous flight. In my mind I had confused total trip time and time after refuel. Had 20 minutes less fuel than I thought. (Link 1 in the chain) Planned to refuel at an airport with 45 minutes remaining. (But I would only really have 25). Headwinds were higher than expected. (Link 2) Arrived at refueling airport and runway lights did not come on. (Link 3) Headed for next airport 12 minutes away. Thought at that time I had 30 minutes (down from 45 due to headwinds), but had only 10. Barely reached a highway. Rolled under power lines on roll out. Walked away with no damage to plane or passengers. 30 seconds before touchdown we were over a lake. 60 seconds before we were over trees. Taking into account my 20 minute mistake, the engine quit when it should have to the minute.

    Classic accident chain. We survived it.

    The runway lights at the planned refueling airport took 7 clicks to turn on. I had never run into that in my 30+ years of flying. 5 had always worked. Had I had no other options, I would probably have eventually discovered the key, but with another airport 12 minutes away and thinking I had 30 minutes of fuel, I decided it would be prudent to head for the next airport instead of wasting more time and fuel messing with the lights, which may have never come on.
     
    Last edited: Nov 10, 2013
  31. Ted DuPuis

    Ted DuPuis Administrator Management Council Member

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    I'm glad your survived. That's one of those 10 incidents for every accident, or some such statistic.

    A suggestion on the above which I implement into my procedure for landing at non-towered airports. Since most airports have 3 clicks for low, 5 for medium, and 7 for high intensity, I always start with 7. This way, when I'm looking for the airport, the lights are their brightest. Makes it easiest for me to find. Then once I've found it, I will usually reset with 3/5 clicks to turn it down at some point in the pattern. Landing with them on high (if they go that high) is typically too bright, as we know.
     
  32. geneseib

    geneseib Line Up and Wait

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    That's my procedure now. I was familiar with some taking 7 clicks for high, but never had encountered one before that took 7 to come on at all. Probably would have tried that next, but felt it better to head for the airport 12 minutes away where lights were on all the time vs continuing to burn fuel over an airport when lights may never come on.
     
  33. denverpilot

    denverpilot Taxi to Parking

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    I suppose that'd be one of my ADM stories. Or screwups. I sticked the tanks once and found 30 min of fuel after a long flight. Since I live by the 1 hr minimum rule, I was dumbfounded.

    It took two pilots an hour to figure out where the other 30 minutes of fuel had gone (flying at a lower altitude and power setting due to overcast than was originally flight planned by either of us separately), and we didn't launch on the next leg until we had figured it out, concerned we had a problem somewhere.

    If we'd have planned for FAA fuel minimums, well... We may have had an off airport landing story to tell the next day.

    Learned a good lesson about power setting complacency that day, too.
     
  34. Unregistered

    Unregistered Guest

    Ok, ok, my stupid fuel mistake(s).

    first one, on the way back to CO from the midwest. VFR all the way. New plane to me, only had it for 3 hours. Over the central states, the weather was solid overcast at 1800-2500', so I wasn't scud running, but was flying low most of the way. Pushing a bit of headwind, maybe 6-10kts. After picking up the plane in Newport News, I made a bit of a deviation southwest for some mogas(cheap guy that I am). I landed at a fairly short runway, hopped out and found the mogas tank empty, sigh - I'll take 100LL for now. Well, no 100LL either. No one around, out in the boonies and I'm in a plane that I don't know very well. I calced my previous endurance, and figured I'd flown almost exactly 3 hours @ 9GPH meaning I had a touch under 10 gal left in the right tank.

    The nearest airport with fuel was about 20 miles away, almost direct north. That would be 10 minutes, or 15 min with a takeoff and a short pattern, and yes I know this is sounding depressingly familiar. I check the fuel calcs again, and looked around for someone to get me some fuel. The place was deserted. I called the other airport and made sure they had fuel, and asked if someone could bring some too me in a spare can. no one avail.

    My accident chain was pretty obvious, and rather simple, but not that tight. So, I took off and headed north. I timed the flight carefully from engine start to landing and it was 14 min 26 seconds. I filled up again and headed home. The only thing I can think of to break this chain is to call each and every fuel stop a few minutes before departure to see if they have run out of fuel. Grrrrrr.


    Strangely, a few months later I was enroute eastbound this time, and stopped again for mogas in N AR. Once again, the mogas tank was empty but they had 100LL on the field.
     
  35. danhagan

    danhagan Pattern Altitude

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    Man! You guys really push the fuel reserves! I top off EVERYTIME on long XC to avoid any fuel issue.

    The Tiger will hold 52 (51 useable). I FP 10 gallons/HR, but am usually at about 9 or slightly less in cruise. Most of my legs are 3 hours or less leaving at least 2 hours on board.

    Had a July 4th trip El Paso to Fullerton a couple of years ago. Showers and rain the entire trip. No one on ATC frequency except me and a couple of SWA flights. ATC indicated storms were worsening PHX to Blythe along the I-10 (my route of flight after Tuscon) and that I had pop ups at my 3,6 and 9 positions as well as the monstor 45 miles ahead that he was warning me about. Landed Marana as it's the 4th and most of the FBOs are closed (was planning Casa Grande, but it was now in that storm as well).

    Departed full fuel again, received same ATC guy and the plan was going to be south of I-10 watch the storms and stop when necessary for weather. He offered a re-route across ALL the restricted areas to Yuma then north where it was clear. Was able to accept it as I had 5 hours on board again and could basically fly anywhere if necessary.
     
  36. JeffDG

    JeffDG Touchdown! Greaser!

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    Or, of course, there's the recent thread:

    1) Unexpected headwinds
    2) Land to check fuel quantity
    3) One empty tank, one tank with 3-4 gallons
    4) Take off for another airport
    5) Fuel exhaustion, forced landing
    6) Sue aircraft manufacturer
    7) PROFIT!
     
  37. Baron2PG

    Baron2PG Pre-takeoff checklist

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    Baron2PG
    Topping off with fuel is perfectly good SOP with a Tiger or a 172; when I had a Tiger I too kept it topped off. However, with my current plane topping of the tanks is simply not feasible as it holds 196 gallons (~1200lbs). For the vast majority of my travel I only need 100 gallons of gas, saving 600lbs for passengers and baggage. Keeping up with the fuel totalizer is a bit trickier when you never top the tanks.
     
  38. Ted DuPuis

    Ted DuPuis Administrator Management Council Member

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    #bandozer
    Also, not topping off has a benefit in OEI performance in a twin.

    Usually I top off because I can only hold 140 gallons, and typically need about 250. So I make a stop.
     
  39. Palmpilot

    Palmpilot Touchdown! Greaser!

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    Richard Palm
    Also, topping off a Tiger or 172 may not be a great idea before taking off from a high altitude airport!
     
  40. Jaybird180

    Jaybird180 Final Approach

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    I time my stop based on the Hobbs (and my watch at engine start), that way I am pretty certain of now screwing up the calculation.

    It has only caused me once to stop 30mins shy of destination and I had MuCH more fuel than real calculations. Had me questioning my aggressiveness with the red knob. To this day, my fuel burn figures have been discarded for lack of realism.