Las Cruces Cessna 421 crash - wrong fuel

[Mike I]

http://bigstory.ap.org/article/medical-flight-got-wrong-fuel-crash

Fueled with Jet Fuel instead of 100LL. Always sample your fuel!

LAS CRUCES, N.M. (AP) — Federal safety investigators say an air ambulance got the wrong fuel at a New Mexico airport before it took off and crashed, killing all four people aboard.

A National Transportation Safety Board preliminary report says the twin-engine aircraft was refueled with 40 gallons of jet fuel instead of aviation gasoline at the Las Cruces airport on Aug. 27.

The plane was headed for Phoenix. All three crew members and one patient were killed.

The NTSB preliminary report issued Monday does not say whether the wrong fuel caused the crash.

The report says a crew member called the dispatcher on a satellite telephone and reported they were returning because smoke was coming from the right engine.

Las Cruces spokesman Udell Vigil said city officials would have no comment on the NTSB preliminary report because the city doesn't operate the fueling service at the airport.

That operator, Southwest Aviation Inc., also had no immediate comment.

The NTSB will issue a final report later on the crash.

The plane was registered to Elite Medical Air Transport, of El Paso, Texas, and was operated by Amigos Aviation Inc. of Harlingen, Texas, the NTSB said.

The preliminary report said the plane had turned and was still at a low altitude before it crashed and burst into flames.

After arriving at the Las Cruces airport, the pilot was in the cockpit when he told an airport technician he needed 40 gallons of fuel, the preliminary report said.

It said the technician refueled the plane and that the pilot helped the technician replace both wings' fuel caps before they walked into the office, where the pilot signed the machine-printed fuel ticket.

Investigators who arrived at the crash site a day later reported smelling jet fuel, the preliminary report said.

Crew members killed have been identified as 29-year-old pilot Freddy Martinez, 27-year-old flight paramedic Tauren Summers and 35-year-old flight nurse Monica Chavez, all from El Paso.

The patient was 59-year-old Fredrick Green, a Phoenix resident who was staying in Las Cruces while undergoing radiation treatment after surgery in Phoenix for a brain tumor. He was returning to Phoenix for further treatment.

 

[warthog1984]

No Hoover Ring/Nozzle?

 

[Henning]

Beats dying of brain cancer.

 

[Geico266]

I do not allow anyone to put fuel in my planes. I must be there to see what it is they are doing. I was at Davenport, IA a couple of years ago and they tried to fuel my RV-10 with Jet A.

 

[N747JB]

That's probably true, but the other 3 that died didn't have brain cancer.

Beats dying of brain cancer.

 

[N747JB]

This happened to a friend of mine in his Navajo, he had just gotten his ME, luckily he had a MEI in the right seat and they got it back to the airport! The FBO bought them 2 new engines and flew them home and back by airline.

I do not allow anyone to put fuel in my planes. I must be there to see what it is they are doing. I was at Davenport, IA a couple of years ago and they tried to fuel my RV-10 with Jet A.

 

[Mike I]

No Hoover Ring/Nozzle?

Plane built in 1974. Hoover Ring/Nozzle (SAE AS 1852) didn't come around until 1984, I believe.

 

[CTLSi]

Inexcusable. Pity this lames passengers. Even if you don't fuel the plane yourself, you still need to ALWAYS pull fuel sample and look at it in the sunlight. If at night, get a bright flashlight.

 

[NJP_MAN]

All of our trucks had a hose with at least 1 rogue spout for Helos. They tell you not to leave them on the hose but they all lived on the hoses.

 

[danhagan]

The pilot was a good friend of mine. I am positive Freddy did not forget to sump. I hope that if you all have an accident, you don't get the Monday morning QBing that is going on here. God speed Freddy ... you're sorely missed already.

 

[James331]

Inexcusable. Pity this lames passengers. Even if you don't fuel the plane yourself, you still need to ALWAYS pull fuel sample and look at it in the sunlight. If at night, get a bright flashlight.

The sample right after fueling doesn't work that well.

What you need to do (as per our GOM) is supervise the fueling, or fuel yourself. I also triple check on the receipt too. Our plane can also burn 100ll, but its sill bad news.

RIP.

 

[jordane93]

The sample right after fueling doesn't work that well.

What you need to do (as per our GOM) is supervise the fueling, or fuel yourself. I also triple check on the receipt too. Our plane can also burn 100ll, but its sill bad news.

RIP.

Yep. The Airplane Flying Handbook recommends pilots supervise their fueling.

 

[Zeldman]

Inexcusable. Pity this lames passengers. Even if you don't fuel the plane yourself, you still need to ALWAYS pull fuel sample and look at it in the sunlight. If at night, get a bright flashlight.

Where did the JetA come from? Was the plane filled from the JetA truck? Was the Av-gas truck filled with JetA? Was the fuel farm Av-gas tank filled with JetA?

When you pull a sample of fuel, what are you looking for? What color is the sample if there is 30% JetA and 70% Av-gas? What color will the sample be under a regular flashlight? Or a LED flashlight? I know the answers, I go through scenarios just to learn what I am looking for.

I fly air ambulance in C-421 for a different company. I was in Las Cruces the night before this, but I didn't require fuel.

 

[alfadog]

Plane built in 1974. Hoover Ring/Nozzle (SAE AS 1852) didn't come around until 1984, I believe.

There is an AD for the 421 that requires it. My crew did a 421 (#56, I believe) for my airframe inspections class.

edit: AD 87-21-02 R1 CESSNA for any interested.

 

[overdrive148]

As a test I mixed some Jet A and 100LL together while sumping (75/25 100ll to Jet A probably) and I could only tell the difference in a clear container by the swirling of the JetA compared to the clear of the 100LL (the 100LL's blue doesn't show up very well in small quantities against the sun). Water is very noticeable though, with a very clear border between.

 

[PaulS]

How would a sniff test work??

 

[alfadog]

As a test I mixed some Jet A and 100LL together while sumping (75/25 100ll to Jet A probably) and I could only tell the difference in a clear container by the swirling of the JetA compared to the clear of the 100LL (the 100LL's blue doesn't show up very well in small quantities against the sun). Water is very noticeable though, with a very clear border between.

Did you feel it? Supposedly, you can feel the difference? Also, did you smell it? You cannot tell by looking without a known sample to compare it to and then it is iffy.

 

[MAKG1]

As a test I mixed some Jet A and 100LL together while sumping (75/25 100ll to Jet A probably) and I could only tell the difference in a clear container by the swirling of the JetA compared to the clear of the 100LL (the 100LL's blue doesn't show up very well in small quantities against the sun). Water is very noticeable though, with a very clear border between.

I must confess I almost never do this, but you can tell the difference by evaporation. Drop a few drops onto some white paper. Avgas (and mogas) evaporates almost completely. Jet fuel (and Diesel) remains oily.

Us musicians use jet fuel all the time. We call it "valve oil" and somehow, it's a whole helluva lot more expensive. Must be the solid gold eyedropper.

 

[alfadog]

The pilot was a good friend of mine. I am positive Freddy did not forget to sump. I hope that if you all have an accident, you don't get the Monday morning QBing that is going on here. God speed Freddy ... you're sorely missed already.

Sorry for your loss. RIP to the deceased.

 

[alfadog]

I must confess I almost never do this, but you can tell the difference by evaporation. Drop a few drops onto some white paper. Avgas (and mogas) evaporates almost completely. Jet fuel (and Diesel) remains oily.

Us musicians use jet fuel all the time. We call it "valve oil" and somehow, it's a whole helluva lot more expensive. Must be the solid gold eyedropper.

I would not do the paper test every time, only if I had a doubt after feel and smell. I need to incorporate that feel and smell into my preflight routine.

 

[overdrive148]

How would a sniff test work??

Probably a lot better than the visual, Jet A is incredibly offensive to the nose and pretty different than avgas in and of itself. The color difference isn't enough with a small sample - the Jet A is straw colored normally. Then again I think that Jet A is more dense so it'd be below the Avgas preventing it from letting out anything. I will test and report back next time I sump at work

Did you feel it? Supposedly, you can feel the difference? Also, did you smell it? You cannot tell by looking without a known sample to compare it to and then it is iffy.

I didn't really try it then and there, but I will next time I'm at work. I think that there is a feel difference though, 100LL dries faster and Jet A has a slimier kind of feel to it. I don't usually spill much on me by my own volition but I will (for science).

 

[CJones]

Wasn't there a report a few years ago where a 100LL tank farm got mixed with Jet-A from the bulk supplier? The only reason I remember it is I use it as a good reason to enter my tail number on the self-serve pumps. Apparently when they realized the mistake, someone (either the airport or fuel company) contacted people that had purchased fuel from that timeframe to 'make things right' for folks that had messed up engines, etc.

What's the 'critical ratio' of 100LL to JetA in a mixture where a typical GA engine can't handle the JetA?

 

[bullwinkle]

Beats dying of brain cancer.

Doesn't beat living, though.

 

[alfadog]

...

What's the 'critical ratio' of 100LL to JetA in a mixture where a typical GA engine can't handle the JetA?

I seem to remember that 10% jet will cause a problem.

 

[CTLSi]

The sample right after fueling doesn't work that well.

What you need to do (as per our GOM) is supervise the fueling, or fuel yourself. I also triple check on the receipt too. Our plane can also burn 100ll, but its sill bad news.

RIP.

No one has fueled my aircraft but me. In fact, I have only used 100LL once in 200 hours. I still sump check before each flight. My autogas is wheat colored, like JetA.

I am not trying to be mean about the pilot missing this, but the fuel is dyed for a reason and he should have been both checking it, and being able to tell when it's diluted. The main reason to check fuel is to look for color and water.

 

[overdrive148]

I was helping a guy fuel his T-6 and he ended up bringing the nozzle too high and absolutely blasting me and himself with avgas. By the time he put the last few gallons in, his socks (which took most of the hit) were close to dry. The smell was still there, but much less powerful.

Compare that to the first time I fueled a helicopter with the angle nozzle on it - I didn't quite stop fast enough and sent Jet A spraying all over me, as well as some from the sky afterwards.

I went to walmart to grab a couple quick things after work (hours later) and the crowd actually split around me from the smell. Cool if you don't mind your skin drying out and the awful smell. Much more potent after a while than the 100LL. I should be working tomorrow, I'll update you guys afterwards with some findings and some pictures if it's slow enough tomorrow morning.

No one has fueled my aircraft but me. In fact, I have only used 100LL once in 200 hours. I still sump check before each flight. My autogas is wheat colored, like JetA.

I am not trying to be mean about the pilot missing this, but the fuel is dyed for a reason and he should have been both checking it, and being able to tell when it's diluted. The main reason to check fuel is to look for color and water.

I dunno man, have you seen a tester with Jet A and AvGas in it at the same time? Sure it's colored but even I was having a hard time picking out where the boundary was, there was close to no color difference. I did it out of curiosity's sake myself, but I can't imagine trying to decide it if it came out of my tanks. Honestly it scared me a bit because if I hadn't known that I was looking for a situation I created I probably wouldn't have noticed it. I was less careful in flight training about it.

 

[alfadog]

I was helping a guy fuel his T-6 and he ended up bringing the nozzle too high and absolutely blasting me and himself with avgas. By the time he put the last few gallons in, his socks (which took most of the hit) were close to dry. The smell was still there, but much less powerful.

Compare that to the first time I fueled a helicopter with the angle nozzle on it - I didn't quite stop fast enough and sent Jet A spraying all over me, as well as some from the sky afterwards.

I went to walmart to grab a couple quick things after work (hours later) and the crowd actually split around me from the smell. Cool if you don't mind your skin drying out and the awful smell. Much more potent after a while than the 100LL. I should be working tomorrow, I'll update you guys afterwards with some findings and some pictures if it's slow enough tomorrow morning.

Cool. The definitive field test is to put a drop of pure gas and a drop of contaminated gas side by side on a sheet of white paper and let them dry. The contaminated fuel will leave a halo after the gas evaporates.

 

[dell30rb]

I was helping a guy fuel his T-6 and he ended up bringing the nozzle too high and absolutely blasting me and himself with avgas. By the time he put the last few gallons in, his socks (which took most of the hit) were close to dry. The smell was still there, but much less powerful.

Compare that to the first time I fueled a helicopter with the angle nozzle on it - I didn't quite stop fast enough and sent Jet A spraying all over me, as well as some from the sky afterwards.

I went to walmart to grab a couple quick things after work (hours later) and the crowd actually split around me from the smell. Cool if you don't mind your skin drying out and the awful smell. Much more potent after a while than the 100LL. I should be working tomorrow, I'll update you guys afterwards with some findings and some pictures if it's slow enough tomorrow morning.

Can you douse yourself with a mixture of 100LL and Jet A and then let us know how that is?

 

[dell30rb]

The pilot was a good friend of mine. I am positive Freddy did not forget to sump. I hope that if you all have an accident, you don't get the Monday morning QBing that is going on here. God speed Freddy ... you're sorely missed already.

Sorry to hear about your friend.

 

[overdrive148]

Can you douse yourself with a mixture of 100LL and Jet A and then let us know how that is?

Next you'll be asking me to light a match!

 

[alfadog]

Re the fuel issues, this is on my YT channel. Skip ahead to 9:30. Sorry about the poor quality, these are rips off old FAA VHS tapes.

 

[James331]

Cool. The definitive field test is to put a drop of pure gas and a drop of contaminated gas side by side on a sheet of white paper and let them dry. The contaminated fuel will leave a halo after the gas evaporates.

....and I'm going to do that while the pt is being loaded into the plane?

"Hey anyone have a white sheet of paper, I need to test the fuel real quick"

"You need EMS power and AC on right now? Hang on, hang on, the fuel is drying"

 

[Jaybird180]

I dunno man, have you seen a tester with Jet A and AvGas in it at the same time? Sure it's colored but even I was having a hard time picking out where the boundary was, there was close to no color difference. I did it out of curiosity's sake myself, but I can't imagine trying to decide it if it came out of my tanks. Honestly it scared me a bit because if I hadn't known that I was looking for a situation I created I probably wouldn't have noticed it. I was less careful in flight training about it.

Good point right there!

 

[N747JB]

Sorry for your loss. Good or bad aviation forums are filled with Monday morning QB's, including me. Hopefully, some good will come of it, whether it's people paying more attention to fueling operations or sumping.

The pilot was a good friend of mine. I am positive Freddy did not forget to sump. I hope that if you all have an accident, you don't get the Monday morning QBing that is going on here. God speed Freddy ... you're sorely missed already.

 

[alfadog]

....and I'm going to do that while the pt is being loaded into the plane?

"Hey anyone have a white sheet of paper, I need to test the fuel real quick"

"You need EMS power and AC on right now? Hang on, hang on, the fuel is drying"

No, you do that if you do not like the way the fuel feels or smells. Or you can pay to have the tanks emptied and refilled.. or you can take off with the doubt in your mind because you could not figure out how to find a piece of paper.

 

[jordane93]

I dunno man, have you seen a tester with Jet A and AvGas in it at the same time? Sure it's colored but even I was having a hard time picking out where the boundary was, there was close to no color difference. I did it out of curiosity's sake myself, but I can't imagine trying to decide it if it came out of my tanks. Honestly it scared me a bit because if I hadn't known that I was looking for a situation I created I probably wouldn't have noticed it. I was less careful in flight training about it.

Jet fuel will evaporate a lot slower than avgas. It is also thicker and has a more oily feeling to it

 

[zaitcev]

Where did the JetA come from? Was the plane filled from the JetA truck? Was the Av-gas truck filled with JetA? Was the fuel farm Av-gas tank filled with JetA?

It appears that the fuel facilities were not compromised. The receipt was printed for Jet-A, if you read the report.

 

[CTLSi]

I was helping a guy fuel his T-6 and he ended up bringing the nozzle too high and absolutely blasting me and himself with avgas. By the time he put the last few gallons in, his socks (which took most of the hit) were close to dry. The smell was still there, but much less powerful.

Compare that to the first time I fueled a helicopter with the angle nozzle on it - I didn't quite stop fast enough and sent Jet A spraying all over me, as well as some from the sky afterwards.

I went to walmart to grab a couple quick things after work (hours later) and the crowd actually split around me from the smell. Cool if you don't mind your skin drying out and the awful smell. Much more potent after a while than the 100LL. I should be working tomorrow, I'll update you guys afterwards with some findings and some pictures if it's slow enough tomorrow morning.



I dunno man, have you seen a tester with Jet A and AvGas in it at the same time? Sure it's colored but even I was having a hard time picking out where the boundary was, there was close to no color difference. I did it out of curiosity's sake myself, but I can't imagine trying to decide it if it came out of my tanks. Honestly it scared me a bit because if I hadn't known that I was looking for a situation I created I probably wouldn't have noticed it. I was less careful in flight training about it.

Correct. That's why no one fuels the plane but me. There is no way to tell if JetA is in the tanks by color because autogas is virtually the same color.

But you should be able to clearly tell when 100LL blue is mixed with JetA wheat.

 

[overdrive148]

Correct. That's why no one fuels the plane but me. There is no way to tell if JetA is in the tanks by color because autogas is virtually the same color.

But you should be able to clearly tell when 100LL blue is mixed with JetA wheat.

I thought so too, but the colors were nowhere near strong enough. I'll take pics tomorrow and show you what I mean. The only difference I could pick out was the consistency - one was clear, one was swirling, and there was no clear boundary between them. I might add in some water to show the boundary being so apparent.

//edit
Also, I drive way more than I fly - if I was putting Mogas in my plane, I would almost instantly tell the difference in smell. If not only because Jet A is terrible, but because I'm much more familiar with the smell of Mogas.

 

[Jaybird180]

It appears that the fuel facilities were not compromised. The receipt was printed for Jet-A, if you read the report.

Good catch. I didn't think to look at the NTSB report.

The pilot then assisted the line service technician with replacing both fuel caps. They both walked into the office and the pilot signed the machine printed fuel ticket....

A postaccident review of refueling records and interviews with line service technicians showed that the airplane had been misfuelled with 40 gallons of Jet A fuel instead of the required 100LL aviation gasoline.

So we know about PIC responsibility, however will the ground crew share some of this responsibility?