The Holidays are Coming!
We are rapidly approaching the year's biggest holidays. Regardless of which holidays you celebrate and how you choose to celebrate them, some holiday travel via general aviation might be in your future. Our video, " Holiday Travel Hazards," can help you be safer. Even if you have watched it before, refresher training is always valuable. Check it out here.
New Episode of "Old Pilot Tips"
Our new Episode 13 of "Old Pilot Tips" is now available. The title of this episode is "The Drowning Brain." In less than one minute it provides a valuable tip on planning restroom stops to avoid the "Drowning Brain" syndrome. Check it out here.
"Just this Once-Fuel"
The next offshoot of our "Just this Once" program is now available on YouTube. This edition addresses fuel exhaustion, fuel management, and fuel contamination from our "Just this Once" perspective. Check it out here.
A Startling Reminder
Richard McSpadden, the senior vice president of the AOPA Air Safety Institute, died along with one other person in the crash of a Cessna 177RG near Lake Placid Airport (KLKP) in upstate New York on October 1. Richard was a respected expert in aviation safety, not only from his work with AOPA, but as a former Air Force pilot and commander of the Thunderbirds. It will be some time before the NTSB will issue a probable cause for the crash and exactly what happened may never be determined. Richard was in the right seat and another rated pilot was in the left seat. At this point we do not know who was acting as PIC or which pilot was flying at the time of the crash. The lesson from this tragedy that I think Richard would want us to learn is that accidents do not just happen to inexperienced pilots or to those who have not been well trained. The risks are always there and we owe it to ourselves, our families and to our passengers to manage those risks to the best of our ability. The NTSB has released the preliminary accident report. Click here to download it from the NTSB website.
The Holiday Season can be Exhausting
Preparation for and participation in holiday events can take a toll on our performance. If we pair that with the increased likelihood of conducting a flight during the holiday season, we can be setting ourselves up for trouble. Check out this "Pilot Minute" video from the Federal Air Surgeon.
One is the Loneliest Number
The great Roy Orbison had a hit record in 1960 with the “One is the Loneliness Number.” The lyrics were based on a lost teenage love. What was once a loving couple is now reduced to just one person and that person is lonely. I do not usually write about love, teenage or any other age, and I promise not to sing. (You’re welcome.)
But there is a loose relationship to flying airplanes here. We enjoy the loving relationship between air and fuel when it comes together in the engine. The shared love spreads so much happiness that the pistons and valves do a dance and the engine is inspired to produce power. All too frequently, air suffers from loneliness when its partner, the fuel, is missing. Broken hearted air just becomes so lonely that it cannot function alone and the engine becomes so depressed that the dance slows and the engine loses its inspiration to produce power.
I recently decided to do some research into “engine issues” as listed, usually several times, in each of the Aviation Safety and Reporting System (ASIAS) daily postings from the FAA. I was trying to learn why so many of our generally reliable airplane engines were having “issues” that were resulting in accidents and incidents.
I expected to find that maintenance was being neglected. I was surprised to learn that the engines were not having “issues” but were much more frequently losing power in flight because of lonely air. In the date range I selected for my survey of accidents in which the investigation had been completed, I found 94 entries with the word “engine” in the probable cause. When I included both “engine” and “fuel” in my probable cause search, the number of entries decreased to 47. I was surprised to learn that about half of the so called “engine issues” are not really engine issues at all but are really fuel related. Those air molecules get very lonely without their partners, the fuel molecules.
The NTSB uses the term “fuel exhaustion” when the fuel supply in the aircraft is depleted, while the term “fuel starvation” sometimes indicates fuel was onboard the airplane but could not reach the engine for whatever reason. Fuel contamination indicates a foreign substance, most commonly water, is in the fuel supply. Sometimes fuel contamination is categorized as fuel starvation. Fuel management is generally used to indicate that there was fuel available, but that it was not sent to the engine, perhaps by a pilot’s failure to switch fuel tanks.
As it turns out, very few of the other half of the accidents listed with “engine” in the probable cause had problems with the actual engine. Carburetor ice was a major contributor and other mechanical and human factors played a role.
The fuel related accidents are largely preventable. I was taught early in my flying career that fuel gauges in small general aviation airplanes are not always reliable and that my watch was a much better fuel gauge. I learned from experience that fuel consumption can vary significantly from published figures based on operating conditions, power settings, leaning procedures and more. I learned that while my watch was still a better indicator of fuel usage than the gauges on the panel, planning additional reserve fuel is also prudent. Preflight planning should also schedule an amount of elapsed time into the flight to switch fuel tanks.
I also learned from experience that fuel contamination, especially from water, can be elusive. A quick sample of a few ounces of fuel from each tank does not always provide an accurate indication of fuel purity. Water has a way of hiding in a fuel system. A detailed discussion of detecting fuel contamination is beyond our scope here. Of course, like many other things, prevention is better than cure. Ensuring that fuel caps and their seals are in good shape goes a long way in preventing the fuel contamination accident.
Reprinted from NASA "Callback" Issue 521 June 2023
Unverified Assumptions
Although all ended well, this Flight Instructor overlooked a detail that quickly placed the aircraft and crew in jeopardy.
■ That morning, I met [my student], a private pilot to whom I am providing instrument instruction, at ZZZ1 airport. When I arrived, [the student] had already conducted a preflight inspection of the aircraft.… Unfortunately, I did not verify the fuel quantity in the aircraft and relied on the student to do so. The plan for this flight was to do the RNAV…approach into ZZZ2, go missed [approach], and then fly VFR back to ZZZ1. After the missed approach at ZZZ2 and upon reaching 3,500 feet, the engine quit without warning. I took control of the airplane, requested priority with ZZZ2 Approach, and turned toward ZZZ. I was cleared for the runway and landed…without further incident. We could not restart the plane in the air or on the ground.
There is some background needed at this point. Prior to this flight, I was the last person to fly this plane. As part of our standard practice, after the last flight, I requested fuel service from the FBO and asked that the plane be put away for the night. Assuming the FBO would honor my request, I left for the evening. When I arrived at the airport, my student had completed the preflight and confirmed there was fuel in the aircraft. I’ve flown with this student many times and found him to be a very competent pilot.… Accordingly, I did not have reason to think there was not enough fuel in the aircraft. When we started the plane, we reset the fuel totalizer for full fuel, so when the engine quit, I expected there to be nearly 40 gallons of fuel in the plane when it was, indeed, empty.
There are several lessons to learn here. As an instructor, you can never fully trust your student, even if he or she is a certificated pilot, and it’s important to verify all information. Another factor was expectation bias. As part of our standard practice, the aircraft is always put away with full fuel, and the FBO has never failed to honor this request. When I arrived at the airport, I expected the aircraft to have full fuel, and I expected my student to verify this for me. Another factor is that it is impossible to view the fuel gauges from the right seat on the Cessna Cardinal as they are on the left of the pilot side yoke, so I was unable to use them to verify the fuel state. In order to prevent a recurrence, I am going to suggest to the club that we standardize a way to measure the fuel and to make it a requirement to measure fuel before every flight. The aircraft’s fuel quantity is difficult to check visually since there is a spring-loaded cover over the fuel port. At the end of the day, however, I was the Flight Instructor and should have verified the fuel quantity before departing.
Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.
NTSB Photo
The 87-year-old private pilot escaped injury when his Piper Tri-Pacer crashed due to fuel exhaustion. The crash occurred in Arkansas in October 2022.
The NTSB accident report includes the following: "The pilot reported that he conducted a preflight inspection and filled both of the airplane’s fuel tanks. While enroute, the airplane’s engine lost power. The pilot switched fuel tanks but was unable to restore power. The pilot then conducted a forced landing to a rough field, during which the airplane impacted a hay bale. The airplane sustained substantial damage to the fuselage. Postaccident examination of the airplane revealed that the fuel tanks contained no usable fuel. No other postaccident malfunctions or failures that would have precluded normal operations were found. Immediately following the accident, the pilot stated that he ran out of fuel."
Also included in the NTSB report is this: "The pilot wrote on NTSB Accident/Incident Reporting Form 6120.1 that it was possible either or both fuel tanks were not completely full “due to difficulty with the ladder and fuel pump.”
In the Pilot-Operator Report submitted to the NTSB, the pilot's recommendations as to how the accident could have been prevented includes: "Get a better ladder, and request help in reassuring that fuel tanks are completely full."
NTSB Photo
The NTSB Probable Cause states, "A total loss of engine power due to fuel exhaustion. Contributing to the accident was the pilot’s inadequate preflight inspection."
Photo Source: NTSB
The pilot was clearly aware of the need to verify the fuel quantity aboard the airplane prior to flight. It is quite possible that at the age of 87 he was not able to easily check the fuel quantity visually in a high wing airplane. That is very understandable and it perhaps illustrates the power that our humanness wields in our decision making. Whatever decrease in physical ability that we may have, whether temporary or permanent, opens the door to optimism bias. We have a difficult time admitting to ourselves that we are not able to do something that we once could do easily. Optimism bias steps in and convinces us that it will be okay "Just This Once."
Click here to download the accident report from the NTSB website.
Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.
Photo Source: NTSB
This crash happened in Illinois in January 2023. The 73-year-old pilot reported 12,000 flight hours and held ATP, Commercial, CFI, and Flight Engineer certification. He was not injured in the crash.
The NTSB accident report includes the following: "The pilot reported the engine lost total power while he was on approach to his destination airport. According to the pilot, he attempted to restart the engine by switching fuel tanks, but he may have forgotten to engage the boost pump, and the restart was unsuccessful. The pilot then conducted a forced landing on a freeway, during which the right and left wings sustained substantial damage. Postaccident examination of the airplane revealed that the left fuel tank contained no usable fuel, the right fuel tank had visible but unknown quantity of fuel. After the airplane was recovered from the freeway, a functional engine test run, with the right fuel tank selected, was completed with no anomalies noted. After the accident, the pilot stated that he should have incorporated better fuel management techniques. The loss of engine power was attributed to fuel starvation."
Photo Source: NTSB
The NTSB probable cause states, "The pilot's inadequate fuel management, which resulted in a total loss of engine power due to fuel starvation."
This accident illustrates how easy it is to make a relatively simple mistake that can have serious consequences. With the pilot's extensive experience, he most certainly knew the importance of fuel management. Perhaps a bit of complacency crept in and interfered with the pilot's procedures or perhaps a distraction just before takeoff led to the error.
We can take some simple steps to help counter complacency and other elements of our humanness that interfere with our processes. Effective use of checklists can help. A before takeoff checklist listing something similar to "Fuel selector on fullest tank" or memorizing the engine-failure-in-flight checklist items that might include "Boost pump on" might have prevented the need for the off-airport landing.
Click here to download the accident report from the NTSB website.
Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.
This accident hit home for me. I once had an experience with elusive water hiding somewhere in the fuel system of a Beech Duchess I had recently purchased. I did not experience a power loss, but I flew the airplane several times believing that I had drained out all the water only to find more on the next sample. (A link to download my account of that is included at the end of this accident analysis.)
This crash happened in Georgia in October 2022 and involved a Piper PA-30, Twin Comanche. The 51-year-old commercial pilot-CFI was not injured after a power loss on both engines necessitated a forced landing on a road.
NTSB Photo
The NTSB accident report includes the following: "According to the pilot, he purchased the multiengine airplane about 3 months prior to the accident, then flew it uneventfully to another airport for an annual inspection and to have other maintenance issues addressed. After the annual inspection was completed, several engine runs and taxi checks were performed with no anomalies noted. On the day of the accident, the pilot completed a preflight inspection and intended to fly to his home airport. The mechanic that completed the annual inspection told him that he had drained black sooty water from the fuel tanks. The pilot went out to the airplane and drained water out of the tanks until the fuel was clean and clear. About 5 to 6 minutes into the flight, the left engine began to run rough and lost partial power. When the pilot increased the power on the right engine, the right engine immediately lost all power. He set up for an off-airport landing and noticed a highway, so he lined up with the centerline of the highway and landed. During the landing rollout, the right-wing tip collided with a highway sign. The airplane subsequently rolled off the highway and came to rest upright in a field. Postaccident examination of the airplane revealed substantial damage to the right-wing spar."
NTSB Photo
The NTSB report continues: "Two days after the accident, more water was sumped from both fuel tanks. After the water was removed, both engines ran normally. The pilot added that there were no preimpact mechanical malfunctions with the airplane. Based on this information, it is most likely that the loss of engine power the pilot experienced during the accident flight was due to fuel contamination."
The NTSB probable cause states: "The pilot's inadequate preflight inspection, which resulted in a total loss of engine power during cruise flight due to fuel contamination."
In the Pilot/Operator Report submitted to the NTSB, the pilot provides the following recommendation: "More aggressive measures should have been taken to remove water and sediment from the fuel system and prevent further water ingestion and inlet screen blockage. This would have been done by draining the tanks completely and flushing them out prior to any flight."
The Pilot-Operator Report for this accidents includes a detailed account of the accident flight. It is a bit too long to publish here, but it can be downloaded from the NTSB docket here.
The lesson learned here and from my experience with water contamination is that water in the fuel system can be elusive. If water is detected, simply sampling until no more water is detected is not sufficient. This pilot sampled repeatedly as did I, but water was still there somewhere. It is much better to delay a flight and take whatever measures are necessary to verify that water is no longer present, than to have an accident.
New Edition to the Aviation Safety Series
Thoughts on Being a Better, Safer Pilot - Vol. 3 is now available in e-book format.
Click here to purchase on Amazon for $3.99
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