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Thu, Mar 26, 2009

Factual Report Implies Fueling Error Led To Emergency Landing

Lineman Admitted To Not Following Proper Procedures

A lineman's confusion appears to have been behind the January 2009 emergency landing of a Cessna 421C Golden Eagle in Wichita, KS, according to the National Transportation Safety Board's factual report on the mishap.

According to the report, the piston-engined twin (similar to type shown above) departed Wichita's Colonel James Jabara Airport (AAO) shortly after 8:00 am local time January 30, bound for Millard Airport (MLE) west of Omaha, NE. It didn't take very long for problems to arise.

"During takeoff, the pilot noted 2,800 rpm, 39 inches of manifold pressure, and all engine instruments were 'in the green,'" the report states. "While climbing to 3,000 feet mean sea level, the airplane's engines began to lose power. The pilot noted propeller rpms were still 2,800 but felt as though no "power" was being produced by the engines; the pilot coordinated for an emergency return. While attempting to troubleshoot the malfunction, the pilot assessed that he could not return to the airport and elected to perform a forced landing."

The aircraft landed gear-up in a field. The pilot and his two passengers suffered minor injuries, but came through the scrap relatively OK. Investigators arrived on-scene soon after... and it didn't take them long to find a problem.

"An examination of the airplane revealed that the fuel tanks contained what appeared to be a mixture of 100 low-lead (100LL) and Jet-A fuel," the NTSB says.

When questioned by FAA inspectors, a lineman at AAO admitted he topped off the Cessna 421 with 80 gallons of Jet-A, not 100LL. He then offered an interesting explanation.

Two Piper PA-46 turboprop conversions were also based at AAO at the time of the incident. Those aircraft are not required under the JetProp STC to have modified fuel filler ports, those with larger openings to accommodate flattened Jet-A fuel nozzles; an adapter is used to move fuel into the narrower Malibu-spec opening.

However, the lineman told investigators FBO personnel had discovered a work-around: by rotating the nozzle, and dispensing fuel at reduced pressure, one can leave the adapter in the truck. "This method became the normal way for the accident line person to refuel the two converted PA-46 airplanes," the NTSB states, "so the line person reported that he incorrectly thought the accident airplane required Jet-A fuel despite having refueled the accident airplane several times previously."

The NTSB notes the 421 had narrow fueling ports required by an airworthiness directive, specifically intended to prevent the kind of error the lineman admitted to. The Cessna 421's basic fuselage is shared with the turboprop-engined Cessna 425 Conquest I; several 421s have also been converted to turboprops.

The report notes the pilot conducted a "normal" pre-flight inspection ahead of the accident flight. He had asked the FBO to top off the tanks upon landing at AAO the night before.

FMI: Read The Factual Report

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