Pilot Initiated Fuel Transfer, But Failed To Notice As Tank Ran Dry

What happens when you don't properly plan for a flight? Sometimes, the very worst... and the NTSB says that's what happened in the case of an Air Tahoma Convair 580 that went down near Cincinnati in August, 2004.

Investigators found the plane's pilot, Bruno Pichelli of Welland, Ontario, spent most of the flight doing fuel-weight calculations that should have been completed before takeoff. The investigation also found Pichelli initiated a crossfeed fuel transfer about 50-minutes into the flight -- then let it continue unmonitored, while he attended to his calculations.

The fuel shut-off valve was left open during the transfer. As a result, investigators say, the left tank ended up dry. The engines quit, because they were both feeding off the left tank.

As Aero-News reported, the 1950s-era twin-turboprop (file photo of type, below) -- which was carrying cargo for DHL -- went down on a golf course near Florence early in the morning August 13, 2004. Copilot Michael Gelwicks of Southaven, MS was killed in the crash.

"Here again we see the tragedy that can result when time-tested procedures are not respected," said NTSB Acting Chairman Mark V. Rosenker. "The accident also points up the severe consequences that can follow when the operator of an aircraft, or any other vehicle, becomes distracted."

The NTSB's finding of probable cause lists as factors the captain's inadequate preflight planning, his subsequent distraction during the flight, and his late initiation of the in-range checklist." In addition, "the flight crew's failure to monitor the fuel gauges and to recognize that the airplane's changing handling characteristics were caused by fuel imbalance."

The Board also recommended that the FAA issue a flight standards information bulletin to familiarize Convair 580 operators with the circumstances of the Air Tahoma accident, including the importance of closing the fuel tank shutoff valve for the tank not being used during crossfeed operations.

Noting that additional details about the flight crew's actions after the loss of engine power would have aided the investigation, the Board also reiterated a previous recommendation to the FAA (A-99-16), which called for retrofitting airplanes with independently powered cockpit voice recorders.

FMI: www.ntsb.gov