ANC20LA050

NTSB accident investigation · Rockwell 500 · Aniak, AK · May 29, 2020

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
May 28, 2020, 16:00 local (May 29, 2020, 00:00 UTC)
Place
Aniak, AK
Injuries
4 serious
Damage
Substantial damage
Phase of flight
Prior to flight
Aircraft
N909AKRockwell 500
Defining event
Prior to flight: Wrong fuel
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Alaska Regional Office
Parties
Federal Aviation Administration
FAA report
20200528011569A
Case key
101338

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

A loss of engine power due to the use of improper fuel. Contributing to the accident was the failure of the pilot and ground personnel to ensure that the airplane was serviced with the proper fuel.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Fluids: fuelAircraft › Fluids/misc hardware · Fluid typeAero Commander 500 S: 3 casesAll aircraft: 1,695 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

After landing at the airport, the pilot had ground service personnel refuel the airplane. According to the fueler, he queried the pilot if he wanted Prist with his jet fuel, which the pilot replied, “No.” After completing the refueling process, he returned to his truck, wrote "Jet A" in the meter readings section of the prepared receipt, and presented it to the pilot for his signature. The pilot said that shortly after takeoff, he noticed a reduction in climb performance, and the airplane's engines began to lose power. Unable to maintain altitude, he selected an area of shallow water-covered terrain as a forced landing site. During the landing, the airplane sustained substantial damage. A postaccident examination revealed that the airplane, which was equipped with reciprocating engines, had been inadvertently serviced with Jet A turbine fuel. A slightly degraded placard near the fuel port on the top of the wing stated, in part: "FUEL 100/100LL MINIMUM GRADE AVIATION GASOLINE ONLY CAPACITY 159.6 US GALLONS." In an interview, the fueler who serviced the airplane stated that he did not see a fuel placard near the fueling port.

Factual narrative

On May 28, 2020, about 1600 Alaska daylight time, an Aero Commander 500S airplane, N909AK sustained substantial damage when it was involved in an accident near Aniak, Alaska. The pilot and three passengers sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 public aircraft flight. The airplane was owned by the State of Alaska and operated by the Division of Forestry. According to the pilot, after arriving in Aniak, he had the local fuel vendor's ground service personnel refuel the airplane. He then signed the fuel receipt, and he returned to the airplane's cockpit to complete some paperwork before departure. Once the paperwork was complete, he then loaded his passengers, started the airplane's engines, and taxied to Runway 29 for departure. The pilot said that shortly after takeoff, and during initial climb, he initially noticed what he thought was mechanical turbulence followed by a reduction in climb performance, and the airplane's engines began to lose power. Unable to maintain altitude and while descending about 400 ft per minute, he selected an area of shallow water covered terrain as an off-airport landing site. The airplane sustained substantial damage during the landing. The fueler reported that he was unfamiliar with the airplane, so he queried the pilot as to where he should attach the grounding strap and the location of the fuel filler port. Before starting to refuel the airplane, he asked the pilot "do you want Prist with your Jet" to which the pilot responded that he did not. After completing the refueling process, he returned to his truck, wrote "Jet A" in the meter readings section of the prepared receipt, and presented it to the pilot for his signature. The pilot signed the receipt and was provided a copy. The fueler stated that he later added "no Prist" to his copy of the receipt, and that he did not see a fuel placard near the fueling port. A postaccident examination revealed that the reciprocating engine airplane had been inadvertently serviced with Jet A fuel. A slightly degraded placard near the fuel port on the top of the wing stated, in part: "FUEL 100/100LL MINIMUM GRADE AVIATION GASOLINE ONLY CAPACITY 159.6 US GALLONS." (see Figure 1.) Figure 1 - Fuel placard on accident airplane located near fueling port.

Aircraft

Registration
N909AK
Reported as
Rockwell 500 (S)
Category
Airplane
Serial number
3232
Built
1975
Airframe hours
6,966.4
Engines
Lycoming IO-540 SER, 325 horsepower, reciprocatingLycoming IO-540 SER, 325 horsepower, reciprocating
Damage
Substantial damage
Flight
Public aircraft - state · Public use
Operator
State Of Alaska
Registered owner
State Of Alaska
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 5, 2020
Departed
Aniak, AK
Destination
Soldotna, AK
Flight plan
Company VFR
Equipment
Electronic primary flight display, Electronic multifunction display, Auto-pilot, ADS-B, Stall warning system, Satellite tracking device

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
53
Injuries
Serious
Certificates
Flight instructor, Airline transport, Commercial
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Left
Flight hours
4,869 total · 30 in this make and model · 4,003 as pilot in command · 40 in the last 90 days · 40 in the last 30 days · 4.5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Visibility
10 statute miles
Lowest ceiling
12,000 ft overcast
Temperature
59 °F, dew point 36 °F
Altimeter
30.15 inHg

Docket · 5

The files NTSB released with the investigation on November 12, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.4 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.