# NTSB ATL03TA078: Aero Commander 500S, N19WL, Mount Pleasant, SC, April 14, 2003 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Final report - Date: April 14, 2003, 11:40 local (15:40 UTC) - Place: Mount Pleasant, SC - Coordinates: 32.897777, -79.782775 - Nearby events: https://openairdocs.org/map.md?lat=32.8978&lon=-79.7828&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report June 28, 2006 - Report: Approved by Office Director - Parties: Columbia FSDO - NTSB case key (mKey): 56814 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL03TA078 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56814/pdf - Page: https://openairdocs.org/ntsb/ATL03TA078 ## Probable cause The improper refueling of the airplane by airport personnel with the incorrect fuel grade that resulted in a total loss in engine power on both engines during initial climb. A factor was the inadequate preflight inspection by the pilot in command. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, takeoff - initial climb - fluid,fuel grade - incorrect (cause) - refueling - improper, airport personnel (cause) - all engines - failure,total - aircraft preflight - inadequate, pilot in command (contributing factor) - Forced landing, descent - emergency - In flight collision with terrain/water, emergency landing - terrain condition - ground ## Analysis According to the pilot, he requested the refueler to top off his fuel tanks with "100 low lead fuel". After refueling, the pilot performed a preflight including taking fuel samples from under the wings, draining the rear fuel drain, and checking the fuel cap for security. The engine start, run-up, and taxi were uneventful. The airplane departed runway 17 and was in a positive rate of climb. At approximately 200 feet AGL the airplane began to lose power. Shortly after the pilot ensured that the throttle, propeller, and mixture controls were in the full forward position, the airplane lost power in both engines. The pilot executed an emergency off field landing. Examination of the wreckage revealed that the left wing had broken off and the aft cabin area was crushed. According to the refueler, he stated that he mistakenly used the Jet-A fuel truck instead of the AVGAS 100 low lead truck, and pumped 58 gallons of Jet-A into the airplane. Examination of the fuel samples taken from both engines revealed the left and right engine contained 70 percent of jet A fuel. ## Factual narrative On April 14, 2003, at 1140 eastern daylight time, an Aero Commander 500S, N19WL, registered to and operated by the South Carolina Department of Natural Resources, collided with the ground following a total loss of power in both engines at East Cooper Airport, Mount Pleasant, South Carolina. The public use flight was operated under the provisions of Title 14 Part 91 and visual flight rules. Visual meteorological conditions prevailed at the time of the accident. The airplane was destroyed, and the airline transport pilot and passenger received serious injuries. The flight departed East Cooper Airport, Mount Pleasant, South Carolina, at 1130, on April 14, 2003. According to the pilot, he requested the refueler to top off his fuel tanks with "100 low lead fuel". The refueler informed the pilot of the amount of gallons of fuel he placed on the airplane and had the pilot sign the fuel ticket. The pilot performed a preflight including taking fuel samples from under the wings, draining the rear fuel drain, and checking the fuel cap for security. The engine start, run-up, and taxi were uneventful. The airplane departed runway 17 on the initial take-off climb. At approximately 200 feet AGL the airplane began to lose power. The pilot ensured that the throttle, propeller, and mixture controls were in the full forward position. The pilot then rechecked that the landing gear was up and that the flap handle was in the up position. The airplane lost full power in both engines, and the pilot executed an emergency off field landing. Examination of the wreckage revealed that the left wing had broken off and the aft cabin area was crushed. According to a lineman employee at Aero-East, he spoke to the refueler shortly after the accident. The refueler explained to the lineman at the time of the accident he was refueling a helicopter as he watched the airplane takeoff. He indicated that the airplane did not seem to be making full power as it leveled off, bank to the left and collided with trees. The lineman asked the refueler if he had refueled the airplane, and he said that he had refueled the airplane with 58 gallons of fuel. The manager of Aero-East ordered all fueling operations stopped, fueling records secure, and fuel samples taken from the 100LL AVGAS truck. The lineman checked the fueling receipts and found a discrepancy on the fuel receipt for the accident airplane. The word "AVGAS" had been handwritten over the product description. The lineman checked the other fueling records and found that the fuel truck logs were also altered. In an interview with the refueler, he stated that he mistakenly used the Jet-A fuel truck instead of the AVGAS 100 low lead truck, and he had pumped 58 gallons of Jet-A into the airplane. The refueler affirmed that the paper work errors were to keep the product inventory in balance because he thought he made wrong entries on the other forms. The document entry changes were made prior to the accident. Fuel samples from the AVGS truck, JET-A truck, left engine and right engine were sent to General Engineering Laboratories, LLC for a fingerprint analysis. Both samples of fuel taken from the left and right engine contained approximately thirty percent AVGAS 100 low lead and seventy percent Jet-A fuel. ## Aircraft - Registration: [N19WL](https://openairdocs.org/deregistered/N19WL-2004-10-08), registration cancelled 2004-10-08, S/N 3160, built 1973 (OpenAirDocs) - Reported make and model: Aero Commander 500S - Registry model: [Aero Commander 500 S](https://openairdocs.org/model/aero-commander-500-s) (registry code 0141107) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 3160 - Airframe hours: 11617 - Engines: Lycoming IO-540-E1B5 290 horsepower reciprocating - Damage: Destroyed - Flight: Public aircraft, Part 91 - Operator: John William Madden - Registered owner: South Carolina Department of Natural Reasoures - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 6, 2002, 94 hours before - Departed: 8S5, MOUNT PLEASANT, SC - Destination: 8S5, MOUNT PLEASANT, SC - Flight plan: Company VFR - Airport: 8S5, East Cooper, runway 17, 3,700 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 39; injuries: serious; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane, helicopter; medical: class 2, valid medical--no waivers/lim.; last flight review December 9, 2001; seat: left; flight hours: 4,578 total, 280 in this make and model, 4,301 as pilot in command, 43 in the last 90 days, 15 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 160° at 12 knots, gusting 15 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 55 °F - Altimeter: 30.29 inHg - Observed at: CHS, 1 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20030414005259A](https://openairdocs.org/incident/20030414005259A), Apr 14, 2003: Gulstm 500S, Mt Pleasant, SC, Destroyed. (-23) Pilot in command reported that shortly after take-off at approximately 100 feet with the gear up both engines quit operating. The aircraft crashed in a… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.