# NTSB CEN20FA002: Piper Aerostar 602P, N326CW, Kokomo, IN, October 5, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: October 5, 2019, 16:37 local (20:37 UTC) - Place: Kokomo, IN - Coordinates: 40.474998, -86.063331 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.4750&lon=-86.0633&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Federal Aviation Administration; Indianapolis FSDO - NTSB case key (mKey): 100366 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20FA002 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100366/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100366 - Page: https://openairdocs.org/ntsb/CEN20FA002 ## Probable cause The pilot's exceedance of the airplane’s critical angle of attack following a dual engine power loss caused by the line service technician fueling the airplane with the wrong fuel, which resulted in an aerodynamic stall and subsequent loss of control. Contributing was the pilot's inadequate supervision of the fuel servicing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Incorrect use/operation (probable cause); cases with it: [Piper AEROSTAR 602P, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7106014), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Piper AEROSTAR 602P, 1 case](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=7106014), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper AEROSTAR 602P, 1 case](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=7106014), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Ground crew (probable cause); cases with it: [Piper AEROSTAR 602P, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=7106014), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper AEROSTAR 602P, 2 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7106014), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Fuel contamination](https://openairdocs.org/ntsb-events/193); cases with it: [Piper AEROSTAR 602P, 1 case](https://openairdocs.org/ntsb-events/193/sequence.md?model=7106014), [All aircraft, 225 cases](https://openairdocs.org/ntsb-events/193/sequence.md) - [Maneuvering: Fuel contamination](https://openairdocs.org/ntsb-events/193); cases with it: [Piper AEROSTAR 602P, 1 case](https://openairdocs.org/ntsb-events/193/sequence.md?model=7106014), [All aircraft, 225 cases](https://openairdocs.org/ntsb-events/193/sequence.md) - [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper AEROSTAR 602P, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=7106014), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Maneuvering: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Piper AEROSTAR 602P, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=7106014), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper AEROSTAR 602P, 3 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7106014), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The airline transport pilot arrived at the departure airport in the reciprocating engine-powered airplane where it was fueled with Jet A jet fuel by an airport employee/line service technician. A witness stated that she saw a "low flying" airplane flying from north to south. The airplane made a "sharp left turn" to the east. The left wing "dipped low" and she then lost sight of the airplane, but when she approached the intersection near the accident site, she saw the airplane on the ground. The airplane impacted a field that had dry, level, and hard features conducive for an off-airport landing, and the airplane was destroyed. The wreckage path length and impact damage to the airplane were consistent with an accelerated stall. Postaccident examination of the airplane found Jet A jet fuel in the airplane fuel system and evidence of detonation in both engines from the use of Jet A and not the required 100 low lead fuel. Use of Jet A rather than 100 low lead fuel in an engine would result in detonation in the cylinders and lead to damage and a catastrophic engine failure. According to the Airplane Flying Handbook, the pilot should witness refueling to ensure that the correct fuel and quantity is dispensed into the airplane and that any caps and cowls are properly secured after refueling. ## Factual narrative The Airplane Flying Handbook (FAA-H-8083-38), Chapter 2, Ground Operations, stated in part: "Jet fuel has disastrous consequences when introduced into AVGAS burning reciprocating airplane engines. A reciprocating engine operating on jet fuel may start, run, and power the airplane for a time long enough for the airplane to become airborne only to have the engine fail catastrophically after takeoff. Jet fuel refueling trucks and dispensing equipment are marked with JET-A placards in white characters on a black background. Because of the dire consequences associated with misfueling, fuel nozzles are specific to the type of fuel. AVGAS fuel filler nozzles are straight with a constant diameter. However, jet fuel filler nozzles are flared at the end to prevent insertion into AVGAS fuel tanks. Using the proper, approved grade of fuel is critical for safe, reliable engine operation. Without the proper fuel quantity, grade, and quality, the engine(s) will likely cease to operate. Therefore, it is imperative that the pilot visually verify that the airplane has the correct quantity for the intended flight plus adequate and legal reserves, as well as inspect that the fuel is of the proper grade and that the quality of the fuel is acceptable. The pilot should always ensure that the fuel caps have been securely replaced following each fueling." "During refueling operations, it is advisable that the pilot remove all passengers from aircraft during fueling operations and witness the refueling to ensure that the correct fuel and quantity is dispensed into the airplane and that any caps and cowls are properly secured after refueling." On-scene inspection of the fuel truck used to refuel the airplane revealed that the truck had markings "JET A.". The owner of the accident airplane stated he was supposed to receive initial training in the airplane from In Flight Review, Inc., but it never happened for "various reasons." He stated that he never gave permission for the accident pilot to fly the airplane. The owner declined to provide more information as who he gave the airplane keys to. On October 5, 2019, about 1637 eastern daylight time, a Piper Aerostar 602P, N326CW, was destroyed when it was involved in an accident near Kokomo, Indiana. The airline transport pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight. According to the airport employee who fueled the airplane, during the pilot’s approach to the Kokomo Municipal Airport (OKK), Kokomo, Indiana, he asked if the pilot wanted jet fuel, and the pilot said "yes." He said that the airplane looked like a jet airplane. When the airplane arrived, the employee parked the Jet A fuel truck in front of the airplane while the pilot was still inside the airplane. The employee said that he asked the pilot again if he was wanted jet fuel, and the pilot said "yes." The employee fueled the airplane with about 163 gallons of Jet A from the fuel truck. Theemployee said that he was able to orient the different-shaped nozzle (relative to the 100 low lead fuel truck nozzle) from the Jet A fuel truck by positioning it 90° over the wing fuel tank filler necks and about 45° over the fuselage filler necks. He said that he initially spilled about 1 gallon of fuel during refueling and adjusted his technique so subsequent fuel spillage was minimal. The student pilot, who received recurrent training from the accident pilot, said that when she arrived in her vehicle to meet the accident pilot, he was walking between the fuel truck that was parked by the airplane and her vehicle. She said that the accident pilot began training right away about 1045. They completed training, and after 1630, the student pilot drove the accident pilot to the airplane. The student pilot said the accident pilot visually checked the fuel tanks of the airplane to ensure they were fueled up and gave a "thumbs-up" to the student pilot. The student pilot did not stay for the rest of the accident pilot's preflight inspection and drove off. The student pilot heard the engines start and "they sounded normal." The student pilot did not see the takeoff. The student pilot said the winds favored runway 14, which was in use on the day of the accident. A witness, on a nearby road, stated that she saw a "low flying" airplane flying from north to south. The airplane made a "sharp left turn" to the east. The left wing "dipped low" and she then lost sight of the airplane, but when she approached the intersection near the accident site, she saw the airplane on the ground. The airport employee said that he was inside the fixed base operator building about 1620 when he heard the engines start. After the engines started, the engines sounded "typical." He said that he did not hear any radio transmissions from the pilot during his departure and did not hear an engine runup. There were no pilot records provided to the National Transportation Safety Board (NTSB) Investigator-in-Charge (IIC) indicating the pilot's flight experience and a recent flight review as required under Part 61.56 received from the accident pilot's wife after two requests were made to her. On November 28, 2008, the pilot was involved in an aviation accident that was investigated under NTSB accident identification number: ERA09CA073. On December 2, 2016, the Federal Aviation Administration terminated the pilot's designation as a pilot examiner due to sub-standard performance while conducting examinations. On November 9, 2018, the pilot reported his flight experience that included 7,500 total hours and 200 hours in last six months as of his last airman medical exam. On-scene examination of the airplane revealed the airplane wreckage path was about 328 ft in length along an approximate heading of 046° on a dry and hard surfaced fallow bean field. The wreckage and the wreckage path displayed features consistent with an accelerated stall. On-scene examination revealed the presence of aclear liquid consistent in color, viscosity, oiliness, and odor with that of Jet A jet fuel in a fuselage tank and in the fuel lines leading to the fuel manifolds of both engines. Several of the engine spark plugs exhibited damage consistent with detonation. Flight control continuity was confirmed. The landing gear was in the retracted position. ## Aircraft - Registration: [N326CW](https://openairdocs.org/deregistered/N326CW-2019-12-05), registration cancelled 2019-12-05, S/N 62P08698165008 (OpenAirDocs) - Reported make and model: Piper AEROSTAR 602P - Registry model: [Piper AEROSTAR 602P](https://openairdocs.org/model/piper-aerostar-602p) (registry code 7106014) (OpenAirDocs) - Registry engine: [Lycoming IO-540 series](https://openairdocs.org/engine/lycoming-io-540-series) (registry code 41530, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 62P08698165008 - Year built: 1981 - Airframe hours: 3002.3 - Engines: Lycoming IO-540-AA1A5 reciprocating; Lycoming IO-540-AA1A5 reciprocating - Damage: Destroyed - Flight: Business, Part 91 - Operator: Pilot - Registered owner: Indiana Paging Network Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 22, 2019 - Departed: OKK, Kokomo, IN - Airport: OKK, Kokomo Municipal Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 59; injuries: fatal; flight instructor, commercial, airline transport; airplane ratings: multi-engine land, single-engine land, single-engine sea; medical: class 2, with waivers/limitations; seat: left; toxicology performed; flight hours: 7,500 total ## Weather - Conditions: Visual (VMC), Day - Wind: 140° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 46 °F - Altimeter: 30.01 inHg - Observed at: OKK, 3 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 20191005015609A](https://openairdocs.org/incident/20191005015609A), Oct 5, 2019: Piper AEROSTAR 602P, Kokomo, IN, Destroyed, 1 fatal. On October 5, 2019, at approximately 1702 EDT, N326CW, a Piper PA-60-602P Aerostar, impacted terrain shortly after departure from the Kokomo Municipal Airport… ## Docket (15 files) The files NTSB released with the investigation on July 22, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100366. 196 MB in all. - Record of conversation - janice klien (item 1, PDF, 1 page, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11373522&FileExtension=pdf&FileName=RECORD%20OF%20CONVERSATION%20-%20Witness%20Janice%20Klien-Rel.pdf - Wreckage diagram (item 2, PDF, 1 page, 185 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8545727&FileExtension=pdf&FileName=Wreckage%20Diagram-Rel.pdf - Record of examination (item 3, PDF, 1 page, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11372352&FileExtension=pdf&FileName=RECORD%20OF%20EXAMINATION%20MASTER-Rel.pdf - Written statement - john yootz (item 4, PDF, 1 page, 19.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8561075&FileExtension=pdf&FileName=Written%20Statement%20John%20Yootz%20Master_Redacted-Rel.pdf - Record of interview - john yoont (item 5, PDF, 2 pages, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8543174&FileExtension=pdf&FileName=RECORD%20OF%20INTERVIEW%20John%20Yoont-Rel.pdf - Written statement - laura stants (item 6, PDF, 1 page, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8562787&FileExtension=pdf&FileName=Statement%20laura%20stants%20master_Redacted-Rel.pdf - Record of interview - laura stants (item 7, PDF, 2 pages, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8543183&FileExtension=pdf&FileName=RECORD%20OF%20INTERVIEW%20Laura%20Stants-Rel.pdf - Wreckage release (item 8, PDF, 1 page, 571 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8545903&FileExtension=pdf&FileName=N326CW%20Signed%20Wreckage%20Release%20Master_Redacted-Rel.pdf - Airplane flying handbook, chapter 2 (item 9, PDF, 20 pages, 7.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8560093&FileExtension=pdf&FileName=04_afh_ch2-Rel.pdf - Ac 20-122A (item 10, PDF, 3 pages, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8561020&FileExtension=pdf&FileName=AC_20-122A_Redacted-Rel.pdf - Ac 20-116 (item 11, PDF, 2 pages, 336 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8561282&FileExtension=pdf&FileName=AC_20-116_Redacted-Rel.pdf - Gama specification no. 3 (item 12, PDF, 17 pages, 732 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8560768&FileExtension=pdf&FileName=gama_specification_3_fueldecals_july_1982_pdf_498caaf984-Rel.pdf - Aircraft logs (item 13, PDF, 192 pages, 161 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11370920&FileExtension=pdf&FileName=Aircraft%20Records%20Excerpt%20Master-Rel.pdf - Photo log (item 14, PDF, 6 pages, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11373354&FileExtension=pdf&FileName=Photo%20Log-Rel.pdf - FAA toxicology report (item 15, PDF, 1 page, 252 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11374860&FileExtension=pdf&FileName=FAA%20Toxicology%20MASTER_Redacted-Rel.pdf 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.