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|
Attributes | |
ACN | 266029 |
Time | |
Date | 199403 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : alo |
State Reference | IA |
Altitude | msl bound lower : 3000 msl bound upper : 3000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : alo |
Operator | general aviation : personal |
Make Model Name | Musketeer 23 |
Operating Under FAR Part | Part 91 |
Flight Phase | descent other landing other |
Flight Plan | None |
Person 1 | |
Affiliation | Other |
Function | flight crew : single pilot |
Qualification | pilot : private pilot : instrument |
Experience | flight time last 90 days : 25 flight time total : 922 flight time type : 15 |
ASRS Report | 266029 |
Person 2 | |
Affiliation | government : faa |
Function | controller : local |
Qualification | controller : non radar |
Events | |
Anomaly | aircraft equipment problem : critical other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : declared emergency other |
Consequence | faa : investigated |
Supplementary | |
Primary Problem | Aircraft |
Narrative:
The flight process began at XA00 am on mar/tue/94 with a call to flight service for a WX briefing followed by a standard preflight of the aircraft. With forecast winds aloft of 30 plus KTS, the flight plan to fort dodge, ia, worked out to 2 hours and 30 mins. A visual check of the fuel tanks showed the right tank to be slightly below the tab, the left slightly above the tab. For this aircraft, that meant 30 gallons of fuel on board. The manual (page attached) calls for a consumption rate of 9 gallons per hour at a power setting of 2450 RPM's. I realized that having a little over 3 hours of fuel didn't leave as much of a margin as I normally liked, but with VFR conditions throughout the route, I reasoned I could stop for fuel prior to fort dodge. My meeting time in fort dodge left plenty of time for this option. Upon departing naper aeronautical (LL10), I set the control to the right tank (lowest) and began to time. My plan was to fly for 1 hour on the right tank and then switch to the left. By doing so, I would be assured of at least 1 hour flight time from the left tank since it contained more fuel than the right. The first hour of flight brought the right fuel gauge to just below 1/4. I switched to the left and reset the time. I began to feel uncomfortable with my fuel situation at 1 hour and 30 mins into the flight (30 mins fuel burn on the left tank) and made the decision to divert to waterloo for fuel. I contacted waterloo approach 22 mi out and switched back to the right tank feeling confident that every mi I got out of the right tank saved fuel in my 'ace in the hole' left tank. The right tank went dry within 3 mins. I switched to the left tank. At this point, I was about 10 mi from the field and still felt that I had over 30 mins of fuel on the left side. Obviously this was not the case, the left tank went dry mins later. I switched back to the right tank and got a spurt of power, then nothing. I went back to the left and added 5 degrees of bank to take advantage of whatever fuel was in the tank. I restarted the engine and set up best rate of climb to gain whatever altitude I could without sacrificing ground track. The engine died a min later, 1 hour and 55 mins into the flight and 2 mi short of the waterloo airport. I set up for best glide, notified approach that I had an engine failure and prepared for an emergency landing. I landed 100 yards short of runway 30 to the left of the approach lights. Very few accidents are the result of 1 gross error in judgement. They are usually the culmination of small, seemingly unconnected events which when looked back upon make the outcome obvious. I have related the chain of events. I consider myself a safe and conscientious pilot. So how did this safe pilot blunder forth committing the most inexcusable preventable act of aviation which is running his aircraft out of fuel? My partner in the plane requests that the tanks only be topped to the tabs so that we can carry 4 passenger. Fueling to the tabs is an inexact science at best. Obviously, I didn't have the 30 gallons of fuel I expected from the tabs' indications when I preflted the aircraft. I realize that the slight distance below the fuel tab represents a significant reduction in perceived fuel. My first mistake. The manual calls for fuel consumption at my power setting to be 9 gph. I checked on the return flight and found it burns just under 11 gph. I should have noted actual fuel burns in the past as a practice of knowing my aircraft better. The second mistake. Upon reporting the events to my partner, he told me he had ground run the aircraft twice for a total of around 30 mins and hadn't noted the times in the log. As far as the logs were concerned, I was the last to fly the aircraft. Based on my previous flight time, I believed there was more fuel on board than what actually was. Had I compared my last tach time entry to the start time on the log I would have noticed the difference. My third mistake. All of the above rationalization may help my ego but it still boils down to my responsibility to never place myself or a passenger in a position danger due to poor judgement or lack of positive action. No matter what a pilot does, he should always look for ways to further increase the odds of completing his flight safely. Leaving fuel on the ground, runway behind you and altitude above does nothing to tip the scales of safety in your favor. To assure I never repeat this mistake, tanks will be topped at every stop and prior to tie-down. I will strive to be more critical in my decision process. Callback conversation with reporter revealed the following information: reporter stated that the aircraft was not damaged as a result of the forced landing as it was a non obstructed flat area near the airport on which the touchdown was made. The aircraft was a beech musketeer A23-24. He advised that he and his partner have started a new procedure in topping the tanks when the aircraft is put back in the hangar along with shorter planned trips than the fuel supply permits.
Original NASA ASRS Text
Title: PVT PLT OF AN SMA SEL ACFT LANDED SHORT OF THE ARPT AFTER THE ENG QUIT DUE TO FUEL STARVATION. THERE WAS NO DAMAGE TO THE ACFT.
Narrative: THE FLT PROCESS BEGAN AT XA00 AM ON MAR/TUE/94 WITH A CALL TO FLT SVC FOR A WX BRIEFING FOLLOWED BY A STANDARD PREFLT OF THE ACFT. WITH FORECAST WINDS ALOFT OF 30 PLUS KTS, THE FLT PLAN TO FORT DODGE, IA, WORKED OUT TO 2 HRS AND 30 MINS. A VISUAL CHK OF THE FUEL TANKS SHOWED THE R TANK TO BE SLIGHTLY BELOW THE TAB, THE L SLIGHTLY ABOVE THE TAB. FOR THIS ACFT, THAT MEANT 30 GALLONS OF FUEL ON BOARD. THE MANUAL (PAGE ATTACHED) CALLS FOR A CONSUMPTION RATE OF 9 GALLONS PER HR AT A PWR SETTING OF 2450 RPM'S. I REALIZED THAT HAVING A LITTLE OVER 3 HRS OF FUEL DIDN'T LEAVE AS MUCH OF A MARGIN AS I NORMALLY LIKED, BUT WITH VFR CONDITIONS THROUGHOUT THE RTE, I REASONED I COULD STOP FOR FUEL PRIOR TO FORT DODGE. MY MEETING TIME IN FORT DODGE LEFT PLENTY OF TIME FOR THIS OPTION. UPON DEPARTING NAPER AERO (LL10), I SET THE CTL TO THE R TANK (LOWEST) AND BEGAN TO TIME. MY PLAN WAS TO FLY FOR 1 HR ON THE R TANK AND THEN SWITCH TO THE L. BY DOING SO, I WOULD BE ASSURED OF AT LEAST 1 HR FLT TIME FROM THE L TANK SINCE IT CONTAINED MORE FUEL THAN THE R. THE FIRST HR OF FLT BROUGHT THE R FUEL GAUGE TO JUST BELOW 1/4. I SWITCHED TO THE L AND RESET THE TIME. I BEGAN TO FEEL UNCOMFORTABLE WITH MY FUEL SIT AT 1 HR AND 30 MINS INTO THE FLT (30 MINS FUEL BURN ON THE L TANK) AND MADE THE DECISION TO DIVERT TO WATERLOO FOR FUEL. I CONTACTED WATERLOO APCH 22 MI OUT AND SWITCHED BACK TO THE R TANK FEELING CONFIDENT THAT EVERY MI I GOT OUT OF THE R TANK SAVED FUEL IN MY 'ACE IN THE HOLE' L TANK. THE R TANK WENT DRY WITHIN 3 MINS. I SWITCHED TO THE L TANK. AT THIS POINT, I WAS ABOUT 10 MI FROM THE FIELD AND STILL FELT THAT I HAD OVER 30 MINS OF FUEL ON THE L SIDE. OBVIOUSLY THIS WAS NOT THE CASE, THE L TANK WENT DRY MINS LATER. I SWITCHED BACK TO THE R TANK AND GOT A SPURT OF PWR, THEN NOTHING. I WENT BACK TO THE L AND ADDED 5 DEGS OF BANK TO TAKE ADVANTAGE OF WHATEVER FUEL WAS IN THE TANK. I RESTARTED THE ENG AND SET UP BEST RATE OF CLB TO GAIN WHATEVER ALT I COULD WITHOUT SACRIFICING GND TRACK. THE ENG DIED A MIN LATER, 1 HR AND 55 MINS INTO THE FLT AND 2 MI SHORT OF THE WATERLOO ARPT. I SET UP FOR BEST GLIDE, NOTIFIED APCH THAT I HAD AN ENG FAILURE AND PREPARED FOR AN EMER LNDG. I LANDED 100 YARDS SHORT OF RWY 30 TO THE L OF THE APCH LIGHTS. VERY FEW ACCIDENTS ARE THE RESULT OF 1 GROSS ERROR IN JUDGEMENT. THEY ARE USUALLY THE CULMINATION OF SMALL, SEEMINGLY UNCONNECTED EVENTS WHICH WHEN LOOKED BACK UPON MAKE THE OUTCOME OBVIOUS. I HAVE RELATED THE CHAIN OF EVENTS. I CONSIDER MYSELF A SAFE AND CONSCIENTIOUS PLT. SO HOW DID THIS SAFE PLT BLUNDER FORTH COMMITTING THE MOST INEXCUSABLE PREVENTABLE ACT OF AVIATION WHICH IS RUNNING HIS ACFT OUT OF FUEL? MY PARTNER IN THE PLANE REQUESTS THAT THE TANKS ONLY BE TOPPED TO THE TABS SO THAT WE CAN CARRY 4 PAX. FUELING TO THE TABS IS AN INEXACT SCIENCE AT BEST. OBVIOUSLY, I DIDN'T HAVE THE 30 GALLONS OF FUEL I EXPECTED FROM THE TABS' INDICATIONS WHEN I PREFLTED THE ACFT. I REALIZE THAT THE SLIGHT DISTANCE BELOW THE FUEL TAB REPRESENTS A SIGNIFICANT REDUCTION IN PERCEIVED FUEL. MY FIRST MISTAKE. THE MANUAL CALLS FOR FUEL CONSUMPTION AT MY PWR SETTING TO BE 9 GPH. I CHKED ON THE RETURN FLT AND FOUND IT BURNS JUST UNDER 11 GPH. I SHOULD HAVE NOTED ACTUAL FUEL BURNS IN THE PAST AS A PRACTICE OF KNOWING MY ACFT BETTER. THE SECOND MISTAKE. UPON RPTING THE EVENTS TO MY PARTNER, HE TOLD ME HE HAD GND RUN THE ACFT TWICE FOR A TOTAL OF AROUND 30 MINS AND HADN'T NOTED THE TIMES IN THE LOG. AS FAR AS THE LOGS WERE CONCERNED, I WAS THE LAST TO FLY THE ACFT. BASED ON MY PREVIOUS FLT TIME, I BELIEVED THERE WAS MORE FUEL ON BOARD THAN WHAT ACTUALLY WAS. HAD I COMPARED MY LAST TACH TIME ENTRY TO THE START TIME ON THE LOG I WOULD HAVE NOTICED THE DIFFERENCE. MY THIRD MISTAKE. ALL OF THE ABOVE RATIONALIZATION MAY HELP MY EGO BUT IT STILL BOILS DOWN TO MY RESPONSIBILITY TO NEVER PLACE MYSELF OR A PAX IN A POS DANGER DUE TO POOR JUDGEMENT OR LACK OF POSITIVE ACTION. NO MATTER WHAT A PLT DOES, HE SHOULD ALWAYS LOOK FOR WAYS TO FURTHER INCREASE THE ODDS OF COMPLETING HIS FLT SAFELY. LEAVING FUEL ON THE GND, RWY BEHIND YOU AND ALT ABOVE DOES NOTHING TO TIP THE SCALES OF SAFETY IN YOUR FAVOR. TO ASSURE I NEVER REPEAT THIS MISTAKE, TANKS WILL BE TOPPED AT EVERY STOP AND PRIOR TO TIE-DOWN. I WILL STRIVE TO BE MORE CRITICAL IN MY DECISION PROCESS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT THE ACFT WAS NOT DAMAGED AS A RESULT OF THE FORCED LNDG AS IT WAS A NON OBSTRUCTED FLAT AREA NEAR THE ARPT ON WHICH THE TOUCHDOWN WAS MADE. THE ACFT WAS A BEECH MUSKETEER A23-24. HE ADVISED THAT HE AND HIS PARTNER HAVE STARTED A NEW PROC IN TOPPING THE TANKS WHEN THE ACFT IS PUT BACK IN THE HANGAR ALONG WITH SHORTER PLANNED TRIPS THAN THE FUEL SUPPLY PERMITS.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.