Factual NTSB Report from Ben's Crash

[WacoFan]

Well, all the other kids in college told me "Take NoDoze to stay awake & study!" According to the placebo effect, I should have been up all night! But I wasn't... I really did fall asleep on my Genetics book that night. I was 19 at the time, and didn't have any preconceived notions about caffeine. I just saw everyone else taking NoDoze to stay awake & study so I did it too and it didn't work the same for me.

BUT - you already knew that coffee didn't work for you - so you already had a preconceived bias against the effectiveness of caffeine...and you don't seem the type that is easily influenced by the experience of others rather than your own experience. That could have played a part in the NoDoze not working.

 

[Crockrocket94]

Thanks for the post J.

 

[GX]

Inconclusive in what way?

I needed to go back to re-read the factual. In my tired, late-night minded brain, I thought that the firefighters had NOT made reference to where the tank switch was, when in fact, they had. My mistake. That was the single mistake I was referencing, though.

When I spoke of Ben being a highly qualified, and competent pilot, I was merely trying to compliment him for where he was vs. where I am. To you, he may look like a rookie. To me, you should have been hand delivered to NASA. All perspective, I suppose.

 

[MikeD]

I needed to go back to re-read the factual. In my tired, late-night minded brain, I thought that the firefighters had NOT made reference to where the tank switch was, when in fact, they had. My mistake. That was the single mistake I was referencing, though.

Thats a big part of ARFF training........Scene Ops 101; that of documenting and reporting any switch, handle, button, or other position changes of items made by rescue crews in the course of working within the wreckage.

 

[nocturnalaviator]

Running tanks dry has happened to me before a few times actually. Took off with all 6 topped and flying lines all day. I make a mental note "After this line, switch from aux to main. Distractions pop up and the thought escaped my mind then the engines at the same time sputter. Shove it all full forward with the exception of the throttles which are pulled back a bit pumps on switch tanks, fire up and reconfigure. Now when I have the thought of switching tanks I don't make mental notes, I just do it and stick to my return to airport deadlines no matter how many survey shots are still left. RIP, complacency is a cold blooded killer.

 

[Muff3n]

Only issue I have is the severe automation of things. We're not talking a B-36 where you are managing 8 or more fuel tanks, the fuel balancing therein for feed and CG purposes, and and managing 8 recip engines and 4 jet engines; with a dedicated FE to do so.

We're talking a single engine GA airplane with two fuel tanks. Why make things more difficult than they need to be, and make the pilot have to do less piloting? It's not difficult to manage fuel in this case, or shouldn't be if you're prioritizing correctly. And with automatic systems, what's to say they won't malfunction in some way or form?

No need to cure the headache by cutting off the head, in my opinion.

While it's not common to run a tank dry, people have. But usually the reason for the sudden power loss is usuall more than obvious, and one of the most common and logical first steps.....switching tanks.....normally alleviates it quickly.

I still wonder about the toxicology; even though no one here seems to want to touch those findings with a ten-foot pole.

I agree with you on this one Mike. At some point, technology can go too far. I guess I am just old school in the fact that I like to have manual control over a lot of things instead of everything being so automated. I feel like everything being automated just creates another point of possible failure on an airplane. Another big part of my belief is that in some abnormal situations you might not want an airplane to do something that is usually done automatically by some automated system, when systems are handled by the pilot it allows them to adapt to the situation and handle it properly.

 

[z987k]

Running tanks dry has happened to me before a few times actually. Took off with all 6 topped and flying lines all day. I make a mental note "After this line, switch from aux to main. Distractions pop up and the thought escaped my mind then the engines at the same time sputter. Shove it all full forward with the exception of the throttles which are pulled back a bit pumps on switch tanks, fire up and reconfigure. Now when I have the thought of switching tanks I don't make mental notes, I just do it and stick to my return to airport deadlines no matter how many survey shots are still left. RIP, complacency is a cold blooded killer.

One more line...... did that so many times. Never was really close to fuel starvation but still.
I ran the outboards dry on the ho all the time though. On purpose though really. You get like 3 seconds(and a light just before they sputter) between sputter and quitting.

 

[ferguson354]

One more line...... did that so many times. Never was really close to fuel starvation but still.
I ran the outboards dry on the ho all the time though. On purpose though really. You get like 3 seconds(and a light just before they sputter) between sputter and quitting.

I've been told by an A&P (that was also a 414 driver) that running those tanks dry enough to sputter an engine is a good way to ruin your fuel pumps. Apparently they had to replace the pumps on the 414 after about 2 months of a pilot doing that.

 

[z987k]

I've been told by an A&P (that was also a 414 driver) that running those tanks dry enough to sputter an engine is a good way to ruin your fuel pumps. Apparently they had to replace the pumps on the 414 after about 2 months of a pilot doing that.

In 7 months we didn't have one fail on 12 of them. I think most people did the same.

 

[ferguson354]

In 7 months we didn't have one fail on 12 of them. I think most people did the same.

Ahhhh... sounds like that A&P was full of crap! In retrospect I'm not surprised

 

[killbilly]

This seems like a good time to ask a question I've been wondering about for a long time....

In an aircraft with a pair of fuel tanks, why not feed fuel from both at the same time? Why separate feeds? I've only flown Cessnas, and there's L/R/Both. "Both" makes sense to me...what's the reason for having separate feeds?

 

[Roger Roger]

This seems like a good time to ask a question I've been wondering about for a long time....

In an aircraft with a pair of fuel tanks, why not feed fuel from both at the same time? Why separate feeds? I've only flown Cessnas, and there's L/R/Both. "Both" makes sense to me...what's the reason for having separate feeds?

So if one drains a little faster than the other you don't suck air from the dry tank and vapor lock the fuel system.

 

[killbilly]

So if one drains a little faster than the other you don't suck air from the dry tank and vapor lock the fuel system.

Ah. That makes sense. Thank you.

 

[Roger Roger]

Ah. That makes sense. Thank you.

14 CFR Part 23 addresses the specifics, but basically if you have an engine fed by multiple tanks you have to ensure that it can't draw air from a dry tank, or if it does, that you get x% power back within y seconds of switching tanks. Easy to meet on a gravity fed system on a 4 cylinder carbureted engine, but apparently something as thirsty as the fuel injection system on a turbo 210 it was just easier for them to not have a both position. Head pressure from the fuel tanks plays a big part in it too, notice that you'll never see a Cherokee series airplane with a both position.

 

[Roger Roger]

I've been told by an A&P (that was also a 414 driver) that running those tanks dry enough to sputter an engine is a good way to ruin your fuel pumps. Apparently they had to replace the pumps on the 414 after about 2 months of a pilot doing that.

Depends on the fuel pump. A 414 fuel pump is different than a PA31 or 32 fuel pump so it may well be that popping tanks kills 414 fuel pumps but not Chieftain ones.

 

[sdfcvoh]

Ben's accident has given all of us the opportunity to learn. He was the first person I knew, as a pilot, to perish in an aircraft accident. His passing affected me deeply. Every one of us that has experienced in flight emergency(s) understand the pucker factor involved. Remaining current in practice of emergency flows is one of the few things we can do to try and stay stay ahead of the curve.

I have been heavily involved in an NIH study in Tucson over the last three years involving OTC medications and their adverse effect on pilots. One of our studies focused entirely on Dyphenhydramine. After spending weeks downloading and combing through NTSB reports that included Dyphenhydramine levels noted in the toxicology, I will say is that there is never a reason for any of us to operate an aircraft within (at a minimum) 48 hours after using any sort of sedative substance. Most often, consider in addition that the underlying cause that leads a person to take OTC meds is usually in-itself reason enough to not fly.

Stay safe and make the right decisions.

RIP Ben

 

[fish314]

Hey MikeD (or anyone else who knows a lot about NTSB reports feel free to chime in),

I write these same kind of reports for the USAF, but I notice that the NTSB report gave ONLY the facts and didn't say something akin to "X was a causal factor in this mishap," or "Y was probably NOT a causal factor in this mishap."

So two questions:

1. Is this typical that the NTSB doesn't officially PRONOUNCE a finding, per se? Something along the lines of, "this mishap was caused by X, Y, and Z.." That seems odd to me, because the whole point of the safety investigation on the USAF side is to boil everything down to those kinds of findings.

2. Does the NTSB frequently come up with recommendations, when they are appropriate, based on a single mishap. Or are recommendations (or FAA rule changes, or technical changes to equipment) handled via an entirely separate process than the mishap investigation itself. Again, I'm compare/contrasting to the USAF method where they are tied together.

 

[Boris Badenov]

I will say is that there is never a reason for any of us to operate an aircraft within (at a minimum) 48 hours after using any sort of sedative substance.

I'd say an easy 50% of the guys I flew with in a crew environment baldly disregarded that stricture on a regular basis. 14th day on the road with "flexible" duty times and the sheer boredom of spending 10-12 hours in a plastic hotel in a place where the only person you know is the guy you've been sitting next to for way too long, and it becomes a question of pop a couple of Dryls or just get drunk at the bar...there is no third option.

Or, I mean, so I'm told. Obviously, I'm Special and require no external Substances to sleep at fungible times like the clockwork-drone I am. That said, the notion that 135 is excluded from the (no doubt necessary and right) new rest rules (which govern guys who are usually on a 2-5 day trip, rather than a 7-14 day trip) just gives you an idea of how much of Government Oversight is about Safety, and how much is about Money.

The Air Ambo schedule is awesome for a lot of reasons, but one of the first in my mind is the fact that I no longer have to try to figure out how to go to sleep RIGHT NOW so I'm halfway awake when it's time to command a freaking aviation appliance at 41,000 feet.

 

[jtrain609]

Hey MikeD (or anyone else who knows a lot about NTSB reports feel free to chime in),

I write these same kind of reports for the USAF, but I notice that the NTSB report gave ONLY the facts and didn't say something akin to "X was a causal factor in this mishap," or "Y was probably NOT a causal factor in this mishap."

So two questions:

1. Is this typical that the NTSB doesn't officially PRONOUNCE a finding, per se? Something along the lines of, "this mishap was caused by X, Y, and Z.." That seems odd to me, because the whole point of the safety investigation on the USAF side is to boil everything down to those kinds of findings.

2. Does the NTSB frequently come up with recommendations, when they are appropriate, based on a single mishap. Or are recommendations (or FAA rule changes, or technical changes to equipment) handled via an entirely separate process than the mishap investigation itself. Again, I'm compare/contrasting to the USAF method where they are tied together.

There are three reports that the NTSB publishes; the preliminary, which comes out shortly after the accident and is scare on much of anything. The factual, which gives all the facts that they've collected. And finally, the probable cause, which I believe contains the information you're talking about.

 

[MikeD]

Hey MikeD (or anyone else who knows a lot about NTSB reports feel free to chime in),

I write these same kind of reports for the USAF, but I notice that the NTSB report gave ONLY the facts and didn't say something akin to "X was a causal factor in this mishap," or "Y was probably NOT a causal factor in this mishap."

So two questions:

1. Is this typical that the NTSB doesn't officially PRONOUNCE a finding, per se? Something along the lines of, "this mishap was caused by X, Y, and Z.." That seems odd to me, because the whole point of the safety investigation on the USAF side is to boil everything down to those kinds of findings.

2. Does the NTSB frequently come up with recommendations, when they are appropriate, based on a single mishap. Or are recommendations (or FAA rule changes, or technical changes to equipment) handled via an entirely separate process than the mishap investigation itself. Again, I'm compare/contrasting to the USAF method where they are tied together.

The format between the USAF and the NTSB is different, but the information is there. Consider the Prelim to be much like our 72 hour. The final will have findings, again written in a different format from ours (ie- doesn't list individual ones as causal in the findings section), and the probable cause will list the causal factors in a primary, secondary, and tertiary format.

Recommendations are made by the NTSB in the report recommendations section, and are both given a priority (ie- Class II, Priority Action), as well as directed to the specific agency to whom the recommendation is being referred to, such as FAA, USFS, military, airline, etc.