Lapsing into the trees

July 19, 2011 by Bruce Landsberg

A few weeks ago a Cessna 182 pilot suffered an engine stoppage after takeoff. They don’t run well without fuel and the fuel selector was set to the ‘off’ position. This is one of those killer items on the before takeoff check and this pilot had a momentary lapse.

How could such an event happen? Easy! The aircraft had been in maintenance and the technician personally told the pilot that the selector was off. It was the pilot’s personal aircraft and he always left the selector on “both.” In running the checklist by rote the check wasn’t actually made and there was just enough fuel in the lines to get up to about 300 agl before the quiet began.

The happier ending was that the pilot had just installed a parachute on the Cessna and had the presence of mind to pull. Amazingly, it was enough to break most of the fall, even at such a low altitude, and the pilot came out with little or no injury. He also had the integrity to admit his lapse. Well done, sir, on several counts!

Now all of us are much too smart, disciplined, experienced (fill in the self-congratulatory adjective of choice) to make such a mistake but if you have a “friend” who might be so prone, just a few things to consider. Really verify the killer items and allow no distractions. It’s much easier said than done and use sticky notes as reminders on stuff that might get forgotten, especially after maintenance. They’re quite handy for IFR reminders as well.

Rental and club aircraft are filled with all kinds of traps and most pilots are pretty careful to check those things. It’s much easier if you’re the only one flying a particular aircraft to take things for granted.

If someone else has a nifty technique for preventing our humanity from getting in the way of safe flight, please share it.

Bruce Landsberg
President, AOPA Foundation

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22 Responses to “Lapsing into the trees”

  1. Robert Scovill Says:

    When are you going to address undetectable water in the fuel tanks of Cessna high-wing aircraft? FAA Safety Recommendations 99.283 and 99.284 clearly demonstrate the lack of positive detection of water in Cessna integral fuel tanks. NTSB Safety Recommendation A-83-6 clearly demonstrated the lack of positive detection in the Cessna 182, Cessna 206, Cessna 205 and other related aircraft with rubber bladder fuel tanks. The NTSB after reaching an impasse with the FAA closed A-83-6 but marked it as UNACCEPTABLE.

    Furthermore, I have personally tested the Cessna 150 and Cessna 152 and both failed positive detection of water in the fuel tank during a properly performed pre-flight.

    What is the difference between leaving the fuel selector in the off position and undetectable water in the fuel tank?

    Why has AOPA remained silent on the lack of positive detection all these years? AOPA has so much to say about prevention but not a word about positive detection. If you don’t know you got it how can you prevent it?

    Want to know why I ended my AOPA membership…re-read above!

  2. Jon Jefferies Says:

    It makes no sense to quit AOPA because they haven’t addressed a particular shortcoming you think important. Do everything you can to encourage a solution to the problem!
    As an aside to the article; why was the pilot able to deploy a parachute so quickly before he would have switched tanks or the selector position, prior to the deployment? Having never used the chute but having surely changed positions on a fuel selector in his career, I would think he would opt for the latter before doing something he has never tried before. Unless he was just out to test the chute in a very expensive way?

  3. Jerry Wells Says:

    There had to be a problem with the selector valve. For certification it must shut off the fuel. If it was in the “Off” position then the pilot should not have even been able to taxi out, let alone take off. Any fuel in the lines should not have been able to migrate to the engine.

  4. Dan Telfair Says:

    Like many pilots, I do not like to pull out my full checklist when I am at the ready line immediately before takeoff. Instead, I have a mini-checklist sealed in clear plastic fixed to my instrument panel above the throttle. The last thing I do before advancing the throttle to cross the hold short line is run through the mini-checklist. The items on the checklist are:

    Fuel Selector Both
    Takeoff Trim
    Cowl Flaps Open
    Flaps 10%
    Mixture rich for T/O
    Oil Pressure and Temp
    Doors and Windows Closed
    Wind Check
    CLEAR!

    The list is impossible to miss when advancing the throttle, short enough to be clearly readable, and also short enough that running through it without skipping an item is easy. The order in which the items are listed facilitates accomplishing the checklist – bottom to top and inside to out.

    Sometimes, as I begin my takeoff roll, I have that nagging doubt that I may have missed something. Knowing that I ran through the mini-checklist is a great comfort.

  5. Bruce Landsberg Says:

    Robert…..

    As I recall, you did pose the question to the Air Safety Foundation some years back. The FAA and Cessna looked into your findings and decided that it was not sufficient to issue an AD. I have to defer to their expertise.

  6. jim neuenburg Says:

    I don’t understand why the 182 was still running before takeoff, if the valve was off. My plane won’t even make it to the runup area (not far) before it quits, – let alone doing a quick check and runup too!
    I’m thinking maybe there wasn’t any fuel in the plane…

  7. Morona Says:

    I agree with the posters who think there is something fishy about this story. At takeoff power, the 182 burns at least 15 gph. Combine the fuel required for taxi and runup with that required for a climb to 300 feet, and at least a half gallon of fuel was burned – probably a lot more. The fuel lines between the fuel selector and the engine simply do not hold a half gallon of fuel. If the fuel selector was found in the off position after the accident, it was because the pilot turned it off sometime after engine start.

  8. Bruce Landsberg Says:

    Morona & Jim …..

    It might be an interesting experiment to check – but don”t actually go flying – just simulate the power settings. This was related to the investigators by the pilot so I have no reason to doubt the veracity, particularly since it doesn’t make absolve him of responsibility.

    The other possibility is that the C-182 had been re-engined, like AOPA’s sweepstakes C-182. That installation uses a header tank – it will come out in the full investigation as to what the fuel load was.

    Thanks for raising some interesting points

  9. Marty Says:

    Hi Bruce!

    Consider asking your webmaster to make it easy to print your postings. I like to put this stuff on my Kindle to read when I am off line.

    thanks!

    Marty

  10. Jan Melkebeek Says:

    About a year ago about 200 l of Avgas was leaked of my 172RG (I had filled it up before putting it in the hangar) due to a faulty O-ring in the fuel strainer. Since then, I always close the fuel selector after flight (imagine the expense with Avgas prices in Europe of about 2 Euro per litre) .
    I am still thinking of a reliable reminder for the closed fuel selector. Yes, I know, it is on the check-list ( but I rarely use a written check-list). For the moment I put a map or chart below the handle.
    As a test, I once tried to start, taxi and do the run-up from the hangar to the nearest holding point with the fuel selector closed. I just wanted to know how long it would last before the engine quit. The taxi in LFQQ is about 200 m to the nearest holding. Well, I couldn’t even reach halfway the taxi to the holding point!

  11. Dwain Pittenger Says:

    My two bits worth;; You have not had proper annual inspections. The fuel valves get worn and will leak enough fuel to taxi & keep Carb bowl full until full throttle advanced for take off, then look out. I have changed several main fuel valves. thats part of any 100 hr or annual Inspection, in my books. Make sure engine dies when shut off. Also there are a lot of bad mag switches out there, causing all kinds of problems For what it’s worth !! “Pitt” Been doing maintance on Cessnas since 1946.

  12. Robert Scovill Says:

    Nice SIDESLIP Bruce.

    NTSB Safety Recommendation A-83-6 dated March 25,1986 states:

    The Safety Board remains concerned that Airworthiness Directive (AD) 84-10-01 may
    not be completely effective in preventing water from entering the fuel system. In
    fact, one member of the Safety Board staff found a significant amount of water in
    the fuel tanks of his Cessna airplane shortly after complying with the AD. While AD
    84-10-01 may help to reduce the entrapment of water within the fuel tanks, it does
    not provide for the positive detection and/or elimination of water from the fuel.
    Additionally, as the aircraft that have complied with the AD have recently had their
    fuel tanks completely “purged” and fuel caps resealed, it is expected that it may be
    some time before the problem redevelops.

    The Safety Board concludes that an impasse has been reached in our efforts to
    convince the FAA that further attention is needed to assure the elimination of water
    form the fuel tanks of the affected airplanes. As we have no further information to
    offer in defense of this recommendation, Safety Recommendation A-83-6 has been
    classified as “Closed–Unacceptable Action.” Although we have closed this
    recommendation our concern for this safety issue has not diminished and we will
    continue to voice our concerns in future pertinent accident investigations.

    FAA Safety Recommendations 99.283 and 99.284 dated March 10, 2000 states:

    Safety recommendation 99.283: We have reviewed the water/contamination egress capability of the Cessna model 172P, and find that it is not adequate. Our findings indicate that this operator’s airplane was designed and manufactured in such a manner as to not provide adequate water/contamination egress capability. Based on our review, we have determined that other Cessna high wing airplanes use a similar design and construction method for their integral wing fuel tanks. Therefore, we believe this condition may exist on other integral fuel tank equipped Cessna high wing airplanes with gravity feed fuel systems.

    Safety recommendation 99.284: We have reviewed the effectiveness of Cessna Service Kit SK 182 -100 and found that it is not adequate to perform it’s intended function of assisting in the detection and removal of water and/or contaminants in the integral wing fuel tanks when the airplane is in a normal ground attitude.

    SAIB CE-10-40R1 dated July 30, 2010 states:

    Subject:

    Aircraft Fuel System; water contamination of fuel tank systems on Cessna single engine airplanes

    This Special Airworthiness Information Bulletin is to inform pilots, owners, operators, and maintenance and service personnel of Cessna Aircraft Company (and formerly Reims Aviation S.A.) Model 100, 200, or 300 series, any model and/or prefix and/or suffix in the series of airplanes as applicable of the hazards associated with water contamination of fuel tank systems. The fuel tank system consists of all tanks, components, lines, fittings, etc., from the fuel tank to the engine.

    I have introduced water into the fuel tanks of the following Cessna aircraft fuel tanks: Cessna 172P, Cessna 172RG, Cessna 150 and Cessna 152. With all aircraft in their normal ground attitude using the Certified Preflight Procedure water was UNDETECTABLE.

    Bruce how many Cessna aircraft fuel tanks have you tested?

  13. Bruce Landsberg Says:

    Bob…..

    Thank you for that complete update. My comments were not intended to “side step”. First – I’m not sure that this is entirely germane to the topic – at least according to the pilot’s account.

    Secondly, FAA action and NTSB recommendations are frequently at odds because their missions are different. NTSB can recommend anything but FAA has to take into account the probabilities and economic factors. Isolated incidents and unique circumstances may not be the basis for a far-ranging and expensive AD. FAA did issue an SAIB but that falls short of mandatory compliance and I’m sure you’ve voiced your concerns to FAA and they’re explained why they made that determination.

    Newer model Cessnas incorporate quite a number of drains that should address the problem. Fuel contamination from water entering the tanks, usually from poorly maintained O-rings in the caps can be a problem and pilots should be especially attentive to aircraft parked outside after heavy rain.

    I haven’t looked at the number of fuel contamination accidents recently but recall that it’s a huge problem. That said, attention to detail is the mark of a safe pilot. Thank you for your concern.

  14. Robert Scovill Says:

    New Cessna models have thirteen fuel drains.

    Ten sump drains are in the wings.

    Five sump drains per wing.

    My Cessna 172P has ten sump drains in the wings.

    Five sump drains per wing, just like the “new” Cessna’s.

    With the FAA present during a test for the positive detection of fuel contaminated with water in my Cerssna 172P, produced the following results.

    Fifty two ounces of water were poured into each of my wings.

    With a total of one hundred and four ounces of water just poured into the fuel tanks, not one drop was observed at any of my ten sump drains.

    Bruce this is not rocket science, it was a simple real world test, like someone sabotaging the aircraft.

    It was this real world test that prompted FAA Safety Recommendations 99.283 and 99.284.

    Bruce you mention that pilots should prevent with proper O-rings. O-rings are not the only problem.

    Cessna aircraft parked in rain or washing the aircraft, water will go right through the middle of the cap vent.

    Personally, I prefer positive detection so I can know that prevention has occurred.

    Bruce, I again ask how many Cessna fuel tanks have you tested?

    Just one simple real world test will, and should, cause you to question the FAA (DOA) certification.

  15. Nate_fl Says:

    I throw this out as an idea…put the a/c keys, headset, or checklist on the fuel selector…reminding you to look at it.

    Of course, a methodical pre-takeoff check will catch killer items such as fuel and trim. One of the big problems IMO is HASTE at the hold short line, usually caused by trying to squeeze out a departure in front of traffic turning final.

    $.02

  16. Bruce Landsberg Says:

    Nate – That’s a good recommendation. Boaters with inboard engines are told to leave their keys on the engine cooling water seacock so as to not start without insuring that it’s open.

    And it’s good to be mindful when leaving mother earth that we don’t defy gravity – we coexist and fuel to the engine is an essential part of that coexistence.

  17. Bruce Landsberg Says:

    Wanting to clarify my earlier post above – fuel contamination is NOT a huge problem but an ever present one. We’ll post the numbers in next week’s blog

  18. Robert Scovill Says:

    Bruce say’s…

    “Wanting to clarify my earlier post above – fuel contamination is NOT a huge problem but an ever present one. We’ll post the numbers in next week’s blog”

    Bruce you had it right when you used the word “huge”. Would be interesting to know who got to you on that? Also, interesting is just where will you get your numbers?

    Should you derive your numbers from the NTSB database, please be advised the NTSB database is flawed!

    NTSB poor investigations that continue to cite pilots with the probable cause of poor pilot preflight, carburetor ice, or worse yet, reason for engine failures in General Aviation Aircraft Engines as UNDETERMINED.

    Six thousand four hundred and eighteen times and I’m still counting the NTSB has written off engine failures in General Aviation Aircraft Engines as UNDETERMINED.

    Bruce would you accept an UNDETERMINED ENGINE FAILURE from you automobile mechanic?

    This is not rocket science. In fact it is AIR, SPARK AND UNCONTAMINATED FUEL!

    Aircraft takes off changes it attitude and UNDETECTABLE WATER hiding in the wing fuel tanks makes it way to the engine which sputters and down goes the aircraft.

    Did the engine run out of air? Did all the spark plugs fail at once? Did both magnetos fail at once?

    One simple test by you Bruce introducing water into the fuel tank of a Cessna high-wing aircraft as it sits in its normal ground attitude and there goes the NTSB database and consequently yours numbers!

  19. Dean White Says:

    It’s simple, when flying single engine airplanes, Mark Twombly stated it best in a one page article he wrote around the year 1997. He stated Fuel – flaps – trim – transponder – direction – instruments – time – track.

    Well put Mark. ALWAYS use your POH published checklist. But before you take the active runway for takeoff, use Marks mini checklist.

    Thanks again Mark!

  20. Morona Says:

    Dwain Pittenger: Thank you for your comment. I never thought to occasionally shut down the engine by using the fuel selector, thus checking for valve leaks. I will do that from now on, along with also occasionally shutting down by turning off the magnetos. Any other good tips?

  21. Erik Wagner Says:

    Water in Fuel: (their term) preflight should be done, in which the tail would be lowered, then drain, then repeat. Drain, then shake each wing and drain again. The idea was to get the water to run to the quick drains. Part of the annual, was to completely driain the tank, especialy on Cessnas that did not have wing quickdrains, but only belly drains. Most of these were converted to quick drains after this publicity.

    Doesn’t someone make an electric sensor that detects water in fuel?

    Fuel Valved Closed:It was quite common to have engine failure at TO when the fuel valve is closed. Somehow there is just enough fuel for a taxi, check and initial run.
    A lot of pilots trained in very old planes had a habit of shutting off the fuel when parked, as it was advised, so that the rubber tubing used would not rot out. Cessna advises in the POH, to leave the fuel cock off while parked. With the interconnected tanks, fuel can run from one tank to another on an uneven surface, causing fuel to run out the overflow. Never assume anything is where you left it or anything is where is should be.
    Does anyone remember the fuel tank unporting problems in some Beechcrafts during continuous turns from taxiway to takeoff roll?

  22. Erik Wagner Says:

    Somehow intial part of my reply was deleted.

    “Doe anyone remember Cessna’s pamplet and campaign in the 80′s, when this problem received after several stoppages, that a “rock and roll” preflight should be done……

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