Keystone 2015 report

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flyinhigh
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Keystone 2015 report

Post by flyinhigh »

Brief summary

http://www.tsb.gc.ca/eng/medias-media/c ... 160906.asp

I always wondered how they put the Jet fuel nozzle in the tanks of a AVGAS machine. This answered that, WOW.

The full report,

http://www.tsb.gc.ca/eng/rapports-repor ... 5c0134.asp
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Heliian
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Re: Keystone 2015 report

Post by Heliian »

flyinhigh wrote:This answered that, WOW.
Exactly, Pilots should always check what goes in the tanks of their aircraft. Unfortunately, many pilots can't even wait till the prop stops to be running to the nearest lounger.
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CpnCrunch
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Re: Keystone 2015 report

Post by CpnCrunch »

flyinhigh wrote:
I always wondered how they put the Jet fuel nozzle in the tanks of a AVGAS machine. This answered that, WOW.
I'm not sure why you're surprised. This is the exact same narrative you see on every one of these accidents, and it's going to keep happening.
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MrWings
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Re: Keystone 2015 report

Post by MrWings »

Yes, the pilots have a responsibility to oversee fueling ... yada yada. But the AFHT and the people that trained him really effed up. They should be held accountable.
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goingnowherefast
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Re: Keystone 2015 report

Post by goingnowherefast »

The pilots are the ones who almost died. I'm sure they learned their lesson, along with many other pilots who are learning from this. The AFHT deliberately removed the flared Jet A nozzle, a physical device that is there for the sole purpose of preventing mis-fueling. He didn't even second guess why the Jet A, flared nozzle didn't fit in the tank.
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flyinhigh
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Re: Keystone 2015 report

Post by flyinhigh »

CpnCrunch wrote:
flyinhigh wrote:
I always wondered how they put the Jet fuel nozzle in the tanks of a AVGAS machine. This answered that, WOW.
I'm not sure why you're surprised. This is the exact same narrative you see on every one of these accidents, and it's going to keep happening.
Only surprised as I didn't realize that 1) The nozzle was a simple screw off, 2) Sounds like this was almost standard practice depending on the type of aircraft.
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Lloyd YWG FIC
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Re: Keystone 2015 report

Post by Lloyd YWG FIC »

I had a conversation with a fueler that revolved around the "turbo" issue. His stance was that because a turbo Beaver took jet fuel, any aircraft with a turbo should take jet fuel. I explained to him the difference between a piston engine v. a turbine engine but I think I just confused him more.

I actually worked as a fueler in Thompson one summer. The owner, Dave Carroll was always whining about not being able to go fishing. I finally tired of this and told him I'd work for him on my days off just so he would shut up. To my surprise, he took me up on the offer and I ended up pumping fuel part time for almost a year. Learned a lot of things about planes I never knew.
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goingnowherefast
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Re: Keystone 2015 report

Post by goingnowherefast »

Hopefully this will open the eyes of fuelers to the consequences and they will be unafraid to question the pilots when needed.
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J31
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Re: Keystone 2015 report

Post by J31 »

The fueler changes the fuel nozzle to fit the tank............un F#$K#$ believable......... :shock:
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Re: Keystone 2015 report

Post by single_swine_herder »

This blame the fueller stuff misses the point entirely.

The crew should have supervised the operation and failed to do so. While standing at the airplane waiting for the gas to be delivered, the first clue should have been ... "Why is this guy pulling up in front of the airplane with the Jet fuel truck?" ... and then stopped the process right there.

Were there contributing factors? Sure, but I'm willing to be the COM directs crews to supervise servicing and ground handling. Somewhere along the way, ignoring that became acceptable from time to time, eventually becoming normal and nobody ever did anything to stop it.

SSH
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phillyfan
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Re: Keystone 2015 report

Post by phillyfan »

This is exactly why the SMS fantasy of a zero incident utopia will never happen. Because the world is full of stupid people..
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Re: Keystone 2015 report

Post by Sidebar »

phillyfan wrote:This is exactly why the SMS fantasy of a zero incident utopia will never happen.
This is an unrealistic statement. I'm pretty sure that neither TC nor operators expect that SMS will result in zero incidents.

On another note, hopefully this report will encourage flight crews to pay more attention to the truck that pulled up in front of their plane and what the fueller is doing. Yes, in this case the fueller screwed up, but so did the crew. There was a requirement for the crew to verify the fuel type being put into their plane, and they didn't do that. How much time does it take to look at the placards on the truck and tell the fueller what type of fuel you need?
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Tanker299
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Re: Keystone 2015 report

Post by Tanker299 »

Glad this place had their ticket pulled. Seems to be the only way to keep pilots from taking these dangerous jobs. I hope Mr C is enjoying his time off. Had an encounter with him once at an airport waiting for a flight and was talking to a pal about how I would never work for keystone, this smug sob comes up hands me his card and confronts me about why I thought it was a bad place. A few months later he got his answer. I keep your card safe somewhere bud....
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Saxub
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Re: Keystone 2015 report

Post by Saxub »

To be fair, I know of a few very great pilots who flew at Keystone and it's my understanding that the pilot who was flying this plane was one of the best they had at the time. People make mistakes, no one is immune. Yes, it was a big mistake and luckily everyone made it out with their lives. But to say every pilot who ever flew there is a bad pilot is wrong. Many are off flying you around at 705 regionals these days.. Are you going to ask the pilots next time you get on a Jazz flight if they every worked at Keystone? Didn't think so.
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Re: Keystone 2015 report

Post by Gear Jerker »

Yes, the fueler is to blame. Yes, the crew is to blame. Lessons to be learned.

What stands out to me is how unbelievably f-ing lucky it is that a plane laden with full inboards and 80L a side outboards crashed into the woods and there was no fire, and everybody survived. The battery, which is housed in the nose on a Chieftain, separated from the aircraft and ended up far enough away that even with all the fuel saturating the crash site, there was no fire! Incredible.
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5400AirportRdSouth
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Re: Keystone 2015 report

Post by 5400AirportRdSouth »

When I used to fuel, the skinny/avgas nozzles were kept in the jet trucks for quick changes when required. Lots of turbine helicopters that will not accept a j-spout.

Realizing the potential for mistakes, they moved to having the nozzles under lock and key in a managers office and only signed out for specific fuelings. For a 24/7 FBO, this system broke down the first time a night shift guy needed the nozzle.

No big deal, says the fueler...wont happen to me......

Now, flying, I hardly ever see guys stick around to, at the very least, check the labels on the truck after they order fuel.

No big deal, says the pilot...wont happen to me....

Lots of blame to go around, but the worst part is, nothing has changed. The situation and all the factors that caused this still exist.
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Re: Keystone 2015 report

Post by CID »

phillyfan wrote:This is exactly why the SMS fantasy of a zero incident utopia will never happen. Because the world is full of stupid people..
That's not an accurate description of SMS which basically places the responsibility on the operator to maintain a culture of safety as well as maintaining a safe operation. It makes sure the responsible people take the blame for problems and sets up a very simple, fair and severe method of oversight. Believe it or not, SMS has been working as the bad operators are disappearing and they find it difficult to start up again.

In the case of Keystone, I had occasion to interface with a few of the players in that organization. My mom tells me that if I don't have anything nice to say, say nothing. In this case I'll do that.
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tommywcom
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Re: Keystone 2015 report

Post by tommywcom »

5400AirportRdSouth wrote: Now, flying, I hardly ever see guys stick around to, at the very least, check the labels on the truck after they order fuel.
I'm guilty of this. In fact, very often I would wait until my day of departure to call in my fuel order over the phone. I'm not even at the airport during refuelling.

BUT I would always do a paper towel test before departure. To me, that's the ultimate insurance. Looking at the label of the fuel truck is only as good as the guy who managed to put the right fuel into the right truck, not to mention a recent accident where one fuel truck ran out, and the fueler hops into another (wrong) one to finish the job.

I got fuel at the Signature FBO at SFO yesterday. That made me extremely paranoid because they rarely have piston planes stopping in. The front desk people said they see maybe 1 piston plane a week because of the hefty landing fees, parking charges and high fuel price. But to their credit, they got it right. Phew.
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linecrew
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Re: Keystone 2015 report

Post by linecrew »

To add to what has already been stated, I have swapped out the nozzle out of necessity for such types as Bell CH-146 Griffon and Bell 429 helicopters because the duck bill nozzle simply doesn't fit...call it maybe a design flaw ? The trickier ones are aircraft that were modified from piston to turbine engine such as the Piper Malibus. The ones I fueled retained the fuel filler opening of the old AVGAS tanks and required a nozzle swap.

Part of the problem is a lack of aircraft recognition skills amongst fuelers. What seems like second nature to some of us aviation geeks is hard learned knowledge for others. For example, most here I would guess would instantly recognize what a Navajo is and could visually identify that it's engines are piston powered. For those less inclined to know this, they might consider it to be one in the same with its similar looking 'cousin', the Cheyenne even though it's sporting PT-6s on the wings. My point is, don't assume that the person fueling your plane knows what it is let alone the type of fuel it requires.
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Re: Keystone 2015 report

Post by oldtimer »

I had an interesting scene a few months ago.
Since I retired from active flying, I still did some ground instruction. During the last course, I took the students onto a clients ramp for orientation. The refueler happend by to refuel a company turbine powered airplane.
One of the students, (who incidently used to fly out of Winnipeg) noticed that the refueler had the Jet A1 placard on the truck as required but the truck's hose nozzle had a blue plastic cover instead of the required black one. So this new hire ran over, questioned the driver, smelled the fuel and was assured the airplane was being fueled with Jet A1.
With that attitude and attention to detail, there is a pilot who is going to have a long and sucessful career. He earned an ATTABOY.
But for the refueler, a mistake repeated 3 times becomes a procedure.
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