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start and taxi out. A thorough engine run up ensued
and “...left and right engines checked OK with all
engine instruments normal. After take off I watched
the cylinder head temperatures closely. As I made the
first power reduction to 25 inches manifold pressure
and 2500 RPM, the left cylinder head temperature
began to rise. I stayed with Tower, reduced power,
came back in and landed.” The third taxi-in and shutdown
of the day was accomplished without incident.
By now convinced that he had a mechanical problem,
the pilot once again entered the offices of the FBO to
search for a mechanic, no easy task on a Sunday.
Entering into discussion with an FBO employee, he
was informed that there was a possibility of fuel
contamination. The pilot of a high wing single-engine
aircraft had spilled some fuel down his arm while
draining his fuel tank sumps, and had become suspicious
when he noticed the faint smell and oily feel of
kerosene. The single-engine pilot conferred with
several other pilots also doing pre-flights and they
collectively decided that the 100 low lead aviation
gasoline was contaminated with jet fuel.
New Twist on an Old Problem
Subsequent investigation revealed that the 100LL
avgas was indeed contaminated, but there is a different
twist to this all too common occurrence. The
fuelers had not made the mistake of pumping jet fuel
into reciprocating engine light aircraft; it was the
trucks themselves that were contaminated. Nor had
the trucks been filled from the wrong storage tank at
the tank farm. Upon delivery from the refinery, 8,000
gallons of jet fuel had been accidentally added to the
FBO’s 100LL storage tank, creating the first level of
contamination. The trucks were filled from this tank,
and the percentage of jet fuel was reduced again,
creating the second level in the contamination.
Finally, the trucks filled the aircraft tanks and the
third level of contamination occurred. By now the
percentage of jet fuel was so low that normal preflight
fuel tank sump inspection did not reveal an
observable color change in the blue 100LL fuel.
A number of aircraft received the contaminated fuel,
of which a few actually got airborne. In the words of
the reporter, “...fortunately no one was injured or
killed as a result of the contaminated fuel, and the
circumstances of this incident merit review to prevent
a recurrence.” Examination of the reporter’s aircraft
the next day revealed significant damage to both
engines. Engines are now being replaced on several
aircraft, including the reporter’s light twin.
continued on page 9...
Page - 8 ASRS Directline
There I Was...
...At Least I Thought I Was by Mike Smiley
Advanced Aircraft
140
18
12
15
TRK M
VOR L
ABC
82.4
VOR R
DEF
39.1
Recently an incident was reported to ASRS that
emphasizes the need for flight crews flying advanced
technology aircraft to back up the computer-generated
route and navigation database with “old fashioned”
navigation charts. Let’s examine this incident
through the eyes of the reporting flight crew:
“We were in the approach portion of the flight,
among scattered cumulus clouds and thunderstorms,
on autopilot with LNAV and VNAV
engaged. We had been told to expect no delays.
Approach Control gave traffic ahead holding
instructions at [intersection A] with right turns
instead of the published left turns because of a
thunderstorm. We verified the cell on our radar
and received holding instructions, also at [intersection
A] with right turns. When we were about
20 miles from [intersection A], Approach Control
issued clearance for us to hold at [intersection B]
because of weather. We tried to enter [intersection
B] as a waypoint but the computer rejected it
as ‘not in NAV DATA BASE.’ By the time we
located the distance from the VOR to [intersection
B] on our charts and switched to VOR mode we
were past the intersection. The controller asked
us if we knew we were 5 miles past [intersection
B] and issued a heading. We complied and shortly
after were vectored inbound.”
A rare occurrence? An isolated event? Not at all!
You can find related incidents in the ASRS database
spanning many years and involving virtually every
phase of flight.
Phase of Flight
Departure Phase
“After receiving clearance, a departure route was
programmed into the FMS. Ground Control asked
if we would accept Runway 01, but we declined
　
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