All Survive Crash Of Historic Goose Amphib

[SpyPilot]

https://www.avweb.com/aviation-news/all ... se-amphib/

[pelmet]

Interesting that both engines lost power........

C-GDDJ, a Wilderness Seaplanes Limited Grumman G-21A aircraft (serial number 1184) was
conducting a flight under visual flight rules from Bella Bella (CBBC), British Columbia (BC) to Port
Hardy (CYZT), BC, with 1 pilot and 4 passengers on board. Shortly after takeoff from Runway 13,
the left engine surged and lost power. A few seconds later, the right engine lost power. The pilot
communicated a Mayday call on the aerodrome traffic frequency and conducted an emergency
landing in a forested area approximately 0.5 nautical miles southeast of CBBC. All occupants
received minor injuries and were able to exit the left cabin door. The occupants walked to a nearby
road where local residents transported them to the Heiltsuk Hospital in Bella Bella, BC. The aircraft
was substantially damaged.

.....From TSB.

It is the same aircraft that crashed a few years back. Anybody have more details?

http://www.avcanada.ca/forums2/viewtopic.php?t=164597

[Capt. Underpants]

I have no inside knowledge whatsoever but my brain goes straight to it being due to jet fuel in the tanks instead of avgas.

[WrightR2600]

Any updates on this ? The pilot is being touted as a hero but hard to believe two R-985s can quit without some serious negligence on the part of the pilot . And how was he unable to make the water southbound off the runway in Bella Bella ?
This airplane was sank 2 years ago due to a missing drain plug in the wing float and apparently it was the same guy flying it .
I see Wilderness has a job add for a single engine pilot this summer with a possible upgrade to the Goose “ program “.
Sounds like one heck of a program.

[pelmet]

Any updates on this ? The pilot is being touted as a hero but hard to believe two R-985s can quit without some serious negligence on the part of the pilot . And how was he unable to make the water southbound off the runway in Bella Bella ?
This airplane was sank 2 years ago due to a missing drain plug in the wing float and apparently it was the same guy flying it .
I see Wilderness has a job add for a single engine pilot this summer with a possible upgrade to the Goose “ program “.
Sounds like one heck of a program.

Why was the drain plug missing? Is that part of the pilot's pre-flight inspection?

[WrightR2600]

Yeah I would assume it’s the PIC responsibility to ensure there are no missing drain plugs but I’ve never flown a Goose .
All my knowledge is second hand so I was hoping someone had more light on the situation.
Strange stuff on the BC Coast .

[SeptRepair]

Rumor has it they had refueled out of barrels and those said barrels had water in them.

[WrightR2600]

Good lord … water in a fuel drum . Well they aren’t reinventing the wheel in how to crash airplanes I guess .

[‘Bob’]

If you’re going to fuel out of a drum.. make sure it’s been stored sideways if it’s in a place that rains all the time and make sure that you sample your fuel after fuelling.

Especially if you’ve been the chief pilot for six years!

Personally… I think he was thrown under the bus by the ops manager. He did it…. but the “solution” seems very reactionary to stop well established norms.

https://www.timescolonist.com/local-new ... b-11581267

[Daniel Cooper]

That's a surprisingly candid article. The public usually never finds out those kinds of details. Probably because of the risk of a lawsuit from the terminated employee.

[pelmet]

Haven’t read the report yet but anybody fueling aircraft out of drums or Jerry cans needs to take positive action to make sure an effective filter of some sort is always being used.

I did quite a bit of flying this summer on an aircraft which involved me purchasing mogas from gas stations in nice clean metal Jerry cans. I always used a funnel with a filter and discovered multiple little flecks of paint, from the Jerry can, on the filter each time. That stuff will anccumulate somewhere. All fuel samples from the aircraft were completely clean after each one of my refuelings, which were tiring and time consuming and a little bit risky high up on top of the wing on the aircraft.

Then, I delivered the aircraft to be flown at a different location temporarily, under someone else’s control, and it had several mogas refuelings. After the aircraft was returned, I went to fly it a month later and discovered significant contamination of some sort of murky solid and liquid crap, enough to completely block any fuel coming out of the the sump drain. Of course, the other guy assured me that proper procedures had been followed, but that contamination came from somewhere.

Ensuring clean fuel is not always easy but is extremely important. One needs to have some paranoia about fuel contamination.

A year and a half ago, I went to do my spring check flight in a tow plane. It had already flown twice after a winter in the hangar. When I sampled the fuel, the entire sampler was water(thousands of tiny bubbles appear initially from the flow of water into the tube and then quickly disappear). That plane also uses mogas as well which is a bit yellowish. It was dark in the hangar, so I took the sample outside to hold it against a white background. It was 100% water with no dividing line for fuel in the tube. It took a lot of samples before I could get 100% fuel. The previous pilot admitted that he had not checked the fuel, and this was a guy with massive aviation experience in more than piloting. I have no idea how the water got there.

Regarding fueling out of drums, we did a lot of that up north on the tundra. It has been a long time but it seems to me that the drums in the fuel caches were typically upright but had been sealed from the fuel company(you can see the white seal/cover on the nearest drum in the picture). But once opened, should be left on the side. We also had no go filters in the refueling system.

https://www.gettyimages.ca/detail/video ... /495646542

[planenuts]

It's quite the read...Sounds like a complete clown show. I mean - it should be common sense to at least use a water filter, and why bother draining the sump for 2 secs without even looking at it????? Kind of useless.

There are so many stupid issues - but this one here speaks volumes about the companies priorities..

A go-no-go filter, which expands upon contact with water and thereby prevents the flow of fuel within the delivery system, was believed to present a risk of getting an aircraft stuck at the airport if the activated water filter rendered the hand pump unusable. This concern contributed to the decision to exclude water filtration from the drum fuelling system.

https://www.bst.gc.ca/eng/rapports-repo ... p0153.html

[airway]

Anybody who is fueling from drums should be reading this:

1.17.1 Fuelling equipment
The investigation examined the equipment used to fuel the occurrence aircraft. The need for this equipment was identified by the operator approximately 3 months before the occurrence, when fuel drums were initially ordered. It included a single-stage hand pump with a telescoping pick-up tube, a ¾ inch diameter rubber hose, and a fuel nozzle. The rubber hose was attached to the hand pump and fuel nozzle with hose clamps. A wire was supplied to bond the aircraft to the fuel drum, but no means was provided to ground the fuel drum.

With respect to drum fuelling, the Transport Canada Aeronautical Information Manual (TC AIM) states that fuel should be filtered “using a proper filter and [emphasis added] water separator.”28 The equipment provided by the operator did not include a particle filter or a water separator.

The hand pump provided for drum fuelling leaked fuel from its top while in use, and the pump was not a model that was suitable for use with fuel, including 100LL Avgas with which the occurrence aircraft was fuelled. After the hand pump was used for the 1st time,29 the operator decided to replace it with an electric pump because the hand pump leaked and transferred fuel at a slow rate. It was planned to introduce the electric pump to service by the end of December 2023. On the day of the occurrence, the replacement pump was not yet available, and the hand pump was still in service.

The threaded outlet on the hand pump, to which the hose was attached with a hose clamp, used ¾-inch NHR thread, commonly used for garden hose applications.30 Fuel particle filters, water separators, and the rotary hand pumps commonly used for drum fuelling are equipped with 1-inch National Pipe Taper (NPT) thread.31 NHR thread and NPT thread are not compatible connections32 and the hand pump would have required an adapter to incorporate the filters recommended in the TC AIM.33

Wilderness Seaplanes did not supply water detection paste34 for drum fuelling operations because the operator understood the purpose of water detection paste to be to determine the level of water in the bottom of a large, permanent tank installation rather than to determine the presence of water within a sample taken from a fuel drum.

1.17.2 Fuel source
The fuel type used by the occurrence aircraft, 100LL Avgas, is normally available at CBBC from a fuel truck. Approximately 2 months before the occurrence, this fuel truck was removed from service and sent for repair due to mechanical issues. Fuel drums were brought to the airport as an interim means of providing 100LL Avgas.

Figure 5. A fuel drum stored horizontally with the vent and bung at the 3 o'clock and 9 o'clock positions, respectively (Source: TSB).
Image
Figure 5. A fuel drum stored horizontally with the vent and bung at the 3 o'clock and 9 o'clock positions, respectively (Source: TSB).
On the subject of storing fuel drums, TC states that “All fuel drums should be stored on their side, with vents and bungs at the 3 o’clock and 9 o’clock positions”35 (Figure 5). The fuel drum used to fuel the occurrence aircraft was stored by the operator in an upright orientation.

It was reported that Wilderness Seaplanes’ intention was to discard any fuel that remained in a drum after it had been unsealed and used for aircraft fuelling. This policy was not found documented in company procedures or written communications to pilots.

Approximately 7 weeks before the occurrence, the drum from which the occurrence aircraft was fuelled had been unsealed and opened in anticipation of being used to fuel another Wilderness Seaplanes aircraft. No fuel was taken from the drum on that occasion, and once it was determined the drum was not required, the bung of the drum was reinserted. The plastic seal that covers the bung, once removed, cannot be reinstalled. The drum was not marked or labelled as having been opened and was returned to storage rather than isolated or quarantined as an unsealed drum. When the drum was opened by the occurrence pilot on the day of the occurrence, the threaded bung was found to be only finger tight.

1.17.3 Aircraft fuelling
The investigation examined the drum fuelling procedures used on the day of the occurrence. Two aircraft were fuelled from the occurrence fuel drum, the 1st being a Beaver, also owned by Wilderness Seaplanes.

A pallet with 4 fuel drums, including the occurrence drum, was brought from the drum storage area to the aircraft using a forklift operated by a Wilderness Seaplanes fuel agent. Before fuelling, communication occurred between this fuel agent and the pilot of the Beaver. Following this communication, the fuel agent did not take part in fuelling the 2 aircraft from the occurrence drum. It is unknown exactly what was communicated; however, the fuel agent had previous experience using the hand pump and may have attempted to explain how to extend its pick-up tube.

Wilderness Seaplanes’ standard operating procedures (SOPs) state that:

[f]or safety reasons, fuelling the Goose is a 2 person job. Pilots are expected to fuel their aircraft. Fuel agent will stand by to pass the fuel hose up and to receive it when fuelling is completed.36

On the day of the occurrence, fuelling was completed by the pilot of the occurrence aircraft, assisted by the pilot of the Beaver.

Before the hand pump was installed into the fuel drum, its telescoping pick-up tube was not extended to its full length (Figure 6). As a result, when a sample of fuel was pumped from the drum into a glass jar, the fuel that was examined was drawn from the mid-height of the drum, rather than the lowest point. The fuel sample that was examined passed the visual clear and bright test but was not representative of the fuel in the lower portion of the drum. After sampling, the Beaver was fuelled.

Figure 6. The hand pump and fuel drum used to fuel the occurrence aircraft. Left: Drum exterior. Middle: Drum cut-away showing the retracted telescoping pick-up tube. Right: Drum cut-away showing the extended telescoping pick-up tube. The approximate fuel pick-up point is indicated by a red dashed line. (Source: TSB)
Image
Figure 6. The hand pump and fuel drum used to fuel the occurrence aircraft. Left: Drum exterior. Middle: Drum cut-away showing the retracted telescoping pick-up tube. Right: Drum cut-away showing the extended telescoping pick-up tube. The approximate fuel pick-up point is indicated by a red dashed line. (Source: TSB)
After fuelling of the Beaver was completed, the occurrence pilot fuelled the occurrence aircraft while the Beaver pilot operated the hand pump. Because the telescoping pick-up tube of the hand pump had not been fully extended, the flow of fuel stopped once it was drawn down to the approximate halfway point of the drum. The Beaver pilot then uninstalled the hand pump and extended the telescoping pick-up tube before reinstalling the pump and resuming fuelling. The remaining contents of the drum accessible by the fully extended telescoping pick-up tube was pumped into the occurrence aircraft. A fuel sample from the lower portion of the drum was not taken or examined.

With respect to examining the fuel in an aircraft during a pre-flight check, the TC AIM states the following:

[d]uring the pre-flight check, a reasonable quantity of fuel should be drawn from the lowest point in the fuel system into a clear glass jar. A “clear and bright” visual test should be made to establish that the fuel is completely free of visible solid contamination and water[...]37

After the occurrence aircraft was fuelled, a sample was not taken from the aircraft wing fuel sumps, or any other part of the aircraft, during the aircraft’s pre-flight inspection.

1.17.4 Company procedures
The Wilderness Seaplanes Company Operations Manual contains guidance on when aircraft pre-flight inspections must occur, but it does not detail these inspections or discuss draining or sampling of aircraft fuel systems. Wilderness Seaplanes had 2 company documents that contained guidance on fuel sampling for the occurrence aircraft type: the Grumman G-21A “Goose” Flight Manual38 and the Goose SOPs.39

The flight manual contains a daily inspection checklist. This checklist itemizes draining the wing fuel sumps using a fuel strainer cup as part of the daily inspection.40 The flight manual does not indicate if the daily inspection is to be performed before each flight, or at the beginning of the aircraft’s operational day; however, the investigation determined that Wilderness Seaplanes’ expectation was that pilots would drain aircraft wing fuel sumps only before an aircraft’s 1st flight of the day and, although required by the flight manual, there was no expectation that fuel samples be collected or examined during this procedure.

The operator’s SOPs for the Goose contain a different daily inspection checklist that is more detailed than the one found in the flight manual. With respect to sampling fuel from the aircraft as part of a daily inspection, this checklist requires that each of the aircraft’s 2 wing fuel sumps be drained for 5 seconds. This checklist further states that the fuel sample can be captured for inspection, but it does not mandate this collection or describe how it should be done,41 unlike the checklist in the flight manual, which specifies that a fuel strainer cup must be used.42 The company pilots regularly drained wing fuel sumps onto the ground before the 1st flight of the day, with no fuel sample collected.

Collecting a fuel sample from the wing fuel sumps of the Goose requires that a valve be operated in the cockpit while the sample is collected from outside the aircraft, ahead of where the main landing gear retracts. One sample is to be collected from each side of the aircraft exterior. It is reportedly possible for 1 person to perform the sampling without assistance by manipulating the valve in the cockpit with 1 hand, and reaching to each wing fuel sump outlet through the cockpit side windows with the other hand. This method of collecting samples, without the assistance of a 2nd person, is difficult and presents ergonomic challenges.

The investigation examined 1 instance of the wing fuel sumps of the occurrence aircraft being drained before a flight in a video recorded in 2021. In that instance, it was observed that the left wing fuel sump was drained for approximately 2 seconds, and the right wing fuel sump was drained for approximately 3 seconds. The samples were not collected or examined by the pilot operating the aircraft.43

Foregoing the collection and examination of fuel samples as part of pre-flight inspections, after fuelling, and as part of the aircraft daily inspection had become normalized at Wilderness Seaplanes. A container that could be used to collect fuel samples from the aircraft wing fuel sumps was supplied by the operator with the drum fuelling equipment, but it was not normally supplied by the operator to pilots, or carried on board the aircraft.

The operator’s Company Operations Manual, flight manual, and SOPs contained no information with respect to fuelling aircraft from fuel drums. There were also no written communications such as memos, emails, or safety bulletins regarding drum fuelling.

1.17.5 Pilot training
TC’s Study and Reference Guide for written examinations for the Commercial Pilot Licence – Aeroplane, defines the knowledge requirements to hold a Canadian commercial pilot licence. This document lists fuel handling and aircraft fuelling as required knowledge but does not list any knowledge specific to drum fuelling.44 TC’s Flight Test Guide – Commercial Pilot Licence – Aeroplane does not list aircraft fuelling, or drum fuelling, as a flight test item.45 TC’s Instructor Guide – Seaplane Rating does include information on fuelling from barrels, but it notes the exercise is not required.46

Wilderness Seaplanes requires a commercial pilot licence with a multi-engine and seaplane rating to operate the occurrence aircraft type. TC’s requirements to obtain these qualifications do not include mandatory training on fuelling aircraft from drums.

The investigation determined that no training was provided by Wilderness Seaplanes to company pilots about fuelling aircraft from fuel drums.

1.18 Additional information
1.18.1 Practices recommended by regulators when fuelling aircraft from drums
The investigation examined the recommended best practices for drum fuelling of aircraft published by TC, the FAA, the U.S. Department of the Interior Office of Aviation Services, and the Australian Government Civil Aviation Safety Authority. The following sections present a composite of the practices recommended by these 4 agencies.

1.18.1.1 Drum storage
Fuel drums should be stored on their sides;47,48 off the ground on wooden rails,49 pallets, or dunnage;50 and with vents and bungs at the 3 and 9 o'clock positions.51,52 Vents, bungs, or openings should be below the fluid level within the drum.53 Drums should be chocked, blocked, or braced to prevent rolling.54 Whenever possible, drums should be stored in sheltered, secondary containment55 and protected from the sun and weather.56 Drums containing different fuel types should be stored in separate areas, at least 50 feet apart.57,58

1.18.1.2 Drum inspection
Before fuelling, the fuel drum should be examined. The drum label should be checked to ensure the drum contains the correct type and grade of fuel.59,60 The drum fill date should be verified to ensure the fuel is not too old to be safely used.61,62 Recommendations on maximum fuel age range from 1263 to 2464 months and may vary with fuel type.65 It should be verified that the bung seal is intact to ensure fuel has not been tampered with.66 The drum should be checked for writing or markings; an X is often used to indicate that a drum contains contamination.67 A drum may be marked with a date, aircraft registration, and the approximate amount of fuel used, if it was partially used.68 In this case, how long the drum has been in an unsealed condition should be taken into consideration. The drum should be inspected for external damage. External damage to the drum may cause the epoxy paint that lines the drum to peel away from the internal surface and contaminate the fuel.69 The interior of the drum can be examined visually through the bung hole, ideally with an explosion-proof flashlight.70

1.18.1.3 Analysis of drum fuel sample
A sample can be collected from the lowest accessible fuel in the drum by pumping the first strokes into a container, which will ensure any contamination downstream of the pump filters will be flushed out.71 A sample may also be collected with a length of tube inserted to the lowest point in the drum by plugging the top end of the tube with a thumb, then releasing the thumb seal to discharge the sample into a container.72 Swirling the fuel sample can make any sediment contained within more visible.73 In addition to visually inspecting the sample, it should always be tested using water detection paste.74,75 The paste should be applied to a clean dry dowel or screwdriver, and swirled throughout the fuel sample.76

1.18.1.4 Electrical bonding and grounding
Bonding connects metal materials to create a complete electrical circuit so that none of the individual parts have electricity building up in them. The bonded circuit then needs to be connected to the ground to safely allow the electricity to drain to the earth.77 Bonding and grounding the aircraft and fuelling equipment is required to prevent a spark from igniting fuel vapour while drum fuelling.78,79 Grounding requires that the fuel drum be bonded to a ground post.80 The condition of bonding and grounding cables should be checked before use.81 When grounding and bonding, the following order should be observed: drum to ground (ground post), drum to pump, pump to aircraft, and nozzle to aircraft, all before the aircraft fuel cap is opened. When finished fuelling, reverse the order.82,83,84

1.18.1.5 Dispensing
The pick-up tube must not reach the lowest point in the drum so that the lowest portion of fuel, likeliest to be contaminated, is not pumped into the aircraft.85 The fuel filters used for drum fuelling should be replaced, at a minimum, annually.86 Filters should also be changed if a reduction in flow rate is observed.87 Fuel should pass through both a fuel particle filter and a water separator,88 or a particle filter and an expanding go-no-go filter89 before being dispensed into the aircraft. The particle filter used should be a 5-micron filter, suitable for use with fuel.90 Drum fuelling must take place a safe distance from buildings, other aircraft, and people not involved in fuelling operations.91

1.18.1.6 Analysis of aircraft fuel sample
After fuelling, the aircraft pre-flight inspection must include draining, collecting, and examining fuel samples from the low points of the aircraft fuel system.92,93 Each sample should be 10 ounces (approximately 300 ml) or more, and should be examined using a transparent container.94,95 Samples should be collected before moving or disturbing the aircraft.96 Pilots must be familiar with the specific requirements of sampling fuel from their aircraft. To obtain a representative fuel sample, it may be necessary to drain reservoirs, gascolators, or filters in addition to fuel sumps.97 Effective sampling may require the operation of fuel pumps or cross-feed valves, and tail-wheel aircraft may require raising the tail to a level flight attitude to ensure water flows to a gascolator or fuel strainer.98

1.18.1.7 Drum fuelling
Even when every precaution is followed, the regulators make it clear that, due to the associated risks, drum fuelling should not occur if other options are available. TC states: “[t]he use of temporary fuelling facilities such as drums or cans is discouraged.”99 Also, the FAA states: “[r]efueling from drum storage [emphasis in original] or cans should be considered as an unsatisfactory operation and one to be avoided whenever possible.”100

[pelmet]

I read the report, which had some interesting information in it, including a list of various sources for a number of recommendations for fuel drum handling(on page 25 and 26). One thing to note is that information sources included TC, FAA, and Australia(as all three jurisdictions have significant areas of remote aircraft operations). Useful information provided by one jurisdiction may not have been provided in other jurisdictions(we don't see much Australian aviation safety info), so it can be time-consuming to maximize collection of good knowledge.

Wilderness had only recently decided to get into drum refueling and ordered the drums and equipment. It should be noted that TC has information about proper procedures that is no doubt easily accessible on-line, yet this was not accessed. Equipment without a particle filter or water separator (as is recommended by TC) were ordered because only unopened drums were planned to be used, which were less likely to be contaminated. The wrong type of fuel pump was acquired which leaked due to incompatible threads with the hose. Water paste was not acquired due to lack of proper familiarization of it's purpose. Assumptions were made that did not go as planned, such as refueling would not happen from an already used drum(and therefore, no need for filters/separators) and that their pilots would somehow, based on previous experience, be thoroughly familiar with the process(therefore, no training required). It would be interesting to know if excuses were being made in order to save money on equipment(insider info).

When it came to the actual fueling, the pilot did decide to use a fuel drum that had already been used before. According to comments on this thread, he was the chief pilot, so perhaps not sticking with his own plan. This is a wet part of the country and the drum had not been placed on its side(meaning rainwater likely had accumulated on top of the drum, making leakage ore likely) and the pilot found the bung to be only finger-tight(a red flag).

The pilot had assistance from another company aircraft pilot for refueling the Goose as the other pilot was refueling the Beaver. A bit of confusion happens here because the handpump has a telescoping pick-up tube. The Beaver pilot did not extend the pick-up tube beyond about half-length for use and therefore when he did take a fuel sample, it was from mid-point and the sample was clean. Then the Beaver was refueled. For the Goose, the pick-up tube was then extended by the Beaver pilot to its full length, perhaps as fuel was no longer being picked up. Once this was done, the pick-up was long enough to reach the water in the drum. However, a second sampling was not done and the contamination from near the bottom of the drum was pumped into the Goose. I suspect that the Goose pilot may not have been aware of telescoping from different depths.

Fuel sampling from the Goose is not easy and required two people to do it easily(although some sort of a special sampling tool has since been created for one person). Therefore, the Goose pilot did not sample fuel from the aircraft. That being said, he could have gotten assistance from the Beaver pilot if he was still there. Notably, company SOP was to only sample fuel for the first flight of the day.

The bottom line is that you have to be paranoid about contamination and sampling fuel. Doing this a second time or waiting for assistance might be very wise. Always try to sample after refueling and especially when refueling from a drum/jerry can. One can get used to the always clean and bright fuel samples we get in certain operations from reliable sources. Other times, one needs to be on high alert.

[phillyfan]

Using drums left standing up ,with a loose bung, without a filter is never going to be successful procedure long term. Good work by the driver that everyone lived.