It’s the little things that get you

The morning was warm and sunny with a light breeze blowing out of the east. Perfect for a runway 8 departure from North County airport in Southern Florida to Flying W airport in Lumberton, New Jersey. This was the return trip of our first long cross country and it was with some excitement, not to mention trepidation, that I checked the weather (again), went over the charts (again) and tried to think of anything I missed.

Joe Weinberg by Bonanza
A beautiful day to fly – what could possibly go wrong?

My wife Diane had flown with me many times before, but most of our trips were within a few hundred miles of home. While not nervous, she was a bit anxious, and I did my best to reassure her that everything was going to be fine. We had planned a stopover in Charleston where we would eat the lunch Diane had packed and stretch our legs before resuming the flight north.

I called Flight Service one last time in the car on the way to the airport and the briefer confirmed what I already knew: the weather was fine for the trip. We were both quiet in the car on the ride to the airport, each ensconced in our own reverie. The sun was just coming up and the few early risers on the way to work that morning drove by us, probably contemplating their own upcoming day… as we did ours. None of us knowing what the day would bring.

At the airport, I returned the rental car and did the pre-flight on my A36 Bonanza, while being especially careful to follow the checklist. After checking off all the items, I loaded the suitcases and verified the weight and balance, noting the CG. Finally I was ready to go.

After announcing on the CTAF that I was taxiing to the run-up area and slowly taxiing into position on the run-up tarmac, I went through the “before takeoff” checklist. At some point, I dropped my pen but after fishing around awhile I could not find it and gave up. Being the good Boy Scout that I am, I was prepared with another pen and continued on with the checklist.

Now, the Bonanza has an item on the checklist that reads:

“Fuel Selector Valve – Check Operation, then Select Fuller Tank (feel for detent/confirm visually)”

Fuel selector in Bonanza
Don’t just feel for it – look at it.

Because the fuel selector is by the pilot’s left foot, and consists of a three-position switch, my procedure was to check it by reaching down and turning the handle to verify that it went from left to right, or vice versa, and was not in the “off” position. (I had full fuel in both tanks so there was no need to look for the fullest tank).

As usual, I reached down and made this check. With everything set to go, I told Diane to be sure she was strapped in and I happily looked forward to soaring into the morning sky. I advanced the power and the 300 hp Continental IO-550 began to barrel us down the runway while I continued looking at the trees at the far end. Racing toward them, I checked my airspeed and fuel flow and began to rotate… and just before I did… the engine died! Like in Dead. Fortunately, its death occurred short of the crossing highway and the trees.

After rolling to a stop and sitting dumbfounded near the end of the runway for a moment, I called the FBO for a tow and tried to determine what happened. Finally, I figured it out… it was the pen.

The pen had dropped onto the top of the fuel selector and wedged itself so that the handle turned, but not all the way. I had never visually checked the selector and simply relied on feel. With the switch in the “in-between” tank positions, neither tank drew fuel and the fuel stopped flowing when I advanced the power. To be sure, we were extremely fortunate that there was not a lot of fuel left in the lines after the taxi, run-up and wait for our clearance. A bit more fuel and I would have been airborne and then collided, with devastating effect, into the trees, and I would not be here to tell you about it. I can tell you that our pleasant reverie in the car on the way to the airport did not envision such a near-death experience.

I guess the moral is: no matter how carefully you check and double check, watch out for the little things. They are the ones that get you.

I suppose there is also an alternate moral which is: if something drops, pick it up!

13 Comments

  • Thank you for sharing. On the same note, I had a stressful landing with an aluminum water bottle stuck behind the rudder, not fun.

  • Complacency … the term has such a negative connotation, that we pilots tend to ascribe it always to others and are loathe to admit it in ourselves, but all of us are subject to it and occasionally guilty of it.

    To mis-control an aircraft for whatever reason and under whatever circumstances, is easy to understand, given that the human mind has only so much band-width available to manage and juggle multiple demands upon our attention, and flight skills acquired with great effort also atrophy all too quickly.

    But fuel mismanagement is also a common source of GA accidents. It doesn’t take any great pilot skill to switch tanks, nor any great skill to monitor the fuel gages, or to track the flight hours to calculate fuel burn and fuel remaining … yet these fuel management accidents, like loss of control, just keep happening, and they’re almost entirely due to pilot complacency.

    With all of the emphasis we pilots devote to monitoring, maintaining, and as necessary, repairing our engines, and given the expense incurred in doing so, it’s rather amazing how little consideration we all too often devote to managing the fuel that keeps them running. It’s a matter of complacency.

  • You left out important details. What did your wife say, did she hop right back in that day and will she still fly with you? LOL

  • I am extremely fortunate and she does fly with me all the time. Although, I will give you that she did not exactly “hop” back in. 🙂

  • This is a VERY good lesson, and brings home a point about preflighting and pre start and after start checklist.

    I could make a strong argument to have as many items on the before start check list that will assure it will fly correctly BEFORE starting. Things like the proper tank, trim, and controls free, and never touch them again until well after takeoff (excepting controls, of course)…. but will be verified in the pre takeoff checklist.

    Also, in the after start, we can check the bulk of the “engine running” items like oil pressure, fuel flow, temps coming up and can really do the entire before takeoff checklist before moving the plane (unless we’re parked by the FBO door, we don’t want to blast any one).

    However, this story is a good reminder.

    I, too, am a Beechcraft fan, having owned a few of them. I could also argue with the Beech line, that one could make a really simple checklist with only the major items on it to be sure to catch the killer ones. And, for the most part, there are only three killers items: fuel, controls and trim….. the rest of them are “embarrassment” items, which also need to be covered but not as critical.

    • Steve – you bring up a good point that I previously glossed over in Joe’s story.

      Why would the checklist call for checking fuel tanks as a “pre-flight” item instead of as a “pre-start item”? That actually seems weird.

      I’ve been so used to my checklist (I use a commercial laminated checklist published by CheckMate designed for my Cherokee 180) wherein the fuel selector check is made prior to engine start, that I didn’t think to question why Beechcraft called for checking the tank selector as a pre-takeoff item.

      Yes, of course, set the fuel tank before you start the engine, and then leave the darn thing alone until you need to change it, preferably at cruising altitude or approach to landing.

      If there is a problem either with the fuel selector itself, or if there is a problem anywhere else in the fuel system (including the fuel), the longer you run the engine before starting the takeoff roll (including the run-up), the more likely a problem will reveal itself in actual engine performance before you start the takeoff roll.

      Thanks for pointing that out for us.

      A question for Joe:

      Is the fuel tank selector position in the Beech checked at any time prior to the pre-takeoff list, making that check redundant? If so, I’d scratch that item from the pre-takeoff list .. and if not, if I were you I’d move the fuel tank selector check from pre-takeoff to pre-start and then leave it alone!

  • My preference is to make sure I switch to the fullest tank prior to landing and not touch the fuel selector until I am back up at altitude. The logic being that it was feeding fuel when I landed so it will continue to feed fuel when I launch. If I add fuel to the airplane, I add the same amount to each tank and still don’t have to change the selector valve until back at altitude and it is time to change tanks. Of course I don’t always get my preference in the instance of maintenance or something else and in those cases I am very, very vigilante.

    • James,

      I could argue that you have a very good profile. And I could argue to NOT touch the rule selector from TOD (top of descent) to TOC on the next flight. Works for me.

  • Duane,
    Good question and good point. The Beech A36 POH for my serial number calls for the fuel selector valve check as item 19 on the “Before Starting” checklist. It is also item 19 on the “Before Takeoff” list. The “Before Starting” list calls for the pilot to “Check Operation” while the “Before Takeoff” list simply says “Check Tank Selected” each with the same caveat to feel and visually check the détente. However, among the points I was trying to make in the article was that the fine print in the checklist calls for the pilot to ” CHECK VISUALLY”. Regardless of when it was done this pilot missed the “visually” part. A small but almost deadly miss.

    • Joe – gotcha … this, however, is another illustration of the old “Murphy’s Law”, or what we in the US Navy used to say, “nothing can be made sailor-proof”.

      I’d just line out completely the redundant “check visually” fuel selector item in the Beech pre-takeoff list. Being redundant, it’s simply not useful, and being as how it can be mis-interpreted or mis-used (proving that it’s not “pilot proof”), it only introduces Murphy’s Law into the pre-takeoff checklist.

      I completely agree with Steve’s suggestion elsewhere in this thread that the only useful way to check fuel system operation in the takeoff process is to verify fuel flow (if you have it on the panel, as the Beech A36 does) along with manifold pressure, long before you rotate. On simpler aircraft like my Cherokee 180, unless an engine monitor system with fuel flow retrofit is installed, all we can do simply check to see that the proper RPMs are being produced.

      As Steve wrote, too many items in the checklist during critical flight operations is itself a problem for a single pilot. Too many and/or redundant checks do not add to safety, and by complicating matters, they actually tend to reduce safety.

  • Another possible contributing factor is that checklists are just too long and contain too much. I’d argue to make you own (perfectly legal and appropriate). Design it to get the killer items for SURE and a logical sequence for the items and equipment in your plane.

    Know what’s in the POH, but design one that’s best for your plane.

    Another thing… have a flow and use the checklist to check.

    And have yourself mandatory call outs, especially early on the takeoff roll….
    Gauges in the green
    Fuel flow normal (or read the actual GPH)
    RPH and MP normal

    I’d bet that the fuel flow was not full flow on the initial takeoff run… just another check.

Leave a Reply

Your email address will not be published. Required fields are marked *