Delivery

Review of the fuel ticket revealed that the misspelled words; "Top Neclles" was handwritten on it. It was also signed by the pilot. Further review revealed that only 25 gallons had been uploaded to the airplane, and this number had been entered in the box labeled "TOTAL GALLONS DELIVERED". Review of the start reading and end reading from the truck meter also concurred with this amount. Furthermore, It was discovered that the "134 gallons" that the pilot believed had been uploaded to the airplane was in fact the employee number of the fueler that had topped off the nacelle tanks and had entered his employee number on the "FUEL DEL BY:" line. Utilizing the information contained on the fuel ticket, it was determined that the airplane had departed with only 261 gallons of fuel on-board. Review of performance data in the POH/AFM revealed that in order to complete the flight the airplane would have needed to depart with 328 gallons on-board.

Findings as to Causes and Contributing Factors:
1. At the fuel compound, the 45-gallon drum containing slops was located near the stock of sealed 45-gallon drums of 100LL AVGAS, contributing to the fuel handler selecting the drum of slops in error.
2. The 45-gallon drum of slops had similar markings to the stock of sealed 45-gallon drums of 100LL AVGAS, preventing ready identification of the contaminated drum.
3. The fuel handler did not notice that the large bung plug was not sealed on the second 45-gallon drum and, as a result, delivered the drum of slops to the aircraft.
4. The pilots did not notice that the large bung plug was not sealed on the second 45-gallon drum and, as a result, fuelled the aircraft with contaminated fuel.
5. The pilots were inexperienced with refuelling from 45-gallon drums and did not take steps to ascertain the proper fuel grade in the second 45-gallon drum. As a result, slops, rather than 100LL AVGAS, was pumped into the aircraft’s fuel system.
6. The fuel system design was such that the fuel from both wing fuel cells combined in the centre fuel cell and, as a result, contaminated fuel was fed to both engines.
7. The contaminated fuel resulted in engine power loss in both engines and the aircraft was unable to maintain altitude after takeoff.
Finding as to Risk:
1. The impact force angles were substantially different from that of the ELT’s G-switch orientation. As a result, the ELT did not activate during the impact. This could have delayed search and rescue (SAR) notification.

For reasons that could not be determined, the aircraft commenced a slight left angle of bank and drifted left after lift-off at a height from which the pilot was unable to recover prior to strinking trees to the left of the runway". The pilot, aged 60, accumulated 2,128 flying hours within 975 on type. The aircraft, built in 1979, totalised approximately 3,254 flying hours.

The following findings were reported:
- The pilot was appropriately licensed, rated and experienced for the series of flights undertaken.
- The aeroplane had a valid airworthiness certificate and had been released to service.
- There was nothing (other than the item in 3.5) to suggest that the aeroplane was operating abnormally on the final flight.
- The aeroplane was being operated at 14 000 feet pressure altitude without supplementary oxygen as required by CAR 91.209 and 91.533.
- The left front fuel filler orifice was observed to be leaking fuel before departure.
- There was no attempt made to further investigate or correct this fuel leak and the pilot stated that it would stop once he departed.
- On most other aircraft this would be true, once the fuel level dropped away from the filler orifice and was no longer affected by aerodynamic suction.
- On the 750XL, the fuel system design was such that the front tanks were continuously topped up.
- The fuel loss would continue until all fuel in the rear tanks and the ferry system was consumed.
- The front fuel caps are thus critical items to be checked before flight.
- The fuel quantity uplifted at Hilo indicated that the problem had existed on the previous leg with a loss rate of up to 125 litres (33.2 US gallons) per hour.
- A comparison of the uplift figure with the expected consumption on the previous leg should have provided sufficient warning to the pilot that a problem existed.
- The existence of the problem could have been detected on the final flight by the shortened top-up intervals and by comparing fuel used by the engine with fuel remaining.
- Cumulative delays, especially including the longer than normal final refuelling time, probably influenced the pilot’s decision to depart without further checking the reason for the fuel leak or the apparent discrepancy between fuel figures.
- Cumulative fatigue, circadian rhythm and hypoxia were probably significant factors in the pilot’s failure to detect the fuel problem in flight, in time to make a safe return.
- By the time the pilot announced that he had a fuel problem, the only course of action open to him was ditching the aeroplane.
- The search and rescue facilities were activated appropriately, and had the potential to effect a successful rescue.
- The water entry impact on ditching was reasonably severe and probably incapacitated the pilot before he could vacate the cockpit.