Pilot Debrief

DASSAULT AVIATION MIRAGE F1 CR near Glendale, AZ — 2022-02-10

Final reportWPR22FA094
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Date
2022-02-10
Location
Glendale, AZ, USA
Airport
LUF
Aircraft
DASSAULT AVIATION MIRAGE F1 CR
Registration
N633AX
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Climb

Probable cause

A loss of engine power due to fuel exhaustion as result of the failure of maintenance personnel to ensure the airplane was serviced with the correct amount of fuel, the failure of maintenance personnel and the pilot to adequately check the airplane’s paperwork to ensure the correct amount of fuel was present for the flight, and the failure of the pilot to adequately monitor the airplane’s fuel status during the flight.

NTSB narrative

A turbo-jet airplane was being operated as a public-use aircraft in support of the United States Air Force’s simulated combat flight training at the time of the accident. The airplane took off and proceeded to the Military Operating Area (MOA) and, near the completion of the flight the pilot reported a discrepancy between the two fuel quantity indications in the cockpit. Shortly thereafter, the pilot headed back to the airport once the airplane reached its briefed minimum fuel status. While en route to the airport, the pilot reported a loss of fuel pressure and shortly afterward the engine flamed out. The pilot attempted to restart the engine but was unsuccessful. When the pilot determined that he could not make the runway at his destination, he turned toward an uninhabited area and successfully ejected from the airplane. Subsequently, the airplane impacted terrain. Postaccident interviews revealed that the airplane was not fueled with the correct amount of fuel for the flight by maintenance personnel before the flight. Although the refueling forms accurately reflected the shorted amount of fuel, the error was not detected by maintenance personnel or the pilot before the airplane took off. During the flight, the pilot failed to notice that his fuel load was incorrect. The pilot relied on a fuel remaining totalizer that had been manually set to the expected full fuel load, not to the actual fuel load, and did not appropriately reference the individual fuel quantity tapes. Postaccident examination of the airplane wreckage revealed that the airplane’s fuel tanks had loose sealant globules inside the main feeder fuel tanks and an additional piece of Foreign Object Debris (FOD) present. Additionally, the operator discovered that several of their F-1 airplanes were found with varies type of FOD in the fuel tanks, including loose pieces of fuel tank sealant, which led to fuel anomalies including issues that caused false full tank fuel indications during refueling. Once the FOD was removed, the airplanes’ fuel system anomalies that were experienced were virtually eliminated. It is possible that the FOD caused anomalies during refueling of the accident airplane and presented a false full tank indication, which contributed to the airplane not being serviced to the correct fuel load.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot failed to verify fuel load before takeoff despite discrepancies.

NTSB coding

Evidence available

  • FDR / data
  • 9 docket documents
View NTSB final reportView NTSB docket

Docket documents9

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