[freebeard]

I fact-checked my memory, but I didn't (still haven't) find the NTSB report but I did find this: www.asktog.com/columns/027InterfacesThatKill.html

Lessons to be Learned

John Denver learned the biggest lesson of all, even if he only had a few seconds to appreciate it: Let the User Beware! And, indeed, the NTSB, as per its long history of setting aside findings, human factors or otherwise, that might conflict with a verdict of pilot error, ruled that the responsibility for this crash lay with the pilot. The interface was relegated to a mere "factor." Had John Denver fueled his aircraft in spite of evidence indicating he had sufficient fuel, had he somehow managed to thoroughly familiarize himself with the idiosyncrasies of this uniquely-assembled experimental aircraft sans manual, he would be alive and well today.

However, to those of us versed in even rudimentary human factors, it is easy to see that the design of this fuel system was a disaster waiting to happen, as was borne out not only by what Denver experienced, but by incidents reported by two previous pilots of this same plane who almost met death under the same circumstances. Presumably, they had a bit more altitude when their fuel starved out and, therefore, a bit more time to react.

Looking further: tighar.org/smf/index.php?topic=563.0

Denver was shorter than the guy who constructed the plane and the seats are not adjustable so Denver had placed a cushion behind his back so that he was moved further forward so he could reach the rudder pedals with his feet. This placed the fuel handle further away, making it hard for Denver to reach it. He asked the mechanic if he could borrow a set of vice-grips which he then clamped to the valve handle so he could turn the handles of the vice-grips which then turned the valve. The mechanic looked at this and said "why don't you just let me put some gas in and you won't have to worry about it" but Denver again refused. The mechanic testified, "I looked at the arrangement of the vice-grips and I didn't like how it looked so I made Denver give me my vice-grips back." That was the smartest thing the mechanic ever did because if he had left those vice-grips in the plane then he would have been sued too.

So Denver took off, did a few touch and goes and then flew off to buzz Clint Eastwood's house. All together now class, if you have been paying attention, how much gas did Denver have left in the plane when he took off for his last flight? Apparently Denver couldn't figure that out for himself. When the engine stopped, because of fuel starvation, Denver attempted to switch fuel tanks, in the process he had to take his right hand off the side stick and twist his body around to the left to reach the fuel valve handle. Since it was far behind his shoulder he pushed on the right rudder pedal to help twist his body to the left and the airplane rolled over to the right and dove into the bay.