ERA14LA111

NTSB accident investigation · Gates Learjet 35A · Ft. Lauderdale, FL · February 3, 2014

Accident · Serious injuriesLimited investigationFinal report
Date
February 2, 2014, 22:30 local (Feb 3, 2014, 03:30 UTC)
Place
Ft. Lauderdale, FL
Injuries
1 serious, 4 uninjured; on the ground: 1 serious
Damage
No damage
Phase of flight
Taxi
Aircraft
N979RFGates Learjet 35A
Defining event
Taxi: Loss of visual reference
Weather
Visual (VMC) · Night/dark
Status
Completed · report September 24, 2014
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20140202001779A
Case key
88753

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot’s failure to ensure that the ground power unit was disconnected from the airplane via hand signals from the lineman providing ground services before taxiing, which resulted in an injury to the lineman.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot, copilot, and two additional crewmembers were preparing to depart on a night medical transport flight. The copilot was at the controls of the airplane while the pilot monitored the airplane's systems and prepared for takeoff. During the engine start, one of the two linemen providing ground services to the airplane departed the ramp area leaving one lineman alone, which the operator allowed for normal ground servicing operations. After completing the engine start, the copilot gave the disconnect ground power hand signal to the lineman. The lineman responded with the hold hand signal and then moved to the left and rear of the airplane to disconnect the ground power unit (GPU). The pilot stated that he monitored the airplane's voltmeter to verify that the GPU was disconnected by observing a drop in the voltage current. However, although the drop in voltage could confirm that the GPU was no longer supplying power, it could not confirm that the GPU cable was disconnected. The pilot then looked out the window and realized that the airplane was moving forward. The pilot took the controls, applied the brakes, and set the parking brake. The pilot did not have visual contact with the lineman, so he asked the two crewmembers seated in the cabin to locate him, and one of the crewmembers reported that she saw him standing next to the GPU. The pilot then began to taxi the airplane for departure within the nonmovement area of the ramp; the pilot did not realize that the GPU was still connected to the airplane. As the airplane turned right, the GPU was pulled onto its side, and it then fell onto the lineman's right leg, which resulted in a serious injury. The pilot stopped the airplane and shut down the engines without further incident. The pilot should have ensured that the GPU was disconnected from the airplane via hand signals from the lineman providing ground services before taxiing the airplane and his failure to do so resulted in the lineman's injury.

Factual narrative

On February 2, 2014, about 2230 eastern standard time, a Gates Learjet Corporation L35A, N979RF, sustained minor damage while taxiing in preparation for a flight at Fort Lauderdale International Airport (FLL), Fort Lauderdale, Florida. The pilot, copilot, and two additional crewmembers were not injured. A lineman sustained serious injuries. The airplane was owned and operated JEDAMI Air, LLC, under 14 Code of Federal Regulations Part 135, as a medical transport flight. Night visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for the flight that was destined for Owen Roberts International Airport (MWCR), Cayman Islands. According to the pilot, he occupied the left seat and the copilot occupied the right seat. The copilot was at the controls of the airplane. During engine start, the copilot observed one of the two linemen depart the ramp area, leaving one lineman remaining to assist the airplane with ground operations. After completion of the engine start, the copilot gave the disconnect ground power hand signal to the lineman. The lineman moved to the left and rear of the airplane to disconnect the ground power unit (GPU). The pilot monitored the airplane's voltmeter to verify disconnect by observing a drop in the voltage current. After placing the airplane's two generators on line, the pilot looked up and outside to find that the airplane was rolling forward at idle power. The pilot applied the brakes and set the parking brake. After about 5 minutes, the flight crew still did not have visual contact with the lineman; however, the additional crewmembers seated in the cabin observed the lineman standing next to the GPU. The pilot took controls of the airplane and began a right turn to taxi in the ramp area. The copilot glanced out of the right cockpit window and notified the pilot that the lineman was lying on the ground. The pilot stopped the airplane and shut down the engines. When the occupants exited the airplane, they observed that the GPU was lying on top of the lineman, and were able to move lift it off of him. According to a statement provided to police, the lineman gave the pilot the "HOLD" signal and proceeded to the GPU that was still connected to the airplane. The lineman stated that as he attempted to disconnect the GPU from the airplane, the airplane began moving forward, pulling the GPU over, and knocking him down to the ground. The GPU came to rest on his right leg. Examination of the airplane did revealed minor damage to the GPU connector points and to the airplane skin. The lineman was transported to the hospital for further treatment. According to the manager of the operator, normal ground servicing operations were conducted utilizing either one or two lineman depending on availability. In the NTSB Pilot/Operator Accident Report Form, the operator noted that an observed drop in voltage confirmed that the GPU was no longer supplying power to the airplane; however, it would not confirmthat the GPU cable had been disconnected.

Aircraft

Registration
N979RF
Reported as
Gates Learjet 35A (A)
Category
Airplane
Serial number
376
Built
1981
Airframe hours
12,555
Engines
Garrett TFE 731 SER, 1,550 lbs thrust, turbo fanGarrett TFE 731 2 2B, 1,550 lbs thrust, turbo fan
Damage
No damage
Flight
Part 135
Operator
Jedami Air LLC
Registered owner
Jedami Air LLC
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · January 31, 2014 · 167 hours before
Departed
KFLL · Ft. Lauderdale, FL
Destination
MWCR · Grand Cayman
Flight plan
IFR
Airport
KFLL · Fort Lauderdale International
Equipment
Electronic multifunction display, Onboard weather, Stall warning system, Auto-pilot, Data recorder, Electronic flight bag or handheld device

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
25
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
October 30, 2013
Seat
Left
Restraint
4-point
Flight hours
2,167 total · 1,543 in this make and model · 607 as pilot in command · 139 in the last 90 days · 32 in the last 30 days
Role
Co-pilot
Age
24
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
January 15, 2014
Seat
Right
Restraint
4-point
Flight hours
1,650 total · 64 in this make and model · 1,461 as pilot in command · 141 in the last 90 days · 70 in the last 30 days

Weather

Conditions
Visual (VMC) · Night/dark
Wind
110° at 10 knots
Visibility
10 statute miles
Lowest ceiling
4,000 ft broken
Temperature
73 °F, dew point 72 °F
Altimeter
30.09 inHg
Observed at
FLL

Docket · 7

The files NTSB released with the investigation on May 8, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.9 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N979RF · 1

Matched to the same aircraft by N-number and date.