# NTSB ERA14LA111: Gates Learjet 35A, N979RF, Ft. Lauderdale, FL, February 3, 2014 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: February 2, 2014, 22:30 local (Feb 3, 2014, 03:30 UTC) - Place: Ft. Lauderdale, FL - Coordinates: 26.078056, -80.142501 - Nearby events: https://openairdocs.org/map.md?lat=26.0781&lon=-80.1425&mi=10 - Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping) - Defining event: [Taxi: Loss of visual reference](https://openairdocs.org/ntsb-events/402) - Highest injury: Serious injuries - Injuries: 1 serious, 4 uninjured; on the ground: 1 serious - Status: Completed, report September 24, 2014 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 88753 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14LA111 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88753/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88753 - Page: https://openairdocs.org/ntsb/ERA14LA111 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Attention/monitoring: monitoring other person](https://openairdocs.org/ntsb-findings/02021535): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Gates Learjet 35A, 1 case](https://openairdocs.org/ntsb-findings/02021535/cases.md?model=5170602), [All aircraft, 200 cases](https://openairdocs.org/ntsb-findings/02021535/cases.md) - [Communication (personnel): following instructions](https://openairdocs.org/ntsb-findings/02063537): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Gates Learjet 35A, 1 case](https://openairdocs.org/ntsb-findings/02063537/cases.md?model=5170602), [All aircraft, 31 cases](https://openairdocs.org/ntsb-findings/02063537/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Taxi: Ground handling event](https://openairdocs.org/ntsb-events/080); cases with it: [Gates Learjet 35A, 1 case](https://openairdocs.org/ntsb-events/080/sequence.md?model=5170602), [All aircraft, 108 cases](https://openairdocs.org/ntsb-events/080/sequence.md) - [Taxi: Loss of visual reference](https://openairdocs.org/ntsb-events/402) (defining event); cases with it: [Gates Learjet 35A, 2 cases](https://openairdocs.org/ntsb-events/402/sequence.md?model=5170602), [All aircraft, 242 cases](https://openairdocs.org/ntsb-events/402/sequence.md) ## 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](https://openairdocs.org/aircraft/N979RF), registered now, S/N 376, built 1981 (OpenAirDocs) - Reported make and model: GATES LEARJET CORP. 35A (A) - Registry model: [Gates Learjet 35A](https://openairdocs.org/model/gates-learjet-35a) (registry code 5170602) (OpenAirDocs) - Registry engine: [Garrett TFE731 series](https://openairdocs.org/engine/garrett-tfe731-series) (registry code 29001, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 376 - Year built: 1981 - Airframe hours: 12555 - Engines: GARRETT TFE 731 SER 1550 lbs thrust turbo fan; GARRETT TFE 731 2 2B 1550 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 25; injuries: none; 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 - Co-pilot; age 24; injuries: none; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20140202001779A](https://openairdocs.org/incident/20140202001779A), Feb 2, 2014: Gates Learjet Corp. 35A, Ft. Lauderdale, FL, Minor damage. Aircraft was connected to a ground power cart unit for starting. The pilot thought that the power unit was dosconnected from the aircraft after start and began… ## Other investigations on N979RF (1) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB ERA23LA081](https://openairdocs.org/ntsb/ERA23LA081), Dec 2, 2022: Learjet 35 (N979RF), Guantanamo Bay, Cuba, substantial damage. Probable cause: The flight crew’s continuation of an unstable approach which resulted in abnormal runway contact during the landing flare and touchdown. ## Docket (7 files) The files NTSB released with the investigation on May 8, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88753. 7.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412117&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Copilot Statement (item 2, .PDF, 156 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412118&FileExtension=.PDF&FileName=Copilot%20Statement%20-Redacted.PDF - Linecrew Statement (item 3, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412119&FileExtension=.PDF&FileName=Linecrew%20Statement-Redacted.PDF - Interview Summary Letchworth (item 4, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412120&FileExtension=.PDF&FileName=Interview%20Summary%20Letchworth-Master.PDF - Weather Reports and Records (item 5, .PDF, 121 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412121&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Photo 1_Picture of the damage to the airplane skin (Courtesy of the FBO) (item 6, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412123&FileExtension=.PDF&FileName=Photo%201_Picture%20of%20the%20damage%20to%20the%20airplane%20skin%20(Courtesy%20of%20the%20FBO)%0D%0A-Master.PDF - Photo 2_Picture of the Ground Power Unit (Courtesy of the FBO) (item 7, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412124&FileExtension=.PDF&FileName=Photo%202_Picture%20of%20the%20Ground%20Power%20Unit%20(Courtesy%20of%20the%20FBO)%0D%0A-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.