# NTSB ERA14LA465: Britten-Norman BN-2A, N906GD, Ceiba, PR, September 28, 2014 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: September 28, 2014, 10:00 local (13:00 UTC) - Place: Ceiba, PR - Coordinates: 18.245277, -65.643333 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=18.2453&lon=-65.6433&mi=10 - Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping) - Defining event: [Taxi-to runway: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) - Highest injury: Minor injuries - Injuries: 1 minor, 6 uninjured - Status: Completed, report April 20, 2016 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA - NTSB case key (mKey): 90223 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14LA465 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90223/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90223 - Page: https://openairdocs.org/ntsb/ERA14LA465 ## Probable cause The pilot’s loss of consciousness during taxi for reasons that could not be determined based on the available information. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Impairment/incapacitation: other loss of consciousness](https://openairdocs.org/ntsb-findings/02012055): Personnel issues › Physical · Pilot (probable cause); cases with it: [Britten-Norman BN2A-26 ISLANDER, 1 case](https://openairdocs.org/ntsb-findings/02012055/cases.md?model=1520226), [All aircraft, 21 cases](https://openairdocs.org/ntsb-findings/02012055/cases.md) - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Britten-Norman BN2A-26 ISLANDER, 1 case](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=1520226), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Taxi-to runway: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) (defining event); cases with it: [Britten-Norman BN2A-26 ISLANDER, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=1520226), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Taxi-to runway: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Britten-Norman BN2A-26 ISLANDER, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=1520226), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The airline transport pilot was taxiing the airplane for takeoff for the on-demand air taxi commuter flight. The pilot reported that, while taxiing to the runway, he felt dizzy and lost consciousness. The airplane subsequently veered off the taxiway into a ditch with the engines were still running. The pilot shut down the engines and instructed the passengers to exit the airplane. The pilot reported that it was hot and that he hadn't eaten breakfast before the accident flight; however, neither of these things should have caused the pilot to lose consciousness without other health issues involved. A review of the pilot's medical history revealed no evidence that he was taking any medications or that he had visited health care providers for any medical issues. The reason that the pilot lost consciousness could not be determined based on the available information. ## Factual narrative On September 28, 2014, about 1000 Atlantic daylight time, a Britten-Norman BN-2A-26, N906GD, collided with a ditch after the pilot reported that he lost consciousness while taxiing for takeoff at Jose Aponte de la Torre Airport (TJRV), Ceiba, Puerto Rico. The airline transport pilot received minor injuries and the six passengers were not injured. The airplane sustained substantial damage. Visual meteorological conditions prevailed and no flight plan was filed. The airplane was registered to Air Charter Incorporated, and operated by Air Flamenco under the provisions of Title 14 Code of Federal Regulations Part 135 as an on-demand air taxi flight from TJRV to Benjamin Rivera Noriega Airport (TJCP), Isla de Culebra, Puerto Rico.The pilot reported that prior to the flight, it was extremely hot that day and he did not eat breakfast. While taxiing to the runway, he felt dizzy, lost consciousness, and subsequently the airplane veered off the taxiway and came to rest in a ditch. When the pilot regained consciousness the engines were still running and the passengers were asking the pilot "what should they do." The pilot shut down the engines and instructed the passengers to open and exit through the rear of the airplane. The passengers exited through the rear doors and gathered on the taxiway behind the airplane. The pilot exited the airplane, verified that there were no injuries, and called for emergency services. Examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed that the airplane sustained substantial damage to the nose gear firewall. A review of the pilot's most recent medical evaluation dated September 25, 2014, for an FAA first-class medical certificate, revealed that the pilot was in good health and only had limitations for wearing corrective lenses. There were no reports of any medications or any visits to health care providers in any of the medical history forms supplied as part of his medical exams. The 0853 recorded weather at the TJRV, included wind from 160 degrees at 5 knots, 10 statute miles visibility, and clear, temperature of 28 degrees C, dew point temperature of 25 degrees C, and an altimeter setting of 30.01 inches of mercury. ## Aircraft - Registration: [N906GD](https://openairdocs.org/aircraft/N906GD), registered now, S/N 847, built 1979 (OpenAirDocs) - Reported make and model: BRITTEN-NORMAN BN-2A (26) - Registry model: [Britten-Norman BN2A-26 ISLANDER](https://openairdocs.org/model/britten-norman-bn2a-26-islander) (registry code 1520226) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 3008 - Year built: 1984 - Airframe hours: 15926 - Engines: Lycoming O-540-E4C5 260 horsepower reciprocating; Lycoming O-540-E4C5 260 horsepower reciprocating - Damage: Substantial damage - Flight: Part 135 - Operator: Air Charter Inc, doing business as Air Flamenco - Registered owner: Air Charter Inc - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, September 9, 2014, 24 hours before - Departed: TJRV, Ceiba, PR - Destination: TJCP, Isla de Culebra, PR - Airport: TJRV, Jose Aponte de la Torre Airpor, runway 7/25, 11,000 × 150 ft, concrete - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: minor; commercial, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review September 1, 2013; seat: left; restraint: 3-point; flight hours: 22,000 total, 4,500 in this make and model, 14,000 as pilot in command, 230 in the last 90 days, 75 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 160° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 82 °F, dew point 77 °F - Altimeter: 30.01 inHg - Observed at: TJNR ## 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 20140928020909A](https://openairdocs.org/incident/20140928020909A), Sep 28, 2014: Britten-Norman BN2A-26 ISLANDER, Ceiba, PR, Substantial damage. On 09/28/2014 @ 10:00 local time flt 3202 of air charter (dba air flamenco) deviated from the taxiway centerline and when off the taxiway and ended in a ditch… ## Docket (3 files) The files NTSB released with the investigation on March 8, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90223. 2.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 410 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437475&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Witness Statements (item 2, .PDF, 443 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437476&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - Accident Photos (item 3, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437479&FileExtension=.PDF&FileName=Accident%20Photos-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.