ERA15LA124

NTSB accident investigation · Dehavilland DHC 6 Twin Otter · Sebastian, FL · February 9, 2015

Accident · No injuriesLimited investigationFinal report
Date
February 9, 2015, 06:15 local (11:15 UTC)
Place
Sebastian, FL
Injuries
3 uninjured
Phase of flight
Standing
Aircraft
N30EADehavilland DHC 6 Twin OtterN70EADehavilland DHC 6 200
Defining events
Standing-engine(s) start-up: Loss of control on groundStanding-engine(s) not oper: Ground collision
Weather
Visual (VMC) · Day
Status
Completed · report July 13, 2015
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Case key
90702

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

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Probable cause

The pilot's failure to conduct all of the required items on the Before Starting Engines checklist, which resulted in her failure to detect an open hydraulic circuit breaker and led to insufficient hydraulic pressure to operate the airplane's brakes, her subsequent loss of airplane control, and ground collision with an airplane.

The failure of the other airplane pilot to conduct all of the required items on the Before Starting Engines checklist, which resulted in her failure to detect an open hydraulic circuit breaker and led to insufficient hydraulic pressure to operate the airplane’s brakes, her subsequent loss of airplane control, and ground collision with an airplane.

Findings · 4

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.

N30EA · Dehavilland DHC 6 Twin Otter

N70EA · Dehavilland DHC 6 200

Use of equip/info: use of checklistPersonnel issues › Task performance · Pilot of other aircraftDehavilland DHC-6-200: 1 caseAll aircraft: 336 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · Pilot of other aircraftDehavilland DHC-6-200: 1 caseAll aircraft: 9,295 casesProbable cause

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.

N70EA · Dehavilland DHC 6 200

Analysis

A de Havilland DHC-6 Twin Otter airplane, N30EA, collided with another Twin Otter airplane, N70EA, on the runway. The pilot of N30EA reported that, once she started the engines, the airplane rolled forward and to the left 180 degrees because the steering-tiller had been positioned sharply to the left when the airplane was last parked. The pilot stated that, when she applied the brakes, there was no response, and the airplane subsequently collided with the right wing of N70EA. The pilot of N30EA reported that, after the collision, she noted that the hydraulic circuit breaker was open; this would have resulted in insufficient hydraulic pressure to control the parking or pedal brakes. The pilot of N30EA said that she should have noticed that the hydraulic circuit breaker was open before she started the engines because it was part of the Before Starting Engines checklist.

A de Havilland DHC-6 Twin Otter airplane, N30EA, collided with another Twin Otter airplane, N70EA, on the runway. The pilot of N30EA reported that, once she started the engines, the airplane rolled forward and to the left 180 degrees because the steering-tiller had been positioned sharply to the left when the airplane was last parked. The pilot stated that, when she applied the brakes, there was no response, and the airplane subsequently collided with the right wing of N70EA. The pilot of N30EA reported that, after the collision, she noted that the hydraulic circuit breaker was open; this would have resulted in insufficient hydraulic pressure to control the parking or pedal brakes. The pilot of N30EA said that she should have noticed that the hydraulic circuit breaker was open before she started the engines because it was part of the Before Starting Engines checklist.

Factual narrative

On February 9, 2015, at 0615 eastern standard time, N30EA and N70EA, both de Havilland Canada DHC 6 Twin Otters, sustained substantial damage when N30EA collided with N70EA, when the pilot lost control during engine start at the Sebastian Municipal Airport (X26), Sebastian, Florida. The pilot of N30EA and the pilot and mechanic on N70EA were not injured. Both airplanes were registered to and operated by Eagle Air Transport, Ottawa, Illinois. An instrument flight rules flight plan was filed for both airplanes and destined for the Exuma International Airport (MYEF), George Town, Bahamas. Visual meteorological conditions prevailed for the positioning flights conducted under the provisions of 14 Code of Federal Regulations Part 91. Both airplanes were parked right next to each other (N30EA was to the right of N70EA) and were preparing to depart. The pilot of N30EA reported that she conducted a normal pre-flight inspection of the airplane and the parking brake was "set." After starting both engines, the pilot advanced the throttles (one at a time) to bring the generators on-line. She said the airplane began to move forward and to the left because the steering-tiller had been positioned "sharply" to the left when the airplane was last parked. The pilot said that when she applied the brakes, there was no response and the airplane turned almost 180 degrees as it collided with N70EA, who also had its engines running. A review of postaccident photographs revealed substantial damage to the right wings and engines of both airplanes. The propeller assembly from N70EA's right engine had sheared off and each blade was damaged. The propeller assembly for N30EA remained attached to the engine and each blade was damaged. The area above the cockpit of N30EA was crushed from impact with N70EA's right wing. The pilot of N30EA reported that after she did an emergency shut-down of the engines; she realized the hydraulic circuit breaker was "pulled." She said she had been told that a mechanic had "pulled" the circuit breaker to bleed down the hydraulic accumulator during maintenance done the night before the accident, which may have resulted in the parking brake and pedal-brakes not having sufficient fluid to operate correctly. However, a review of maintenance logs for N30EA revealed there was no maintenance to the hydraulic system on the airplane prior to the accident. The pilot also stated that she learned after the accident that even though it is not on the checklist, some pilots will pull the hydraulic circuit breaker when shutting down the aircraft to "save a little wear and tear" on the hydraulic pump. It is not known how or why the hydraulic circuit breaker had opened prior to the accident. According to the airplane's Normal Operating procedures, section 2.1.2, Before Starting Engines checklist, the pilot was to confirm that all circuit breakers were "In". When asked how this accident could have been prevented, the pilot said she, "...should have seen the pulledcircuit breaker on the prestart flow." The pilot of N70EA stated that he was parked to the left of N30EA and he had just started the engines. He was bringing the generators on-line when the operator's Director of Maintenance (DOM) was boarding the rear of the airplane. The pilot then reached down to turn on the avionics master switch, when N30EA collided with N70EA. He immediately shut down both engines while the DOM exited the airplane.

On February 9, 2015, at 0615 eastern standard time, N30EA and N70EA, both DeHavilland DH 6 Twin Otters, sustained substantial damage when N30EA collided with N70EA, when it lost control during engine start at the Sebastian Municipal Airport (X26), Sebastian, Florida. The pilot of N30EA and the pilot and mechanic on N70EA were not injured. Both airplanes were registered to and operated by Eagle Air Transport, Ottawa, Illinois. An instrument flight rules flight plan was filed for both airplanes and destined for the Exuma International Airport (MYEF), George Town, Bahamas. Visual meteorological conditions prevailed for the positioning flight conducted under the provisions of 14 Code of Federal Regulations Part 91.Both airplanes were parked right next to each other (N30EA was to the right of N70EA) and were preparing to depart. The pilot of N30EA reported that she conducted a normal pre-flight inspection of the airplane and the parking brake was "set." After starting both engines, the pilot advanced the throttles (one at a time) to bring the generators on-line. She said the airplane began to move forward and to the left because the steering-tiller had been positioned "sharply" to the left when the airplane was last parked. The pilot said that when she applied the brakes, there was no response and the airplane turned almost 180 degrees as it collided with N70EA, who also had its engines running. A review of postaccident photographs revealed substantial damage to the right wings and engines of both airplanes. The propeller assembly from N70EA's right engine had sheared off and each blade was damaged. The propeller assembly for N30EA remained partially attached to the engine and each blade was damaged. The area above the cockpit of N30EA was crushed from impact with N70EA's right wing. The pilot of N30EA reported that after she did an emergency shut-down of the engines; she realized the hydraulic circuit breaker was "pulled." She said she had been told that a mechanic had "pulled" the circuit breaker to bleed down the hydraulic accumulator during maintenance done the night before the accident, which may have resulted in the parking brake and pedal-brakes not having sufficient fluid to operate correctly. However, a review of maintenance logs for N30EA revealed there was no maintenance to the hydraulic system on the airplane prior to the accident. The pilot also stated that she learned after the accident that even though it is not on the checklist, some pilots will pull the hydraulic circuit breaker when shutting down the aircraft to "save a little wear and tear" on the hydraulic pump. It is not known how or why the hydraulic circuit breaker had opened prior to the accident. According to the airplane's Normal Operating procedures, section 2.1.2, Before Starting Engines checklist, the pilot was to confirm that all circuit breakers were "In". When asked how this accident could have been prevented, the pilot said she, "...should have seen the pulled circuitbreaker on the prestart flow." The pilot of N70EA stated that he was parked to the left of N30EA and he had just started the engines. He was bringing the generators on-line when the operator's Director of Maintenance (DOM) was boarding the rear of the airplane. The pilot then reached down to turn on the avionics master switch, when N30EA collided with N70EA. He immediately shut down both engines while the DOM exited the rear of the airplane.

Aircraft · 2

Registration
N30EA
Reported as
Dehavilland DHC 6 Twin Otter
Category
Airplane
Serial number
191
Built
1968
Engines
Pratt and Whitney PT6A-34, 750 horsepower, turbo propPratt and Whitney PT6A-34, 750 horsepower, turbo prop
Damage
Substantial damage
Flight
Positioning · Part 91
Operator
Eagle Air Transport Inc
Registered owner
Eagle Air Transport Inc
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · January 8, 2015 · 32,305 hours before
Departed
X26 · Sebastian, FL
Destination
MYEF · Exuma
Flight plan
IFR
Airport
X26 · Sebastian Municipal

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.

Registration
N70EA
Reported as
Dehavilland DHC 6 200
Category
Airplane
Serial number
139
Engines
Pratt and Whitney PT6A-34, 750 horsepower, turbo propPratt and Whitney PT6A-34, 750 horsepower, turbo prop
Damage
Substantial damage
Flight
Positioning · Part 91
Operator
Eagle Air Transport Inc
Registered owner
Eagle Air Transport
Airworthiness certificate
Standard, Normal
Departed
X26 · Sebastian, FL
Destination
MYEF · Exuma
Flight plan
IFR
Airport
X26 · Sebastian Municipal

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, aircraft N30EA
Age
40
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
September 4, 2013
Seat
Left
Flight hours
2,654 total · 372 in this make and model · 2,524 as pilot in command · 141 in the last 90 days · 54 in the last 30 days · 0 in the last 24 hours
Role
Pilot, aircraft N70EA
Age
54
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Left
Flight hours
5,000 total · 550 in this make and model · 102 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
290° at 5 knots
Visibility
10 statute miles
Lowest ceiling
9,500 ft overcast
Temperature
12 °F
Altimeter
29.95 inHg
Observed at
VRB, 10 nm away

Docket · 5

The files NTSB released with the investigation on May 26, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.4 MB in all.

FAA reports on this event · 2

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

Other investigations on N30EA · 1

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