# NTSB ERA15LA124: Dehavilland DHC 6 Twin Otter, N30EA, Sebastian, FL, February 9, 2015

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: February 9, 2015, 06:15 local (11:15 UTC)
- Place: Sebastian, FL
- Coordinates: 27.815555, -80.469718 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=27.8156&lon=-80.4697&mi=10
- Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping)
- Defining events: [Standing-engine(s) start-up: Loss of control on ground](https://openairdocs.org/ntsb-events/230); [Standing-engine(s) not oper: Ground collision](https://openairdocs.org/ntsb-events/200)
- Highest injury: No injuries
- Injuries: 3 uninjured
- Status: Completed, report July 13, 2015
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- NTSB case key (mKey): 90702
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15LA124
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90702/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90702
- Page: https://openairdocs.org/ntsb/ERA15LA124

## Probable cause (aircraft 1)

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.

## Probable cause (aircraft 2)

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

NTSB's coded findings; those marked are part of the probable cause.

- [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause), aircraft 1; cases with it: [Dehavilland DHC-6 TWIN OTTER, 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=2802606), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause), aircraft 1; cases with it: [Dehavilland DHC-6 TWIN OTTER, 2 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2802606), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot of other aircraft (probable cause), aircraft 2; cases with it: [Dehavilland DHC-6-200, 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=2802620), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot of other aircraft (probable cause), aircraft 2; cases with it: [Dehavilland DHC-6-200, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2802620), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Standing-engine(s) start-up: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event), aircraft 1; cases with it: [Dehavilland DHC-6 TWIN OTTER, 2 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2802606), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md)
- [Standing-engine(s) start-up: Ground collision](https://openairdocs.org/ntsb-events/200), aircraft 1; cases with it: [Dehavilland DHC-6 TWIN OTTER, 2 cases](https://openairdocs.org/ntsb-events/200/sequence.md?model=2802606), [All aircraft, 618 cases](https://openairdocs.org/ntsb-events/200/sequence.md)
- [Standing-engine(s) not oper: Ground collision](https://openairdocs.org/ntsb-events/200) (defining event), aircraft 2; cases with it: [Dehavilland DHC-6-200, 1 case](https://openairdocs.org/ntsb-events/200/sequence.md?model=2802620), [All aircraft, 618 cases](https://openairdocs.org/ntsb-events/200/sequence.md)

## Analysis (aircraft 1)

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.

## Analysis (aircraft 2)

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 (aircraft 1)

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.

## Factual narrative (aircraft 2)

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 1

- Registration: [N30EA](https://openairdocs.org/aircraft/N30EA), registered now, S/N 191, built 1968 (OpenAirDocs)
- Reported make and model: DEHAVILLAND DHC 6 TWIN OTTER
- Registry model: [Dehavilland DHC-6 TWIN OTTER](https://openairdocs.org/model/dehavilland-dhc-6-twin-otter) (registry code 2802606) (OpenAirDocs)
- Registry engine: [Pratt & Whitney PT6A series](https://openairdocs.org/engine/pratt-whitney-pt6a-series) (registry code 52032, turbo-prop) (OpenAirDocs)
- Category: Airplane
- Serial number: 191
- Year built: 1968
- Engines: Pratt and Whitney PT6A-34 750 horsepower turbo prop; Pratt 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

## Aircraft 2

- Registration: [N70EA](https://openairdocs.org/aircraft/N70EA), registered now, S/N 139 (OpenAirDocs)
- Reported make and model: DEHAVILLAND DHC 6 200
- Registry model: [Dehavilland DHC-6-200](https://openairdocs.org/model/dehavilland-dhc-6-200) (registry code 2802620) (OpenAirDocs)
- Registry engine: [Pratt & Whitney PT6A series](https://openairdocs.org/engine/pratt-whitney-pt6a-series) (registry code 52032, turbo-prop) (OpenAirDocs)
- Category: Airplane
- Serial number: 139
- Engines: Pratt and Whitney PT6A-34 750 horsepower turbo prop; Pratt 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot, aircraft N30EA; age 40; injuries: none; 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
- Pilot, aircraft N70EA; age 54; injuries: none; 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

## FAA reports on this event (2)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 20150209000891A](https://openairdocs.org/incident/20150209000891A), Feb 9, 2015: Dehavilland DHC-6 TWIN OTTER, Sebastian, FL, Substantial damage. On 2/9/2015, at approximately 0630, N30EA (piloted by [privacy data omitted]) and N70EA had a head on collision on the ramp of the Sebastian Municipal Airport.…
- [Accident 20150209000881A](https://openairdocs.org/incident/20150209000881A), Feb 9, 2015: Dehavilland DHC-6-200, Sebastian, FL, Substantial damage. On 2/9/2015, at approximately 0630, N30EA (piloted by[privacy data omitted]) and N70EA had a head on collision on the ramp of the Sebastian municipal airport.…

## Other investigations on N30EA (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 CHI01LA167](https://openairdocs.org/ntsb/CHI01LA167), Jun 16, 2001: de Havilland DHC-6 Twin Otter (N30EA), Ottawa, IL, minor damage. Probable cause: the failure of the passenger to maintain clearance from the windmilling propeller after exiting the airplane.

## Docket (5 files)

The files NTSB released with the investigation on May 26, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90702. 3.4 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426839&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Statement - Pilot of N70EA (item 2, .PDF, 132 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426840&FileExtension=.PDF&FileName=Statement%20-%20Pilot%20of%20N70EA-Redacted.PDF
- DHC6 200, Before-Starting-Engines checklist (1) (item 3, .PDF, 134 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426841&FileExtension=.PDF&FileName=DHC6%20200,%20Before-Starting-Engines%20checklist%20(1)-Master.PDF
- Photo 1 – Both airplanes after they collided on the ramp (photo courtesy of FAA) (item 4, .PDF, 356 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426842&FileExtension=.PDF&FileName=Photo%20%201%20%E2%80%93%20Both%20airplanes%20after%20they%20collided%20on%20the%20ramp%20(photo%20courtesy%20of%20FAA)-Master.PDF
- Photo 2 – Damage to each airplane’s right wings and engine assemblies (item 5, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426843&FileExtension=.PDF&FileName=Photo%202%20%E2%80%93%20Damage%20to%20each%20airplane%E2%80%99s%20right%20wings%20and%20engine%20assemblies-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.

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