# NTSB ERA15LA288: Canadair CL-600-2B16, N613PJ, West Palm Beach, FL, July 22, 2015 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: July 22, 2015, 14:10 local (18:10 UTC) - Place: West Palm Beach, FL - Coordinates: 26.685556, -80.092781 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.6856&lon=-80.0928&mi=10 - Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping) - Defining event: [Taxi: Ground collision](https://openairdocs.org/ntsb-events/200) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report May 1, 2017 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Paragon Jets - NTSB case key (mKey): 91657 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15LA288 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91657/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91657 - Page: https://openairdocs.org/ntsb/ERA15LA288 ## Probable cause The flight crew's failure to properly use the before start checklist, to monitor the airplane's motion, and to see and avoid objects around the airplane, which resulted in an inadvertent roll into a ground vehicle. ## 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 · Flight crew (probable cause); cases with it: [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) - [Attention/monitoring: task monitoring/vigilance](https://openairdocs.org/ntsb-findings/02021520): Personnel issues › Psychological · Flight crew (probable cause); cases with it: [All aircraft, 330 cases](https://openairdocs.org/ntsb-findings/02021520/cases.md) - [Attention/monitoring: monitoring environment](https://openairdocs.org/ntsb-findings/02021545): Personnel issues › Psychological · Flight crew (probable cause); cases with it: [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Taxi: Ground collision](https://openairdocs.org/ntsb-events/200) (defining event); cases with it: [All aircraft, 618 cases](https://openairdocs.org/ntsb-events/200/sequence.md) ## Analysis According to the captain, the pilots were "rushed" as they performed their preflight preparations of the jet and forgot to close the baggage door. Ground personnel noticed the discrepancy and drove an all-terrain vehicle (ATV) out to the airplane so that they could advise the crew. After dismounting from the ATV, which they had parked about 10 ft in front of the airplane's left wing, they warned the captain, who left the cockpit to close the baggage door. Once the door was closed, he returned to the cockpit. The captain then looked out the side window and noticed that the airplane was rolling forward, and he asked the first officer what she was doing. About that time, the airplane struck the ATV. The flight crew stated that once they realized the airplane was moving, they attempted to apply the brakes, but it was not until they shut down the engines and re-applied the parking brake that the airplane came to a stop. A postaccident functional check of the airplane's hydraulic and braking systems did not reveal any anomalies. Review of the airplane's cockpit voice recorder revealed that the crew did not verbally follow the airplane's before start checklist, which required them to verify hydraulic system pressure, and that the parking brake was set before starting the engines. Had the flight crew followed this procedure, monitored the airplane's motion during and immediately after the engine start, and been more cognizant of the objects surrounding the airplane, it is likely that the ground collision would have been avoided. ## Factual narrative On July 22, 2015, about 1410 eastern daylight time, a Canadair CL-600-2B16, N613PJ, registered to Paragon Transport Management LLC, and operated by USAC Airways 691 LLC, doing business as Paragon Jets, was substantially damaged when it struck an all-terrain ground vehicle (ATV) while taxiing at Palm Beach International Airport (PBI), West Palm Beach, Florida. Both airline transport pilots were not injured. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for the flight, which was destined for Opa-Locka Executive Airport (OPF), Miami, Florida. The positioning flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91.According to the captain, the flight crew was under pressure from the operations department to continue to southern Florida to complete their flight and pick up customers that were waiting. The flight crew forgot to close the baggage door; they began the prestart checklist and started both engines. The flightcrew then noticed that ground personnel drove up in an ATV and were waving their arms to get their attention. The captain then remembered that he forgot to close the baggage door and got up to go back and close the door. Once closed, he returned to his seat, on the right side, buckled his seat belt and resumed reviewing the checklist. The captain then looked out the side window and noticed the airplane was rolling forward and he asked the first officer what she was doing. At that time, they heard a noise and bounce in the airplane and thought they travelled over a wheel chock. The captain further stated that he was pushing very hard on the brakes and the airplane would not stop. They both made several attempts to stop the airplane and applied maximum brake pressure, but it would not stop. The captain then reached over with both hands and shut down the engines at the same time the first officer released and re-applied the parking brake. The airplane then came to a stop. The captain added that he heard no alarms or sounds during this event. According to ground service personnel at OPF, they observed the accident airplane as it prepared to taxi and noticed that its baggage door was open. Two of the ground handlers subsequently boarded an ATV and drove out to the airplane, parking about 10 feet in front of the left wing. One of the ground handlers then dismounted the ATV and proceeded in front of the airplane while motioning to the flightcrew in the cockpit that the baggage door was open. The pilot seated in the right seat then stood up and proceeded into the cabin. Shortly after, the airplane began moving forward. The ground handler then attempted to gain the attention of the pilot seated in the left seat, but was unsuccessful as that pilot never looked up. The airplane's left wing then struck the ATV before it came to a stop. About 1 week after the accident, the operator's director of maintenance completed a preflight inspection and check of the airplane'shydraulic and braking systems under the supervision of a Federal Aviation Administration inspector, with no anomalies noted. The airplane's cockpit voice recorder (CVR) and flight data recorder (FDR) were forwarded to the NTSB Vehicle Recorders Laboratory, Washington, DC for data download. Review of the CVR data did not reveal any tasks associated with the formal prestart checklist being completed. The CVR recorded a conversation about programming the flight management system and then it recorded the captain asking the first officer if she wanted to fly from the left seat. One minute later the first officer replied that she did want to fly from the left seat. The recorder then captured a conversation of an informal checklist usage along with a departure briefing. Two minutes later the recorder captured sounds consistent with both engines starting and then the captain stated, "baggage door… I'll get it." Then sounds consistent with switch manipulation and shortly after the captain asked "what are you doing" with an immediate sound of a warning or alert tone as the captain stated, "no brakes….what are you doing?" the first officer responded, "ah I didn't do anything. What's going on? What is going on? Stop." The captain replied, "I don't know." Then the CVR recorded sounds of engines shutting down, followed by one second later a sound consistent with a collision. Review of the plotted data from the FDR revealed that it only recorded in-flight parameters and that it did not record any on-ground parameters. Review of the Challenger 601-3A/3R pilot checklist manual, before shut down, the crew was to verify the parking brake was set and check the hydraulic pressure. If this was the last flight of the day, once the airplane wheels were chocked, the parking brake should be released. The before starting checklist stated the wheel chocks must be removed, hydraulic pressure verified, and the parking brakes set before engine start. The 13-seat airplane was manufactured in 1992, and was equipped with two GE, CF34-3A, turbine engines. The aircraft maintenance records indicated that airplane was maintained on a continuous airworthiness inspection program, and the brake accumulators test was last performed on May 1, 2015, with an airframe total time recorded of 9,649.3 hours. The total time on the airframe at the time of the accident was 9,770.9 hours. ## Aircraft - Registration: N613PJ (not matched to a registry record) - Reported make and model: CANADAIR CL-600-2B16 - Category: Airplane - Serial number: 5123 - Year built: 1992 - Engines: GE CF34-3A 8500 lbs thrust turbo fan; GE CF34-3A 8500 lbs thrust turbo fan - Damage: Substantial damage - Flight: Positioning, Part 91 - Airworthiness certificate: Standard, Transport - Departed: PBI, West Palm Beach, FL - Destination: OPF, Opa Locka, FL - Flight plan: IFR - Airport: PBI, Palm Beach International - Equipment: Electronic multifunction display, Data recorder, Auto-pilot, Electronic primary flight display, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: none; commercial, airline transport; airplane ratings: single-engine land, multi-engine land, single-engine sea; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review May 7, 2015; seat: right; restraint: 4-point; flight hours: 11,926 total, 3,324 in this make and model, 10,191 as pilot in command, 92 in the last 90 days, 77 in the last 30 days - Co-pilot; age 40; injuries: none; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1; last flight review May 13, 2015; seat: left; restraint: 4-point; flight hours: 1,800 total, 105 in this make and model, 300 in the last 90 days, 65 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 250° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: 5,500 ft broken - Temperature: 93 °F, dew point 72 °F - Altimeter: 30.02 inHg - Observed at: KPBI ## 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 20150722012989A](https://openairdocs.org/incident/20150722012989A), Jul 22, 2015: Canadair CL-60-2B16, West Palm Beach, FL, Substantial damage. A ground collision between N613PJ, a CL-601-3AER (CL600-2B16), and a kubota atv occurred on the ramp of atlantic aviation at approximately 1410 local time. The… ## Docket (15 files) The files NTSB released with the investigation on March 15, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91657. 7.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 961 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449981&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Inspector's Statement (item 2, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449982&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Master.PDF - Memorandum for Record - Telephone Interview, Pilot (item 3, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449983&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Telephone%20Interview,%20Pilot-Master.PDF - Memorandum for Record - Telephone Interview, Co-Pilot (item 4, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449984&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Telephone%20Interview,%20Co-Pilot-Master.PDF - Ground Service Personnel Statements (item 5, .PDF, 135 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449985&FileExtension=.PDF&FileName=Ground%20Service%20Personnel%20Statements-Master.PDF - Flight Data Recorder - Specialist's Factual Report (item 6, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449986&FileExtension=.PDF&FileName=Flight%20Data%20Recorder%20-%20Specialist%27s%20Factual%20Report-Master.PDF - Flight Data Recorder - Attachment 1 (item 7, .CSV, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449987&FileExtension=.csv&FileName=Flight%20Data%20Recorder%20-%20Attachment%201-Master.csv - Checklist Excerpts (item 8, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449988&FileExtension=.PDF&FileName=Checklist%20Excerpts-Master.PDF - Cockpit Voice Recorder - Specialist's Factual Report (item 9, .PDF, 219 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449989&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%20-%20Specialist%27s%20Factual%20Report-Master.PDF - Maintenance Records (Excerpts) (item 10, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449990&FileExtension=.PDF&FileName=Maintenance%20Records%20(Excerpts)-Master.PDF - Investigation Photographs (Courtesy of McLaren's Claim Service) (item 11, .PDF, 4 photos, 205 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449991&FileExtension=.PDF&FileName=Investigation%20Photographs%20(Courtesy%20of%20McLaren%27s%20Claim%20Service)-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 12, .PDF, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449992&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Memorandum of Record (item 13, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482331&FileExtension=.PDF&FileName=Memorandum%20of%20Record-Master.PDF - Petition for Reconsideration (item 14, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40485125&FileExtension=.PDF&FileName=Petition%20for%20Reconsideration-Master.PDF - Response to Petition for Reconsideration (item 15, .PDF, 202 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40485126&FileExtension=.PDF&FileName=Response%20to%20Petition%20for%20Reconsideration-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.