# NTSB ERA18LA117: Stanley Lancair, Sebring, FL, March 28, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: March 28, 2018, 08:30 local (12:30 UTC) - Place: Sebring, FL - Coordinates: 27.462499, -81.344718 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=27.4625&lon=-81.3447&mi=10 - Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping) - Defining event: [Taxi-from runway: Prop/jet/rotor blast/suction](https://openairdocs.org/ntsb-events/082) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 96953 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA18LA117 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96953/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96953 - Page: https://openairdocs.org/ntsb/ERA18LA117 ## Probable cause The failure of ground personnel to obtain permission from airport management to conduct engine test runs; adequately monitor the area behind the B737 for traffic; and install barricades to prevent access behind the running airplane, which resulted in the accident pilot's loss of control during taxi due to an encounter with the jet blast. Contributing to the accident were the accident pilot's failure to detect that the B737 engines were running, and the airport management's failure to establish written standard operating procedures regarding engine runs. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Info processing/decision: understanding/comprehension](https://openairdocs.org/ntsb-findings/02041515): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [All aircraft, 70 cases](https://openairdocs.org/ntsb-findings/02041515/cases.md) - [Planning/preparation](https://openairdocs.org/ntsb-findings/02061000): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [All aircraft, 113 cases](https://openairdocs.org/ntsb-findings/02061000/cases.md) - [Policy/procedure](https://openairdocs.org/ntsb-findings/04021000): Organizational issues › Management · Maintenance provider (probable cause); cases with it: [All aircraft, 15 cases](https://openairdocs.org/ntsb-findings/04021000/cases.md) - [Organizational issues](https://openairdocs.org/ntsb-findings/04010000): Organizational issues › Development · Airport (probable cause); cases with it: [All aircraft, 1 case](https://openairdocs.org/ntsb-findings/04010000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Taxi-from runway: Prop/jet/rotor blast/suction](https://openairdocs.org/ntsb-events/082) (defining event); cases with it: [All aircraft, 44 cases](https://openairdocs.org/ntsb-events/082/sequence.md) - [Taxi-from runway: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Taxi-from runway: Dragged wing/rotor/float/other](https://openairdocs.org/ntsb-events/093); cases with it: [All aircraft, 319 cases](https://openairdocs.org/ntsb-events/093/sequence.md) ## Analysis The pilot made position reports over the airport's common traffic advisory frequency (CTAF) while inbound to the airport for landing. After landing and exiting the runway onto a taxiway, the pilot stopped and reconfigured the airplane and noticed a Boeing 737 (B737) south of his position with the left engine cowling missing. Neither he nor his front seat passenger perceived that either engine was running, and there were no barricades positioned around the airplane to indicate that engine runs were in progress. The accident pilot proceeded to taxi about 200 to 300 ft behind the B737, which was operating with both engines at 85% power. The accident airplane cartwheeled in the jet blast from the running engines and came to rest upright on grass, resulting in substantial damage. The pilot of another airplane and a groundcrew member monitoring the engine runs both attempted to warn the accident pilot over the CTAF of the running B737 engines, but were unsuccessful. The airport director reported that there was an "unwritten" policy in place that his approval was required before B737 engine maintenance runs. Although personnel from the maintenance facility that conducted the engine runs reported that they had received permission from airport management to do so, the airport director reported that neither he nor his staff approved the activity on the day of the accident. In addition, the installation of barricades to block the taxiway behind the running airplane would have prevented the accident by keeping other airplanes a safe distance from the B737. ## Factual narrative On March 28, 2018, about 0830 eastern daylight time, an experimental Lancair IV-P, Canadian registration C-GSQQ, was substantially damaged when it was involved in an accident near Sebring, Florida. The private pilot and two passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. While inbound for landing, the pilot made multiple position reports on the airport's published common traffic advisory frequency (CTAF). He landed uneventfully on runway 01 after completing a GPS approach, exited the runway onto taxiway A4, and stopped. He reconfigured the airplane, performed the taxi checks, and noticed a Boeing 737 (B737) south of his position, facing south on a taxiway that paralleled the runway. He thought that the airplane was parked, and neither he nor the right front seat passenger recalled seeing any people on the ground around the B737. He noticed that the left engine cowling was missing, but he could not perceive whether either engine was running, adding that there were no barricades to block the taxiway. The pilot began taxiing westbound about 200 to 300 ft behind the B737 with no aileron control input applied, when the left wing suddenly rose, and the right wing contacted the taxiway. The airplane cartwheeled and came to rest upright on grass at the north edge of the taxiway with the nose landing gear fork and wheel assembly separated. He reported that the empennage was cracked and that there was damage to both wings at their roots, consistent with up-and-down flexing. Maintenance personnel onboard the B737 reported that they were in contact with personnel in two vehicles on the ground near the nose landing gear, but that they were not monitoring the CTAF. Both engines of the B737 were stabilized at 85% power while the individual in one vehicle had a portable radio transceiver and was monitoring the CTAF. That individual reported seeing the accident airplane when it first turned off the runway and crossed the hold short line. He attempted to communicate with the accident pilot on the CTAF, but his transmission was stepped on by another pilot, who was airborne and also attempting to warn the pilot that the B737's engines were running. He then began driving toward the accident airplane, but when it had encountered the jet blast, he broadcast to the B737 cockpit to secure the engines, then went to the accident airplane to render assistance. At the time of the accident, the B737 was positioned at the "north spot," one of its two pre-approved engine run locations on the airport. The executive director of the airport reported that there was an unwritten policy requiring his direct approval for maintenance engine runs for the B737. Personnel involved in the engine runs reported that airport personnel gave such approval; however, the director reported that neither he nor any airport staff gave approval for engine runs that day. ## Aircraft - Registration: C-GSQQ (not matched to a registry record) - Reported make and model: STANLEY Lancair (IV-P) - Category: Airplane, amateur-built - Serial number: LIV-230 - Year built: 1999 - Airframe hours: 520 - Engines: Continental TSIO-550B 350 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Annual, September 25, 2017 - Departed: FL59, Fort Myers, FL - Destination: SEF, Sebring, FL - Airport: SEF, Sebring Regional Airport - Equipment: Auto-pilot, Electronic flight bag or handheld device, Electronic multifunction display, Electronic primary flight display, Onboard weather, Stall warning system, ADS-B, Angle of attack indicator ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 72; injuries: none; private; airplane ratings: single-engine land, single-engine sea, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review May 20, 2016; seat: left; restraint: 3-point; flight hours: 8,130 total, 420 in this make and model, 8,150 as pilot in command, 19.5 in the last 90 days, 12.1 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 100° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 61 °F, dew point 54 °F - Altimeter: 30.18 inHg - Observed at: OBE, 29 nm away ## Docket (7 files) The files NTSB released with the investigation on April 15, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96953. 11.4 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 5.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7797907&FileExtension=pdf&FileName=NTSB%206120%20for%20CGSQQ_Recd%204_5_2018_Redacted-Rel.pdf - Record of NTSB conversations (item 2, PDF, 22 pages, 800 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9322240&FileExtension=pdf&FileName=Record%20of%20NTSB%20Conversations_Redacted-Rel.pdf - Passenger statements (item 3, PDF, 2 pages, 21 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9322534&FileExtension=pdf&FileName=Passenger%20Statements_ERA18LA117_Redacted-Rel.pdf - Google earth plot of portion of sebring regional airport with key positions annotated (item 4, PDF, 1 page, 168 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9321778&FileExtension=pdf&FileName=Annotated%20Google%20Earth%20Image%20of%20SEF%20with%20Key%20Positions%20Documented-Rel.pdf - Liveatc. Net audio recording (item 5, MP3, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9324889&FileExtension=mp3&FileName=KSEF-Mar-28-2018-1200Z-Rel.mp3 - NTSB audio review (item 6, PDF, 1 page, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9324042&FileExtension=pdf&FileName=NTSB%20Audio%20Review%20of%20KSEF%20LiveATC%20CTAF%20Recording_ERA18LA117-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 7, PDF, 1 page, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9322543&FileExtension=pdf&FileName=Fully%20Executed%20Scanned%20Wreckage%20Release%20Form_Redacted-Rel.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.