MIA94LA166

NTSB accident investigation · British Aerospace BAE 3201 · Orlando, FL · June 24, 1994

Accident · No injuriesLimited investigationFinal report
Date
June 24, 1994, 08:04 local (12:04 UTC)
Place
Orlando, FL
Injuries
16 uninjured
Damage
Substantial damage
Phase of flight
Taxi
Aircraft
N495UEBritish Aerospace BAE 3201
Weather
Visual (VMC) · Day
Status
Completed · report January 12, 1995
Report
Approved by Office Director
FAA report
19940624019469A
Case key
37567

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

Inadvertent deactivation of the parking brake by the pilot-in-command. Contributing to the accident was the worn condition of the parking brake assembly.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

On ground/water collision with objectTaxi - from landing
Landing gear,parking brake - wornFactor
Parking brakes - inadvertent deactivationPilot in commandCause

Analysis

The captain stated that he applied the parking brake during the shutdown checklist but the airplane rolled forward. The left engine propeller contacted a ground power unit (gpu) that was correctly prepositioned at the gate. The CVR was readout which revealed that the captain did state that the parking brake was set but after the gpu contact, the captain stated that the brake is set to which the first officer (f/o) responded 'I just set it.' The f/o further stated 'released it when you...' After the accident a tug and tow bar were attached to the nose landing gear of the airplane and the parking brake was applied. Attempts to move the airplane were unsuccessful. The parking brake assembly was removed for examination which revealed no evidence of mechanical failure or malfunction. It was noted that the second notch from the bottom was worn. The maintenance manual states that beyond three notches the handle should pull tight. Post accident inspection of the parking brake revealed no evidence of failure or malfunction.

Factual narrative

On June 24, 1994, about 0804 eastern daylight time, a British Aerospace BAE Jetstream 3201, N495UE, registered to First Security Bank of Utah, operated by Atlantic Coast Airlines (ACA) dba United Express, collided with a ground power unit while arriving at the gate after landing at the Orlando International Airport, Orlando, Florida. The flight was operating under 14 CFR Part 135 as flight 5500, a scheduled, domestic, passenger flight. Visual meteorological conditions prevailed at the time and an IFR flight plan had been filed. The airplane was substantially damaged and the airline transport-rated pilot, first officer, and 14 passengers were not injured. The flight originated from the Jacksonville Municipal Airport, Jacksonville, Florida, about 0710.

The captain stated that after stopping the airplane at the parking spot at the gate, he advised the first officer that "Cool down's complete, parking brake is set." When the engine instruments indicated that the engines were at 50 percent rpm, the power levers were moved to the full reverse position during which the left propeller contacted the ground power unit (GPU) that was prepositioned at the gate. The passengers were later deplaned and the airplane was secured. The cockpit voice recorder (CVR) was removed and sent to the NTSB laboratory in Washington, DC.

The CVR was read out at the NTSB laboratory in Washington, DC. Review of the transcript revealed that the captain did call out over the interphone system, "cool down's complete-brake's set." About 1 minute 5 seconds after the propeller contacted the GPU, the captain was heard stating "the brake is set." About 1 second later the first officer responded by saying "I just set it." About 4 seconds later the first officer stated "released it when you..."

The maintenance manual for the airplane states that testing of the parking brake is accomplished by verifying that the airplane remains stationary with both engines operating to full power with the handbrake fully applied. Damage to the left engine propeller precluded performing this test; however, a tow bar and tug were attached to the nose landing gear of the airplane and with the parking brake handle engaged, attempts to move the airplane were unsuccessful. Additionally, the parking/emergency system was inspected according to the maintenance manual with no discrepancies noted. The parking/emergency system is described as incorporating a brake lever mounted on the left side of the center console. The brake lever is horn shaped with a notched pull-on shaft, the notches locating the shaft at selected pull-on brake settings. A trigger release serves to release the handle and also retain the shaft in the required setting. The handbrake shaft is painted orange on the top and sides to provide a warning indication that the handbrake is on. A spring assists in returning the shaft to the off position.

Immediately following the operational test of the parking brake it was discovered by the Regional Flight Manager of ACA and the FAA inspector that the handbrake could be disengaged by movement of only the handbrake shaft. The handbrake assembly was removed from the airplane for examination.

Examination of the handbrake housing assembly revealed evidence that the second notch from the bottom of the handbrake housing was slightly worn. There were no other discrepancies noted. The painted orange stripe was visible. Review of the maintenance manual regarding adjustment of the handbrake cable revealed that the handle should be pulled out three notches and beyond this point the handle should pull solid.

According to the airplane manufacturer, there have not been any reported problems associated with inadvertent release of the handbrake assembly. Review of the FAA Service Difficulty Reports data base revealed no records regarding the handbrake assembly used on Jetstream 3201 aircraft. Review of the maintenance completion report records for the accident airplane from January 1, 1994, to the date of the accident revealed no discrepancies regarding the parking brake system.

Aircraft

Registration
N495UE
Reported as
British Aerospace BAE 3201
Category
Airplane
Serial number
818
Airframe hours
6,623
Engine
Garrett TPE331-12UAR, 1,050 horsepower, turbo prop
Damage
Substantial damage
Flight
Part 135
Operator
Atlantic Coast Airlines, doing business as United Express
Registered owner
First Securities Bank Of Utah
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · June 21, 1994 · 14 hours before
Departed
JAX · Jacksonville, FL
Flight plan
IFR
Airport
MCO · Orlando International

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
32
Certificates
Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
4,192 total · 3,182 in this make and model · 2,760 as pilot in command · 231 in the last 90 days · 77 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
200° at 7 knots
Visibility
10 statute miles
Lowest ceiling
25,000 ft broken
Temperature
79 °F, dew point 79 °F
Altimeter
30.00 inHg
Observed at
MCO, 1 nm away

FAA reports on this event · 1

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