# NTSB MIA99FA012: Aerospatiale ATR-42-300, N143DD, San Juan, PR, October 25, 1998 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Field investigation · Final report - Date: October 25, 1998, 13:21 local (17:21 UTC) - Place: San Juan, PR - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 4 minor, 24 uninjured; on the ground: 1 minor - Status: Completed, report February 11, 2000 - Report: Approved by Office Director - NTSB case key (mKey): 45151 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA99FA012 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/45151/pdf - Page: https://openairdocs.org/ntsb/MIA99FA012 ## Probable cause The pilot's failure to verify that the parking brake was applied prior to engine start, and the resultant inadvertent movement of the aircraft and collision with the ground power cart once No. 2 was started. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - On ground/water collision with object, standing - engine(s) operating - object - vehicle - parking brakes - not verified, pilot in command (cause) - Fire, standing - engine(s) operating ## Analysis The pilot gave the ground marshaller the hand signals to disconnect ground power and to pull the chocks after a normal start of No. 2 engine. The ground marshaller disconnected the power cord and secured it to the ground power cart, and when she pulled the nose wheel chocks, the nose tire ran over her foot. The airplane taxied forward until the No. 2 propeller collided with the ground power cart and ignited a fire in the No. 2 engine that spread to the ground and under the aircraft. The flight attendant commanded a passenger emergency evacuation, absent any communications from the cockpit, and three passengers received minor injuries from tripping and falling on the tarmac. The airport fire department extinguished the fire 3 minutes after its initiation. ## Factual narrative HISTORY OF FLIGHT On October 25, about 1321 Atlantic standard time, an Aerospatiale ATR-42, N143DD, registered to Wilmington Trust Company, operated by American Eagle Airlines, Inc., dba Executive Airlines, Inc., as a 14 CFR Part 121 scheduled air carrier flight number 5404, collided with a ground power unit, (GPU) after starting No. 2 engine, initiating a ground fire. The ATP-rated pilot, ATP-rated copilot, and the flight attendant were not injured and a ramp worker and 3 of 24 passengers received minor injuries. Visual meteorological conditions prevailed and an instrument flight plan was filed. The airplane sustained substantial damage. The flight was originating at the time of the accident. According to the pilot's statement, when he arrived at the airplane at about 1240 for a 1303 departure, he noticed that two previous maintenance write-ups had not been cleared. He radioed the company's maintenance control, and while waiting for the mechanic's arrival, called for and completed the, "Before Start Checklist" with his first officer, except for the item, "AML and Release", (aircraft maintenance log and release). The write-ups were cleared and signed off by maintenance at about 1315. At this time, he called for the "Engine Start Checklist" and gave the ground marshaller the hand signal for engine start. Following a normal No. 2 engine start, he gave the ground marshaller two hand signals in succession, (1) disconnect the GPU, and (2) remove the chocks. He left No. 2 in feather for about 15 seconds while monitoring engine instruments and then moved the condition lever to high rpm. His first officer was computing weight and balance, and was not looking outside. The first realization that either crewmember had that the airplane moved after No. 2 engine start was the collision. There were actually two NTSB forms 6120.1/2, (Pilot/Operator Aircraft Accident Report) submitted by the pilot, one was received at the NTSB Southeast Regional Office on November 25, 1998, and was signed by the pilot; the other was received at the same office on December 30, 1998, and was written by the Director of Safety for the airline. Both forms are attached. The copilot's statement confirmed the facts as stated by the pilot, and added that, once the mechanic gave the flight crew the signal that No. 2 was on fire, the pilot followed with the, "Engine Fire On Ground" procedures. Once this was accomplished, the copilot proceeded to the cabin to help with the passenger evacuation. According to the flight attendant's statement, the passenger emergency evacuation was commanded and accomplished by she when she could not establish communications with the cockpit. She received no notification from the cockpit of an emergency, or of any evacuation signals. According to statements by the two-person ground marshalling crew, after starting the No. 2 engine, the pilot gave two hand signals to the forward stationed ground handler in succession; (1) to disconnect electrical power, and (2) to pull the chocks. The ground handler disconnected the electrical cable, closed the airplane's ground service access door, wound the cable and stored it on its GPU mounted rack. She then proceeded directly to the right side nose area, made eye contact with the first officer, and bent down to pull the nose wheel chocks. When she pulled the forward chock, the right nose tire passed over her foot, and the aircraft rolled forward. Observing the mishap, the second ground handler ran over to pick her off the ground and they both ran forward trying to give the flight crew the emergency stop signal. The airplane continued forward about 10 to 15 feet until collision by the No. 2 propeller with the top of the GPU. The propeller was in high rpm at the time of the propeller strike. According to a statement by a company line mechanic who observed the accident from behind the airplane during the engine start, he confirmed that he observed the sequence of events as stated by the marshalling crew and added that he ran to the front of the airplane to confirm the damage. He stated that fuel was pouring from the engine, that a small fire had ignited in the engine intake, and that he signaled the flight crew to pull the T-handle, (engine emergency shutdown handle) and shoot the extinguisher. He stated he saw the copilot reach for and activate the emergency shutdown handle and fire the extinguisher. When fire developed under the airplane, he ran to the left side main passenger loading door, and he and the flight attendant got the door open and assisted the passenger deplanement. The three passenger injuries were sustained from falling off the steps of the rear main passenger loading door during deplanement. He saw a girl and an older woman trip and fall onto the tarmac, suffering minor scrapes. He saw the pilot exit out the left fuselage emergency exit. He stated that two large cart extinguishers were wheeled to the area of the fire before the airport fire crew's arrival, but could not confirm that they were used. A statement from one of the airport fire crew who responded to the airplane fire mentioned that after the fire was extinguished, he asked the pilot to reenter the cockpit with him to verify that the airplane's battery switch(s) were positioned to "off". He observed the pilot actuate two switches that were described to him as air conditioning switches. He observed the pilot move two "shift stick" type controls on the right-center console aft, and he further stated he observed the pilot, ".. put his hands on the brake handle and apparently he shift it back". According to FAA tower logs, the airport fire rescue unit was notified at 1320, and the fire was declared under control at 1324. PERSONNEL INFORMATION Information on the pilot and copilot is included in this report in the attached Pilot/Operator Aircraft Accident Report, and Supplement E. AIRCRAFT INFORMATION The airplane had completed a San Juan to St. Thomas round trip previously with the same flight and cabin crew, returning to San Juan at 1003. The crew entered two maintenance items in the logbook on their return, and planned to finished their work day with a Ponce round trip, departing at 1303. The two items were, (1) first officer's radio microphone producing feedback, and (2) some escape path lights out. METEOROLOGICAL INFORMATION Visual meteorological conditions prevailed at the time of the accident. For additional information, see Weather Information included in this report. FLIGHT RECORDERS The cockpit voice recorder, (CVR) was a Fairchild model A-100A, SN 61860. It was removed and sent to the NTSB Vehicle Recorders Laboratory, Washington, DC, on October 28, 1998, for readout. The recording consisted of four channels of excellent quality audio information from the pilot's and copilot's hot microphone/radio/intercom selector panels, cockpit area microphone, and from the aircraft's public address system. A transcript of about the last 5 minutes of CVR tape recording, representing the cockpit and cabin crew conversation before and during the accident was made and is attached. That portion of recording applicable to the accident flight begins with the reading and response to the, "Before Engine Start Checklist" and ends with the flight attendant's attempts to communicate with the cockpit before she commands the passenger emergency evacuation. WRECKAGE AND IMPACT INFORMATION The airplane and GPU were towed to the company's hangar facilities on the San Juan airport soon after the accident, and was the location for the NTSB examination. The accident occurred as the airplane was starting engines near gate C-7 on a painted centerline at about a 45 degree angle from the centerline of the concourse, with the tail toward the concourse and the main terminal in accordance with company procedure. The GPU had been parked forward of the No. 2 engine, per company proced ## Aircraft - Registration: [N143DD](https://openairdocs.org/deregistered/N143DD-2013-04-01), registration cancelled 2013-04-01, S/N 056 (OpenAirDocs) - Reported make and model: Aerospatiale ATR-42-300 - Registry model: [Aerospatiale/Aeritalia ATR 42-300](https://openairdocs.org/model/aerospatiale-aeritalia-atr-42-300) (registry code 8680920) (OpenAirDocs) - Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs) - Category: Airplane - Serial number: 056 - Airframe hours: 22818 - Engines: P&W PW-120 1800 horsepower turbo prop - Damage: Substantial damage - Fire: On-Ground - Flight: Part 121 - Operator: Executive Airlines, Inc., doing business as Americal Eagle Airlines - Registered owner: Wilmington Trust Co. - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, September 30, 1998, 127 hours before - Departed: SJU - Destination: PSE, PONCE, PR - Flight plan: IFR - Airport: SJU, Luis Munoz Marin Intl ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; flight hours: 5,053 in this make and model, 127 in the last 90 days, 22 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 50° at 11 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 90 °F, dew point 79 °F - Altimeter: 29.00 inHg - Observed at: SJU ## 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 19981025030129A](https://openairdocs.org/incident/19981025030129A), Oct 25, 1998: Aerosp ATR42300, San Juan, Puerto Rico, Substantial damage. After having started the right engine the airplane started rolling forward resulting in the right engine propeller striking the air conditioner/power unit and… 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.