NYC03LA046

NTSB accident investigation · Mitsubishi MU-2B-60 · Cleveland, OH · January 28, 2003

Accident · FatalLimited investigationFinal report
Date
January 28, 2003, 00:15 local (05:15 UTC)
Place
Cleveland, OH
Injuries
1 fatal, 1 uninjured; on the ground: 1 fatal
Damage
Minor damage
Phase of flight
Standing
Aircraft
N941MAMitsubishi MU-2B-60
Weather
Visual (VMC) · Night/bright
Status
Completed · report February 5, 2004
Report
Approved by Office Director
Parties
Federal Aviation Admininstration
Case key
56406

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

the bank couriers inadequate visual lookout, as he approached an airplane with operating engines. A factor was the lack of guidance and training from the bank, for working around airplanes with operating engines.

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.

Miscellaneous/otherStanding - engine(s) operating
Visual lookout - inadequateOther personCause
Condition(s)/step(s) insufficiently definedOther government personnelFactor

Analysis

The bank courier for the federal reserve bank drove his vehicle onto the ramp, and helped load the accident airplane. He then drove to another nearby airplane and assisted in the loading of that airplane. He then found two bags that belonged on the accident airplane. In the mean time, the pilot of the accident airplane had closed the door, secured his cargo, and started his engines. After the line person gave the pilot the OK to taxi, the pilot momentarily looked inside the cockpit to remove the propellers from the start locks. When he looked up, the bank courier was walking toward the left propeller holding two bags. The courier walked into the rotating propeller of the left engine as the pilot was attempting to shut it down. Witnesses reported the navigation lights and red rotating beacons were illuminated on the accident airplane. Witnesses also reported that nothing in the bank courier actions gave them concern. Interviews disclosed the bank had an on-the-job training program, but it did not include any training about the hazards of working around airplanes with operating engines, nor did the bank have a policy about approaching and/or loading airplanes with the engines operating.

Factual narrative

On January 28, 2003, about 0015 eastern standard time, a Mitsubishi MU-2B-60, N941MA, operated by Epps Air Service Inc, sustained minor damage when a ground courier walked into the propeller, while the airplane was standing with operating engines, at Burke Lakefront Airport (BKL), Cleveland, Ohio. The certificated airline transport pilot was not injured. The ground courier was fatally injured. An instrument flight rules (IFR) flight plan had been filed, for the flight that was destined for Chicago Midway International Airport (MDW), Chicago, Illinois. Night visual meteorological conditions prevailed for the flight that was conducted under 14 CFR Part 135.

According to the pilot, the airplane was parked pointed northwest, with the left side parallel to an open hanger door. A second MU-2 was parked about 20 feet ahead, 50 feet further outboard, and pointed southwest toward the hanger.

Witnesses reported that the courier, an employee of the Federal Reserve Bank of Cleveland, drove his vehicle onto the ramp, and assisted the accident pilot in loading the airplane with cancelled checks. The courier then drove his vehicle to the second airplane and assisted that pilot with his load of cancelled checks.

While the courier was loading the second airplane, the pilot of the accident airplane, closed the main cabin door, secured his cargo, and prepared to start both engines. Two line persons were in attendance, one on the left side of the nose of the airplane, and a second line person manning the ground power unit (GPU). The GPU was connected to the left rear side of the airplane, and both engines were started. The pilot signaled to the line person in front of him to have the GPU disconnected. The GPU was disconnected, and the GPU access door was secured. The line person in front of the airplane then signaled the pilot that the GPU was clear, and the pilot was clear to taxi.

The pilot reported that after he received a clear to taxi signal from the line person, he focused his attention inside the cockpit to move the propellers off the start locks. The pilot reported that when he looked up again, he saw the courier was walking toward the outboard side of the left engine, with two bags. When he realized that the courier was not going to stop, he immediately placed both engines in emergency shutdown with the condition levers. The courier made contact with the propeller and fell to the ground. After the accident, the pilot notified the control tower and requested assistance. The pilot added that he believed both engines were shutdown prior to propeller contact.

The line person from the front of the airplane reported that after he gave the pilot a clear to taxi, he turned and walked toward the left wing tip, and on to the hanger. As he reached the tip tank of the airplane, he looked back over his left shoulder and saw the courier walking toward the propeller. The courier had already passed the position of the pilot and was about 2 feet in front of the propeller when first observed. After the accident, the line person went into the hanger and called for emergency personnel.

The pilot of the second airplane reported that as the courier finished loading his airplane, he found two bags that needed to go on the accident airplane. He observed the courier walk toward the accident airplane, which had both engines operating. He then turned his attention to securing his own load, and did not see the accident.

The line person with the GPU reported that he was not looking in the direction of the propeller, and did not see the accident.

The pilot and several witnesses reported that the navigation lights and the red rotating anti-collision lights were illuminated at the time of the accident. The wing tip taxi light and nose mounted landing lights were not illuminated.

Interviews were conducted with 4 couriers who worked for the Federal Reserve Bank of Cleveland. They had all received two to three weeks of on-the-job training which included bank procedures, and where to park the vehicle on the ramp. None of the employees were aware of any direction, verbal or written that said they should not approach an airplane with the engines operating. Some of the employees reported that they had loaded airplanes, both jets and propeller driven airplanes with the engines operating. None had received any training on the hazards of working around airplanes with the engines operating.

The toxicological testing report from the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma, was negative for drugs and alcohol for the bank courier.

Aircraft

Registration
N941MA
Reported as
Mitsubishi MU-2B-60
Category
Airplane
Serial number
744SA
Airframe hours
10,056.5
Engines
Garrett-AiResearch TPE331-10-511, 715 horsepower, turbo propGarrett-AiResearch TPE331-10-511, 715 horsepower, turbo prop
Damage
Minor damage
Flight
Part 135
Registered owner
Epps Air Service, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · August 16, 2002 · 193.9 hours before
Departed
BKL · Cleveland, OH
Destination
MDW · Chicago, OH
Flight plan
IFR
Airport
BKL · Burke Lakefront

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
48
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1
Last flight review
November 11, 2002
Seat
Left
Flight hours
5,584 total · 2,703 in this make and model · 5,462 as pilot in command · 254 in the last 90 days · 82 in the last 30 days

Weather

Conditions
Visual (VMC) · Night/bright
Wind
170° at 8 knots
Visibility
10 statute miles
Lowest ceiling
6,500 ft overcast
Temperature
16 °F, dew point 1 °F
Altimeter
30.21 inHg
Observed at
BKL

Docket · 7

The files NTSB released with the investigation on November 21, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 836 KB in all.

Other investigations on N941MA · 1

Matched to the same aircraft by N-number and date.