Pilot Debrief

CANADAIR CL-600-2B16 near West Palm Beach, FL — 2015-07-22

Final reportERA15LA288
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Date
2015-07-22
Location
West Palm Beach, FL, USA
Airport
PBI
Aircraft
CANADAIR CL-600-2B16
Registration
N613PJ
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Taxi

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.

NTSB narrative

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.

Analysis

Primary failure mode
Human factors
First missed decision gate
Flight crew should have ensured baggage door was closed before starting engines.

NTSB coding

Evidence available

  • CVR
  • FDR / data
  • Photos
  • 15 docket documents
View NTSB final reportView NTSB docket

Docket documents15

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