Pilot Debrief

STANLEY Lancair near Sebring, FL — 2018-03-28

Final reportERA18LA117
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Date
2018-03-28
Location
Sebring, FL, USA
Airport
SEF
Aircraft
STANLEY Lancair
Registration
C-GSQQ
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Taxi

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.

NTSB narrative

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.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have confirmed B737's status before taxiing.

NTSB coding

Evidence available

  • ATC audio
  • Photos
  • 7 docket documents
View NTSB final reportView NTSB docket

Docket documents7

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