Monday, May 29, 2017

Canadair CL-600-2B16 Challenger 604, N613PJ, registered to Paragon Transport Management LLC, and operated by USAC Airways 691 LLC, doing business as Paragon Jets: Accident occurred July 22, 2015 at Palm Beach International Airport (KPBI), West Palm Beach, Palm Beach County, Florida

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Miramar, Florida
Paragon Jets; Teterboro, New Jersey 

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

Aviation Accident Data Summary - National Transportation Safety Board: https://app.ntsb.gov/pdf

Paragon Transport Management LLC: http://registry.faa.gov/N613PJ

 NTSB Identification: ERA15LA288
14 CFR Part 91: General Aviation
Accident occurred Wednesday, July 22, 2015 in West Palm Beach, FL
Probable Cause Approval Date: 05/01/2017
Aircraft: CANADAIR CL-600-2B16, registration: N613PJ
Injuries: 2 Uninjured.

NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

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.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
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.

On July 22, 2015, about 1410 eastern daylight time, a Canadair CL-600-2B16, N613PJ, registered to Paragon Transport Management LLC, and operated by USAC Airways 691 LLC, doing business as Paragon Jets, was substantially damaged when it struck an all-terrain ground vehicle (ATV) while taxiing at Palm Beach International Airport (PBI), West Palm Beach, Florida. Both airline transport pilots were not injured. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for the flight, which was destined for Opa-Locka Executive Airport (OPF), Miami, Florida. The positioning flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91.

According to the captain, the flight crew was under pressure from the operations department to continue to southern Florida to complete their flight and pick up customers that were waiting. The flight crew forgot to close the baggage door; they began the prestart checklist and started both engines. The flightcrew then noticed that ground personnel drove up in an ATV and were waving their arms to get their attention. The captain then remembered that he forgot to close the baggage door and got up to go back and close the door. Once closed, he returned to his seat, on the right side, buckled his seat belt and resumed reviewing the checklist. The captain then looked out the side window and noticed the airplane was rolling forward and he asked the first officer what she was doing. At that time, they heard a noise and bounce in the airplane and thought they travelled over a wheel chock. The captain further stated that he was pushing very hard on the brakes and the airplane would not stop. They both made several attempts to stop the airplane and applied maximum brake pressure, but it would not stop. The captain then reached over with both hands and shut down the engines at the same time the first officer released and re-applied the parking brake. The airplane then came to a stop. The captain added that he heard no alarms or sounds during this event.

According to ground service personnel at OPF, they observed the accident airplane as it prepared to taxi and noticed that its baggage door was open. Two of the ground handlers subsequently boarded an ATV and drove out to the airplane, parking about 10 feet in front of the left wing. One of the ground handlers then dismounted the ATV and proceeded in front of the airplane while motioning to the flightcrew in the cockpit that the baggage door was open. The pilot seated in the right seat then stood up and proceeded into the cabin. Shortly after, the airplane began moving forward. The ground handler then attempted to gain the attention of the pilot seated in the left seat, but was unsuccessful as that pilot never looked up. The airplane's left wing then struck the ATV before it came to a stop.

About 1 week after the accident, the operator's director of maintenance completed a preflight inspection and check of the airplane's hydraulic and braking systems under the supervision of a Federal Aviation Administration inspector, with no anomalies noted.

The airplane's cockpit voice recorder (CVR) and flight data recorder (FDR) were forwarded to the NTSB Vehicle Recorders Laboratory, Washington, DC for data download. Review of the CVR data did not reveal any tasks associated with the formal prestart checklist being completed. The CVR recorded a conversation about programming the flight management system and then it recorded the captain asking the first officer if she wanted to fly from the left seat. One minute later the first officer replied that she did want to fly from the left seat. The recorder then captured a conversation of an informal checklist usage along with a departure briefing. Two minutes later the recorder captured sounds consistent with both engines starting and then the captain stated, "baggage door… I'll get it." Then sounds consistent with switch manipulation and shortly after the captain asked "what are you doing" with an immediate sound of a warning or alert tone as the captain stated, "no brakes….what are you doing?" the first officer responded, "ah I didn't do anything. What's going on? What is going on? Stop." The captain replied, "I don't know." Then the CVR recorded sounds of engines shutting down, followed by one second later a sound consistent with a collision.

Review of the plotted data from the FDR revealed that it only recorded in-flight parameters and that it did not record any on-ground parameters.

Review of the Challenger 601-3A/3R pilot checklist manual, before shut down, the crew was to verify the parking brake was set and check the hydraulic pressure. If this was the last flight of the day, once the airplane wheels were chocked, the parking brake should be released. The before starting checklist stated the wheel chocks must be removed, hydraulic pressure verified, and the parking brakes set before engine start.

The 13-seat airplane was manufactured in 1992, and was equipped with two GE, CF34-3A, turbine engines. The aircraft maintenance records indicated that airplane was maintained on a continuous airworthiness inspection program, and the brake accumulators test was last performed on May 1, 2015, with an airframe total time recorded of 9,649.3 hours. The total time on the airframe at the time of the accident was 9,770.9 hours.

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