|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1801 To 2400|
|Locale Reference||airport : cvg|
|Altitude||agl bound lower : 0|
agl bound upper : 0
|Operator||common carrier : air carrier|
|Make Model Name||Light Transport, Low Wing, 2 Turboprop Eng|
|Flight Phase||ground other : taxi|
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Qualification||pilot : atp|
|Experience||flight time last 90 days : 200|
flight time total : 3600
flight time type : 95
|Function||other personnel other|
|Anomaly||aircraft equipment problem : less severe|
conflict : ground critical
|Independent Detector||other flight crewa|
|Resolutory Action||none taken : unable|
|Miss Distance||horizontal : 0|
vertical : 0
|Air Traffic Incident||Pilot Deviation|
I entered an aircraft for the sole purpose of repositioning the aircraft to another ramp on the field. After completing a before start checklist, I started both engines normally. After both engines were running, I completed an after start checklist. I then released the emergency brake and parking brake. I then brought the propeller levers out of feather and into taxi. The aircraft began to move forward and I tested the brakes. At that time I became aware that the brakes were inoperative. The aircraft moved approximately 75' during which time I tried to stop the aircraft by putting the propellers into reverse pitch. I was unsuccessful in stopping the aircraft and it impacted some cargo carts. After the aircraft came to a complete stop, I executed an emergency shutdown checklist. I then exited the aircraft to inspect the damage (minor damage to the nose and left stub wind occurred). It was later determined that the hydraulic inlet valves were left closed after maintenance was done on the aircraft, thus allowing no hydraulic power to the systems. I had taxied the aircraft earlier and the valves were open. Complacency while using a checklist I believe was the cause of this incident, while not being notified that maintenance was performed on the aircraft previously. All pilots should realize that even moving an aircraft not for the purpose of flight should be done with as much caution and attention as while flying, and not only read the checklist, but visually check the items on that checklist. Callback conversation with reporter revealed the following: the hydraulic inlet valves are normally only operated by maintenance when they do work on the aircraft. They are not on the flight crew pre start checklist and are located on the bulkhead behind and beside the seat, where they are not in a normal scan pattern of the cockpit. Because there was no indication in the logbook of maintenance since the aircraft had been repositioned by the same pilot in the morning, and the aircraft had not flown, was no reason for the pilot to suspect anything unusual. The emergency brake works on accumulator pressure, which was down, so they also had no effect. Pilot has heard nothing from the FAA, although the incident was reported by company. Pilot did receive 2 week suspension from the company, but as far as he knows, mechanic received no discipline.
Original NASA ASRS Text
Title: PLT REPOSITIONING ACFT ON RAMP FOUND BRAKES INOPERATIVE AND COLLIDED WITH CARGO CARTS.
Narrative: I ENTERED AN ACFT FOR THE SOLE PURPOSE OF REPOSITIONING THE ACFT TO ANOTHER RAMP ON THE FIELD. AFTER COMPLETING A BEFORE START CHKLIST, I STARTED BOTH ENGS NORMALLY. AFTER BOTH ENGS WERE RUNNING, I COMPLETED AN AFTER START CHKLIST. I THEN RELEASED THE EMER BRAKE AND PARKING BRAKE. I THEN BROUGHT THE PROPELLER LEVERS OUT OF FEATHER AND INTO TAXI. THE ACFT BEGAN TO MOVE FORWARD AND I TESTED THE BRAKES. AT THAT TIME I BECAME AWARE THAT THE BRAKES WERE INOP. THE ACFT MOVED APPROX 75' DURING WHICH TIME I TRIED TO STOP THE ACFT BY PUTTING THE PROPS INTO REVERSE PITCH. I WAS UNSUCCESSFUL IN STOPPING THE ACFT AND IT IMPACTED SOME CARGO CARTS. AFTER THE ACFT CAME TO A COMPLETE STOP, I EXECUTED AN EMER SHUTDOWN CHKLIST. I THEN EXITED THE ACFT TO INSPECT THE DAMAGE (MINOR DAMAGE TO THE NOSE AND LEFT STUB WIND OCCURRED). IT WAS LATER DETERMINED THAT THE HYD INLET VALVES WERE LEFT CLOSED AFTER MAINT WAS DONE ON THE ACFT, THUS ALLOWING NO HYD PWR TO THE SYSTEMS. I HAD TAXIED THE ACFT EARLIER AND THE VALVES WERE OPEN. COMPLACENCY WHILE USING A CHKLIST I BELIEVE WAS THE CAUSE OF THIS INCIDENT, WHILE NOT BEING NOTIFIED THAT MAINT WAS PERFORMED ON THE ACFT PREVIOUSLY. ALL PLTS SHOULD REALIZE THAT EVEN MOVING AN ACFT NOT FOR THE PURPOSE OF FLT SHOULD BE DONE WITH AS MUCH CAUTION AND ATTN AS WHILE FLYING, AND NOT ONLY READ THE CHKLIST, BUT VISUALLY CHK THE ITEMS ON THAT CHKLIST. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: THE HYD INLET VALVES ARE NORMALLY ONLY OPERATED BY MAINT WHEN THEY DO WORK ON THE ACFT. THEY ARE NOT ON THE FLT CREW PRE START CHKLIST AND ARE LOCATED ON THE BULKHEAD BEHIND AND BESIDE THE SEAT, WHERE THEY ARE NOT IN A NORMAL SCAN PATTERN OF THE COCKPIT. BECAUSE THERE WAS NO INDICATION IN THE LOGBOOK OF MAINT SINCE THE ACFT HAD BEEN REPOSITIONED BY THE SAME PLT IN THE MORNING, AND THE ACFT HAD NOT FLOWN, WAS NO REASON FOR THE PLT TO SUSPECT ANYTHING UNUSUAL. THE EMER BRAKE WORKS ON ACCUMULATOR PRESSURE, WHICH WAS DOWN, SO THEY ALSO HAD NO EFFECT. PLT HAS HEARD NOTHING FROM THE FAA, ALTHOUGH THE INCIDENT WAS RPTED BY COMPANY. PLT DID RECEIVE 2 WK SUSPENSION FROM THE COMPANY, BUT AS FAR AS HE KNOWS, MECH RECEIVED NO DISCIPLINE.
Data retrieved from NASA's ASRS site as of August 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.