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Wed, Mar 20, 2024

NTSB Prelim: Pilatus Crew Re-Learns Importance of Checklists

Location: Ronkonkoma, New York  Accident Number: ERA22LA115
Date & Time: February 2, 2022, 06:55  Local Registration: N357JK
Aircraft: PILATUS AIRCRAFT LTD PC12/47E   Aircraft Damage: Substantial
Defining Event: Miscellaneous/other Injuries: 2 None  
Flight Conducted Under: Part 91: General aviation - Positioning

A Pilatus PC-12 went for a brief taxiway adventure after startup, running headlong into a parked aircraft when the pilot in command failed to ensure adequate checklist adherence.

The NTSB found that a February 2022 incident was largely initiated when the pilot and their pilot-rated passenger up front failed to place the power lever into the idle position before engine start. Unfortunately, they did manage to call out the command to place the lever into idle, but without manually ensuring it had been placed there physically. In the cold wintry conditions of Ronkonkoma, New York at the time, the cold engine came to life, skittering across the icy tarmac. The prop speed got up to 1,870 rpm, allowing the Pilatus to skitter across at 26 knots as the PIC tried to exercise the toe brakes and halt its momentum. Unfortunately, the power lever remained untouched throughout the affair, which ended when the aircraft impacted another parked plane, resulting in substantial damage.

The investigation did yield some out-of-spec conditions in the rigging, both for the power lever and condition levers. Regardless, there wasn't any pre-impact failure or malfunction to explain away the accident in the controls, fuel control, engine, or brakes. The separation of the right wing precluded a full investigation into the right brake's potency, but it's probably not something that would have done much to take the blame. Indications of skidding along the ramp were attributed to icing conditions at the time, and the tires showed no flat spots. 

The NTSB even tried to see how much forward momentum would arise with a similar Pilatus. "The PCL was found in a forward position following the accident. Although the exact position of the PCL at engine start could not be determined from the FDR information, based on the maximum engine and propeller parameters recorded by the FDR, and the speed the airplane reached before the collision, it is likely that the PCL was nearly fully advanced during the engine start. Had the pilot performed a flow check then reviewed the checklists for any missed items or engaged the passenger to perform challenge-and-response to the entire checklist, the incorrect position of the PCL could have been detected and corrected before engine start."

The report notes that the PIC reported being unable to secure the power lever while accelerating from a stop, but they found no discrepancies with the cutoff guard, and post-accident testing found nothing else of note. Ergo, the final verdict was a simple checklist slipup. Callouts aren't enough, particularly in cases of major flight controls.

FMI: www.ntsb.gov

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