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Aviation safety reports, made easier to study

NTSB Reports is an independent research and search tool for public aviation accident and incident records. It brings NTSB aviation reports, structured fields, docket files, extracted figures, photos, videos, and update history into one searchable interface.

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NTSB Report

December 29, 1991 · Beech 1900C · N811BE

Block Island, RI

Overview

Report Status
Probable Cause
Event Type
Accident
Date
December 29, 1991
Injury Outcomes
3 injuries (3 fatalities)
Location
Block Island, RI
Aircraft
Beech 1900C
Tail Number
N811BE
Operator
Business Express
Injuries
Fatal
Aircraft Damage
Destroyed
NTSB Number
NYC92FA053

THE PURPOSE OF THE FLIGHT WAS TO PREPARE TWO FIRST OFFICERS FOR A CAPTAIN UPGRADE FLIGHT. THE INSTRUCTOR PILOT DISABLED THE STUDENT'S ATTITUDE INDICATOR DURING FLIGHT, AND THE STUDENT HAD DIFFICULTY MAINTAINING AIRPLANE CONTROL. DURING A SIMULATED INSTRUMENT APPROACH, WHILE IN THE PROCEDURE TURN, THE INSTRUCTOR SIMULATED AN ENGINE FAILURE IN ADDITION TO THE ATTITUDE INDICATOR FAILURE. THE STUDENT ASKED THE INSTRUCTOR TO TAKE CONTROL OF THE AIRPLANE BECAUSE HE BECAME DISORIENTED, HOWEVER, THE INSTRUCTOR REFUSED. THE INVESTIGATION REVEALED THAT THE INSTRUCTOR WOULD TURN HIS OWN FLIGHT INSTRUMENT LIGHTS TO THE 'DIM' POSITION WHEN THE STUDENT WAS FLYING SO THAT HE COULD NOT 'PEEK' AT THE OPERABLE ATTITUDE INDICATOR. EXAMINATION OF THE WRECKAGE REVEALED THAT THE INSTRUCTOR'S LIGHT RHEOSTAT WAS IN THE DIM POSITION. THE ACCIDENT OCCURRED OVER THE OCEAN, ON A MOONLESS NIGHT. NEITHER THE OPERATOR, NOR THE FAA WERE AWARE THAT THIS INSTRUCTOR WAS USING BLOCK ISLAND FOR TRAINING, OR WHAT TRAINING METHODS HE WAS EMPLOYING.

NTSB Probable Cause

THE INSTRUCTOR PILOT'S LOSS OF ALTITUDE AWARENESS AND POSSIBLE SPATIAL DISORIENTATION, WHICH RESULTED IN THE LOSS OF CONTROL OF THE AIRPLANE AT AN ALTITUDE TOO LOW FOR RECOVERY; AND COMPANY MANAGEMENT'S LACK OF INVOLVEMENT IN AND OVERSIGHT OF ITS BEECHCRAFT 1900 FLIGHT TRAINING PROGRAM. CONTRIBUTING TO THE ACCIDENT WAS THE INSTRUCTOR PILOT'S EXERCISE OF POOR JUDGMENT IN ESTABLISHING A FLIGHT SITUATION AND AIRPLANE CONFIGURATION CONDUCIVE TO SPATIAL DISORIENTATION THAT AFFORDED THE PILOTS LITTLE OR NO MARGIN FOR ERROR.

Full Narrative

THE PURPOSE OF THE FLIGHT WAS TO PREPARE TWO FIRST OFFICERS FOR A CAPTAIN UPGRADE FLIGHT. THE INSTRUCTOR PILOT DISABLED THE STUDENT'S ATTITUDE INDICATOR DURING FLIGHT, AND THE STUDENT HAD DIFFICULTY MAINTAINING AIRPLANE CONTROL. DURING A SIMULATED INSTRUMENT APPROACH, WHILE IN THE PROCEDURE TURN, THE INSTRUCTOR SIMULATED AN ENGINE FAILURE IN ADDITION TO THE ATTITUDE INDICATOR FAILURE. THE STUDENT ASKED THE INSTRUCTOR TO TAKE CONTROL OF THE AIRPLANE BECAUSE HE BECAME DISORIENTED, HOWEVER, THE INSTRUCTOR REFUSED. THE INVESTIGATION REVEALED THAT THE INSTRUCTOR WOULD TURN HIS OWN FLIGHT INSTRUMENT LIGHTS TO THE 'DIM' POSITION WHEN THE STUDENT WAS FLYING SO THAT HE COULD NOT 'PEEK' AT THE OPERABLE ATTITUDE INDICATOR. EXAMINATION OF THE WRECKAGE REVEALED THAT THE INSTRUCTOR'S LIGHT RHEOSTAT WAS IN THE DIM POSITION. THE ACCIDENT OCCURRED OVER THE OCEAN, ON A MOONLESS NIGHT. NEITHER THE OPERATOR, NOR THE FAA WERE AWARE THAT THIS INSTRUCTOR WAS USING BLOCK ISLAND FOR TRAINING, OR WHAT TRAINING METHODS HE WAS EMPLOYING.

Flight

Event TypeAccident
Event Time21:46 EST
Nearest Airport0nm N
Runway0
Flight Plan FiledNone
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftBeech 1900C
Tail NumberN811BE
Aircraft CategoryAir
DamageDestroyed
OperatorBusiness Express
Operating RulePart 91
Engines2
Engine TypeTurboprop
Engine DetailsP&W · PT-6A-65B · Turboprop · 1100
Seats21

People & Injuries

Injury Summary3 injuries (3 fatalities)
Fatal3
Serious0
Minor0
Uninjured0
Total3
Crew 1Age 28 · First Class

Conditions

ConditionsVMC
LightDark Night
Wind280° @ 12 kt
Visibility20 sm
CeilingNone
Temperature / Dew Point37 C / 0 C
Altimeter30.00 inHg
Observation Time02:00
Weather SourceWFAC

Appendix: Source Data