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Accident description
Last updated: 17 August 2017
Status:Final
Date:Saturday 28 December 1991
Time:21:46
Type:Silhouette image of generic B190 model; specific model in this crash may look slightly different
Beechcraft 1900C
Operating for:Delta Connection
Leased from:Business Express Airlines
Registration: N811BE
C/n / msn: UB-49
First flight: 1985
Total airframe hrs:11265
Engines: 2 Pratt & Whitney Canada PT6A-65B
Crew:Fatalities: 3 / Occupants: 3
Passengers:Fatalities: 0 / Occupants: 0
Total:Fatalities: 3 / Occupants: 3
Airplane damage: Destroyed
Airplane fate: Written off (damaged beyond repair)
Location:17 km (10.6 mls) ENE off Block Island, RI (   United States of America)
Phase: Maneuvering (MNV)
Nature:Training
Departure airport:Bridgeport-Igor I. Sikorsky Memorial Airport, CT (BDR/KBDR), United States of America
Destination airport:Bridgeport-Igor I. Sikorsky Memorial Airport, CT (BDR/KBDR), United States of America
Narrative:
Two co-pilots were preparing for an upgrade flight. The instructor disabled the student's attitude indicator and an engine failure was simulated in the procedure turn for an instrument approach. The student became disoriented and asked the instructor to take control, which he refused. The aircraft later struck the sea.

Probable Cause:

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."
The ALPA did not agree with the probable cause adopter by the NTSB. In a 1997 ALPA petition they claim that a whirl mode flutter was induced to the right engine and propeller assembly, due to pre-existing right engine truss tube failures. This whirl mode flutter caused a catastrophic failure within the truss mount system. This failure allowed the right engine and nacelle to depart the right wing. The right engine struck and removed the right horizontal stabilizer. The propeller probably damaged the left horizontal stabilizer. The aircraft then pitched over violently and instantly and crashed.

Accident investigation:
cover
Investigating agency: NTSB
Status: Investigation completed
Duration: 1 year and 4 months
Accident number: NTSB/AAR-93-01-SUM
Download report: Final report

Classification:
Loss of control

Sources:
» Aircraft Damage Detection From Acoustic Signals Found By A Cockpit Voice Recorder / Ronald O. Stearman et al
» Air Safety Week 3.5.1993 (p. 3)
» ICAO Adrep Summary 4/94 (#14)
» Petition for Reconsideration of Probable Cause, N811BE (The Investigation Process Research Resource Site)


Follow-up / safety actions

NTSB issued 5 Safety Recommendations

Show all AD's and Safety Recommendations

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This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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