Statuts: | Accident investigation report completed and information captured |
Date: | samedi 28 décembre 1991 |
Heure: | 21:46 |
Type/Sous-type: |  Beechcraft 1900C |
Opérant pour: | Delta Connection |
Loué à : | Business Express Airlines |
Immatriculation: | N811BE |
Numéro de série: | UB-49 |
Année de Fabrication: | 1985 |
Heures de vol: | 11265 |
Moteurs: | 2 Pratt & Whitney Canada PT6A-65B |
Equipage: | victimes: 3 / Ã bord: 3 |
Passagers: | victimes: 0 / Ã bord: 0 |
Total: | victimes: 3 / Ã bord: 3 |
Dégats de l'appareil: | Détruit |
Conséquences: | Written off (damaged beyond repair) |
Lieu de l'accident: | 17 km (10.6 milles) ENE de Block Island, RI ( Etats-Unis d'Amérique)
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Phase de vol: | En cours de manoeuvre (MNV) |
Nature: | Entrainement |
Aéroport de départ: | Bridgeport-Igor I. Sikorsky Memorial Airport, CT (BDR/KBDR), Etats-Unis d'Amérique |
Aéroport de destination: | Bridgeport-Igor I. Sikorsky Memorial Airport, CT (BDR/KBDR), Etats-Unis d'Amérique |
Détails: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:

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Investigating agency: | NTSB  |
Status: | Investigation completed |
Duration: | 1 year and 4 months | Accident number: | NTSB/AAR-93-01-SUM | Download report: | Final report
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Sources:
»
Aircraft Damage Detection From Acoustic Signals Found By A Cockpit Voice Recorder / Ronald O. Stearman et al» Air Safety Week 3 May 1993 (p. 3)
» ICAO Adrep Summary 4/94 (#14)
»
Petition for Reconsideration of Probable Cause, N811BE (The Investigation Process Research Resource Site)
Opérations de secours
NTSB issued 5 Safety Recommendations
Issued: 08-JUN-1993 | To: FAA | A-93-76 |
AMEND 14 CFR PART 43, APPENDIX B TO REQUIRE THAT REPAIR STATIONS COMPLETE FEDERAL AVIATION ADMINISTRATION (FAA) FORM 337 OR EQUIVALENT RECORDS FOR ALL MAJOR REPAIRS AND/OR ALTERATIONS AND PROVIDE COPIES OF THE RECORDS TO THE FAA AND TO THE OWNER, TO BE RETAINED WITH THE AIRCRAFT HISTORICAL RECORDS. (Closed - Acceptable Alternate Action) |
Issued: 25-JUN-1993 | To: FAA | A-93-70 |
REQUIRE PRINCIPAL OPERATIONS INSPECTORS OF COMMUTER AIRLINES TO VERIFY THAT APPROPRIATE AND QUALIFIED LEVELS OF AIRLINES\' MANAGEMENT ARE ACTIVELY INVOLVED IN THE AIRLINES\' FLIGHT TRAINING PROGRAMS. (Closed - Acceptable Action) |
Issued: 25-JUN-1993 | To: FAA | A-93-71 |
ENCOURAGE COMMUTER AIRLINES MANAGERS TO USE APPROVED FLIGHT SIMULATORS FOR PILOT TRAINING, QUALIFICATION, AND COMPETENCY AND INSTRUMENT CHECK PURPOSE TO THE MAXIMUM EXTENT FEASIBLE. (Closed - Acceptable Action) |
Issued: 25-JUN-1993 | To: FAA | A-93-72 |
CONSIDER AN AMENDMENT TO 14 CFR PART 135 TO REQUIRE THAT COMMUTER AIR CARRIERS PERFORM CERTAIN HAZARDOUS TRAINING, TESTING, AND CHECKING MANEUVERS, SUCH AS ENGINE-OUT OPERATIONS, AND RECOVERY FROM UNUSUAL FLIGHT ATTITUDES, IN APPROVED FLIGHT SIMULATORS TO THE MAXIMUM EXTENT FEASIBLE. (Closed - Acceptable Action) |
Issued: 25-JUN-1993 | To: | A-93-73 |
ENCOURAGE ITS MEMBERS TO USE APPROVED FLIGHT SIMULATORS FOR REQUIRED PILOT TRAINING, QUALIFICATION, AND COMPETENCY AND INSTRUMENT CHECK PURPOSES TO MAXIMUM EXTENT FEASIBLE. (Closed - Acceptable Action) |
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Les informations ci-dessus ne représentent pas l'opinion de la 'Flight Safety Foundation' ou de 'Aviation Safety Network' sur les causes de l'accident. Ces informations prélimimaires sont basées sur les faits tel qu'ils sont connus à ce jour.