Narrative:The Beechcraft B200 Super King Air was destroyed when it impacted terrain near Delhi-Indira Gandhi International Airport (DEL), India. All ten on board were killed.
The aircraft was scheduled to perform a round trip from Delhi to Ranchi, India. As per the weight & load data sheet there were 8 passengers with 20 kg of baggage in the aft cabin compartment. The actual take-off weight shown was 5668.85 kg, which was just below the maximum take-off weight of 5669.9 kg Fuel uplifted was 1085 kg.
The passengers were mainly technical personnel who were to carry out scheduled maintenance of a Mil Mi-17 helicopter of the Border Security Force at Ranchi. They were carrying their personnel baggage along with tools and equipment required for the maintenance. While the personal baggage was 152 kg (8 kg below the 20 kg per person used in the calculations), tools and equipment weighed at least another 63 kg.
At around 09:15 hrs the flight crew contacted ATC Delhi and requested for clearance to operate the flight to Ranchi. The aircraft was cleared to Ranchi via R460 and FL210. Runway in use was given as 28. At 0918 hrs the doors were closed and the flight crew had started carrying out the check list. After the ATC issued taxi clearance, the aircraft had stopped for some time after commencing taxiing. The pilot informed the ATC that they would take 10 minutes delay for further taxi for administrative reasons. The taxi clearance was accordingly cancelled. After a halt of about 6 to 7 minutes, the pilot again requested the ATC for taxi clearance. The Tower then cleared the aircraft to taxi via E, line-up and wait on runway 28. The aircraft was then cleared for take-off. The weather at the time of take-off was: Visibility 800 meters with Winds 100 degrees at 3 knots.
The speed call outs were given followed by rotate call out after the aircraft attained a speed of 110 knots at 51 seconds before the crash. Shortly after take-off and attaining a height of approximately 400 feet AGL, the aircraft progressively turned left with simultaneous loss of height. At 43 seconds before the crash, the Pilot Monitoring (PM) asked the Pilot Flying to maintain direction. At 21 seconds prior to the crash, the PM realised that the heading mode of the autopilot was not engaged, so he attempted to fly the aircraft manually.
Simultaneously, at 17 seconds prior to the crash there were successive warnings of the autopilot disengage, altitude alert, bank angle alarm and stall warning alarm. At 8 seconds prior to the crash the stall warning alarm came on. The alarm continued till the end along with Bank Angle warning from the EGPWS. The aircraft had taken a turn of approximately 180° and impacted some trees before hitting the outside perimeter road of the airport in a left bank attitude. Thereafter, it impacted head on with the outside boundary wall of the airport. After breaking the outside boundary wall, the wings impacted two trees and the aircraft hit the holding tank of the water treatment plant. The tail portion and part of the fuselage overturned and went into the water tank. There was a post impact fire and the portion of the aircraft outside the water tank was destroyed by fire. All passengers and crew received fatal injuries due impact and fire.
The total PIC experience of the PF on the B200 aircraft was 77:00 hours and that of the PM was 196:35 hours as PIC. The PF was released as PIC after 620:35 hours of co-pilot experience on Type, while the PM was released as PIC after 183 hours of co-pilot experience on Type. Most of the on Type experience of these two flight crew was gained while flying amongst themselves. Despite written instructions of the Accountable Manager that an experienced pilot should be on board as the second pilot whenever the PF or PM were flying as PIC, these low experienced pilots did not fly under supervision of an experienced pilot while building their respective PIC experience.
Therefore, in such a scenario there was no opportunity available to this flight crew to identify their deficiencies in flying techniques, operational procedures, correct interpretation of the effects of weather, airmanship, etc. and applicable appropriate correction/ response even though a well experienced and seasoned Senior Pilot on Type was available in-house. Also, the series of occurrences in the past 6 months prior to the crash and their non-reporting indicates lack of flying expertise and complete non-supervision of their unsafe acts.
Probable Cause:
Probable Cause of the Accident:
The accident was caused due to engagement of the autopilot without selecting the heading mode by the flight crew just after liftoff (before attaining sufficient height) in poor foggy conditions and not taking corrective action to control the progressive increase in left bank; thereby, allowing the aircraft to traverse 180° turn causing the aircraft to lose height in a steep left bank attitude followed by impact with the terrain.
Accident investigation:
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Investigating agency: | AAIB India  |
Status: | Investigation completed |
Duration: | 1 year and 8 months | Accident number: | Final report | Download report: | Final report
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Classification:
Loss of control
Sources:
»
The Hindu
METAR Weather report:
03:30 UTC / 09:00 local time:
VIDP 220330Z 00000KT 0800 R28/1600 R29/1000 MIFG FEW100 11/07 Q1021 NOSIG04:00 UTC / 09:30 local time:
VIDP 220400Z 11003KT 0800 R28/P2000 R29/1100 FU FEW100 13/08 Q1022 NOSIG04:30 UTC / 10:00 local time:
VIDP 220430Z 10003KT 0800 R28/P2000 R29/1100 FU FEW100 14/08 Q1022 NOSIG
Follow-up / safety actions
AAIB India issued 5 Safety Recommendations
Issued: -- | To: DGCA India | VT-BSA(1) |
The DGCA should amend the para 6.15 of CAR Sec 3 Air Transport Ser C Part X dated 02nd June 2010 as follows:
o When operating VIP flights with fixed wing aircraft, the pilot-incommand shall possess CPL or ATPL with at least 3000 hours out of which 1000 hours on Multi/ Twin Engine aircraft including 2000 hours as PIC out of which 500 hrs as PIC on Multi/ Twin engine aircraft, 100 hours as PIC on type of aircraft to be flown and 50 hours of night flying experience. In addition, the pilot should have a minimum of 30 hours as PIC experience in the last 6 months including five hours on type in the last thirty days of the intended flight. In case 30 hrs. recency during the last 6 months is not met with, then in last 30 days, a satisfactory skill test (as required for licence renewal) shall be carried out followed by 5 hrs. of PIC experience. |
Issued: -- | To: | VT-BSA(2) |
The Organisation must carry out procedural and systemic introspection of the Air Wing Operations in view of the subject accident and follow one system of regulation to avoid resultant unsafe practices at ground level. |
Issued: -- | To: | VT-BSA(3) |
The Organisation should ensure that risk analysis is carried out for every action and mitigation action is evolved. Ways and means be developed to avoid false sense of safe operations. |
Issued: -- | To: DGCA India | VT-BSA(4) |
The DGCA should carry out thorough regulatory audit of the organisation and ensure that the Organisation meets at least all the requirements of CAR Section 3 - Air Transport Ser C Part X, and issue the Organisation with the requisite authorisation, if found suitable. |
Issued: -- | To: DGCA India | VT-BSA(5) |
The DGCA should ensure continued compliance with the regulations through continuous oversight checking, acting as one of the stake holders. |
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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Delhi-Indira Gandhi International Airport to Ranchi-Birsa Munda International Airport as the crow flies is 1001 km (626 miles).
Accident location: Exact; as reported in the official accident report.
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.