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Last updated: 5 June 2020
Status:Schlussbericht
Datum:Mittwoch 30 Januar 2019
Zeit:09:12
Flugzeugtyp:Silhouette image of generic BE20 model; specific model in this crash may look slightly different
Beechcraft 200 Super King Air
Fluggesellschaft:Air Tindi
Kennzeichen: C-GTUC
Werknummer: BB-268
Baujahr: 1977
Betriebsstunden:20890
Anzahl Zyklen der Zelle:18863
Triebwerk: 2 Pratt & Whitney Canada PT6A-42
Besatzung:Todesopfer: 2 / Insassen: 2
Fluggäste:Todesopfer: 0 / Insassen: 0
Gesamt:Todesopfer: 2 / Insassen: 2
Sachschaden: Zerstört
Konsequenzen: Written off (damaged beyond repair)
Unfallort:39 km (24.4 Meilen) ESE of Whatì/Lac La Martre Airport, NT (YLE) (   Kanada)
Flugphase: Während des Fluges (ENR)
Betriebsart:Unbekannt
Flug von:Yellowknife Airport, NT (YZF/CYZF), Kanada
Flug nach:Whatì/Lac La Martre Airport, NT (YLE), Kanada
Flugnummer:TIN503
Unfallbericht:
The Air Tindi Beechcraft 200 King Air aircraft departed controlled flight during its initial descent and crashed near Whatì, Northwest Territories, Canada. Both pilots were killed.
The aircraft operated flight 503, an instrument flight rules flight itinerary from Yellowknife to Whatì Airport, Wekweètì Airport, and Ekati Aerodrome.
During the flight preparations at Yellowknife the first officer (FO) noted that the right-side vacuum-driven attitude indicator was not erect. The captain assured the FO that the instrument would start to operate. The flight took off from Yellowknife at 08:51.
During the climb, while working the after-takeoff checklist, it appeared that the right-side ADI still wasn't working. The captain suggested to the FO that he should tap the attitude indicator to see if it was stuck or frozen. The FO replied that the attitude indicator was still not erect.
While en route at FL120 the pilots attempted to troubleshoot the right-side attitude indicator, but to avail.
At 09:11, after having commenced the descent, the captain’s attitude indicator on the left-side instrument panel displayed a red "GYRO" flag and the autopilot disconnected. At this time the captain began to manually fly the aircraft with partial flight instruments. The aircraft continued to descend, and the captain attempted to initiate a climb. The aircraft climbed briefly before beginning to descend again. The aircraft subsequently entered a gradual left turn that progressed into a steep descending left turn (spiral) from which the aircraft never recovered.

The investigation established that both the captain and the FO had an iPad mini equipped with the ForeFlight Mobile application which had the capability to provide a backup attitude indication and synthetic vision view to both pilots. Since it was a backup feature, Air Tindi did not have a formal training program in place for using the attitude and heading reference system (AHRS) feature of ForeFlight.

Probable Cause:

Findings as to causes and contributing factors:
1. For undetermined reasons, the left-side attitude indicator failed in flight.
2. Although just before take off the crew acknowledged that the right-side attitude indicator was not operative, they expected it to become operative at some point in the flight. As a result, they did not refer to the minimum equipment list, and departed into instrument meteorological conditions with an inoperative attitude indicator.
3. The crew’s threat and error management was not effective in mitigating the risk associated with the unserviceable right-side attitude indicator.
4. The crew’s crew resource management was not effective, resulting in a breakdown in verbal communication, a loss of situation awareness, and the aircraft entering an unsafe condition.
5. The captain did not have recent experience in flying partial panel. As a result, the remaining instruments were not used effectively and the aircraft departed controlled flight and entered a spiral dive.
6. The captain and first officer likely experienced spatial disorientation.
7. Once the aircraft emerged below the cloud layer at approximately 2000 feet above ground, the crew were unable to recover control of the aircraft in enough time and with enough altitude to avoid an impact with terrain.

Accident investigation:
cover
Investigating agency: TSB Canada
Status: Investigation completed
Duration: 1 year and 3 months
Accident number: A19W0015
Download report: Final report

Informationsquelle:
» CBC
» Transport Canada


Fotos

photo of Beechcraft-200-Super-King-Air-C-GTUC
 

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 Yellowknife Airport, NT to Whatì/Lac La Martre Airport, NT as the crow flies is 160 km (100 miles).
Accident location: Approximate; accuracy within a few kilometers.

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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