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Last updated: 2 July 2020
Status:Definitief
Datum:woensdag 30 januari 2019
Tijd:09:12
Type:Silhouette image of generic BE20 model; specific model in this crash may look slightly different
Beechcraft 200 Super King Air
Luchtvaartmaatschappij:Air Tindi
Registratie: C-GTUC
Constructienummer: BB-268
Bouwjaar: 1977
Aantal vlieguren:20890
Aantal vluchten:18863
Motoren: 2 Pratt & Whitney Canada PT6A-42
Bemanning:slachtoffers: 2 / inzittenden: 2
Passagiers:slachtoffers: 0 / inzittenden: 0
Totaal:slachtoffers: 2 / inzittenden: 2
Schade: Vernield
Gevolgen: Written off (damaged beyond repair)
Plaats:39 km (24.4 mijl) ESE of Whatì/Lac La Martre Airport, NT (YLE) (   Canada)
Fase: Kruisvlucht (ENR)
Soort vlucht:Onbekend
Vliegveld van vertrek:Yellowknife Airport, NT (YZF/CYZF), Canada
Vliegveld van aankomst:Whatì/Lac La Martre Airport, NT (YLE), Canada
Vluchtnummer:TIN503
Beschrijving:
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

Bronnen:
» CBC
» Transport Canada


Foto's

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

Kaart
Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen Yellowknife Airport, NT en Whatì/Lac La Martre Airport, NT bedraagt 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.
languages: languages

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