- Date
- December 28, 1991, 21:46 local (Dec 29, 1991, 02:46 UTC)
- Place
- Block Island, RI
- Injuries
- 3 fatal
- Damage
- Destroyed
- Phase of flight
- Approach
- Aircraft
- N811BEBeech 1900C
- Weather
- Visual (VMC) · Night/dark
- Status
- Completed · report August 13, 1993
- Report
- Approved by Office Director
- Investigation class
- Class 1
- Safety recommendations
- Yes
- FAA report
- 19911228057459A
- Case key
- 37050
From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.
On this page
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.
Sequence of events
NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.
Analysis
The purpose of the flight was to prepare two first officers for a captain upgrade flight. The instructor pilot disabled the student's attitude indicator during flight, and the student had difficulty maintaining airplane control. During a simulated instrument approach, while in the procedure turn, the instructor simulated an engine failure in addition to the attitude indicator failure. The student asked the instructor to take control of the airplane because he became disoriented, however, the instructor refused. The investigation revealed that the instructor would turn his own flight instrument lights to the 'dim' position when the student was flying so that he could not 'peek' at the operable attitude indicator. Examination of the wreckage revealed that the instructor's light rheostat was in the dim position. The accident occurred over the ocean, on a moonless night. Neither the operator, nor the FAA were aware that this instructor was using Block Island for training, or what training methods he was employing.
Aircraft
- Registration
- N811BE
- Reported as
- Beech 1900C
- Category
- Airplane
- Serial number
- UB49
- Airframe hours
- 11,265
- Engine
- P&W PT-6A-65B, 1,100 horsepower, turbo prop
- Damage
- Destroyed
- Flight
- Instructional · Part 91
- Operator
- Business Express Inc.
- Registered owner
- Concord Commercial Corp
- Airworthiness certificate
- Standard, Transport
- Last inspection
- Continuous airworthiness · December 24, 1991 · 13 hours before
- Departed
- BDR · Bridgeport, CT
Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.
Flight crew
As NTSB recorded them. NTSB leaves out names.
- Role
- Pilot
- Age
- 28
- Certificates
- Airline transport, Commercial, Flight instructor
- Airplane ratings
- Multi-engine land, Single-engine land
- Instrument ratings
- Airplane
- Medical
- Class 1, Valid Medical--no waivers/lim.
- Seat
- Right
- Flight hours
- 5,628 total · 2,200 in this make and model · 203 in the last 90 days · 64 in the last 30 days · 3 in the last 24 hours
Weather
- Conditions
- Visual (VMC) · Night/dark
- Wind
- 280° at 12 knots
- Visibility
- 20 statute miles
- Lowest ceiling
- None
- Temperature
- 37 °F
- Altimeter
- 30.00 inHg
- Observed at
- PVD, 63 nm away
FAA reports on this event · 1
The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.
Other investigations on N811BE · 1
Matched to the same aircraft by N-number and date.