# NTSB NYC92FA053: Beech 1900C, N811BE, Block Island, RI, December 29, 1991 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 1 · Field · Final report - Date: December 28, 1991, 21:46 local (Dec 29, 1991, 02:46 UTC) - Place: Block Island, RI - Location: 41.1918° N, 71.5745° W: Placed by OpenAirDocs: center of Block Island, RI, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=41.1918&lon=-71.5745&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report August 13, 1993 - Report: Approved by Office Director - Investigation class: Class 1 - Safety recommendations: Yes - NTSB case key (mKey): 37050 - NTSB case page: https://www.ntsb.gov/investigations/Pages/NYC92FA053.aspx - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/37050/pdf - Board report AAR9301S (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR9301S.pdf - Page: https://openairdocs.org/ntsb/NYC92FA053 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - iaf to faf/outer marker (ifr) - flight/nav instruments,attitude gyro - disabled (contributing factor) - emergency procedure - simulated, pilot in command(cfi) - powerplant - disabled (contributing factor) - emergency procedure - simulated, pilot in command(cfi) - judgment - poor, pilot in command(cfi) (cause) - aircraft control - not maintained, pilot in command(cfi) (cause) - spatial disorientation, pilot in command(cfi) (contributing factor) - light condition - dark night - inadequate surveillance of operation, company/operator mgmt (cause) - inadequate surveillance of operation, faa(organization) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - water ## 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](https://openairdocs.org/deregistered/N811BE-2011-10-12), registration cancelled 2011-10-12, S/N UB49, built 1985 (OpenAirDocs) - Reported make and model: BEECH 1900C - Registry model: [Beech 1900C](https://openairdocs.org/model/beech-1900c) (registry code 1154161) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PT6A-60A](https://openairdocs.org/engine/pratt-whitney-canada-pt6a-60a) (registry code 52043, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: UB49 - Airframe hours: 11265 - Engines: P&W PT-6A-65B 1100 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 28; 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 (OpenAirDocs). - [Accident 19911228057459A](https://openairdocs.org/incident/19911228057459A), Dec 28, 1991: Beech 1900C, Block Island, RI, Destroyed, 3 fatal. CFI gave student simulated IFR approach covered gyros and single engine. Student gave up. CFI allowed water impact. ## Other investigations on N811BE (1) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB NYC87LA117](https://openairdocs.org/ntsb/NYC87LA117), Apr 7, 1987: Beech 1900 (N811BE), Boston, MA, substantial damage From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.