3 fatalities

1991-12-28: Beechcraft 1900C (N811BE) — Business Express - USA — Block Island, United States of America

Block Island, United States of AmericaFlight

On December 28, 1991, a Beechcraft 1900C (registration N811BE) operated by Business Express - USA was involved in an aviation accident near Block Island, United States of America in flight. 3 people were killed. Investigators recorded the probable cause as: 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… This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A).

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781211417Data APIEditorial standards

A flight instructor disabled a student's attitude indicator and simulated an engine failure during a night training flight over the ocean, leading to a loss of control. The instructor refused to take control when the student became disoriented. The investigation cited the instructor's loss of altitude awareness and poor judgment, as well as inadequate company oversight.

Flight Training Scenario

The purpose of the flight was to prepare two first officers for a captain upgrade. During the flight, the instructor pilot disabled the student's attitude indicator, and the student subsequently had difficulty maintaining airplane control. While conducting a simulated instrument approach and executing a procedure turn, the instructor additionally simulated an engine failure. The student, becoming disoriented, asked the instructor to take control of the airplane, but the instructor refused.

Instructor's Actions

The investigation revealed that the instructor would turn his own flight instrument lights to the 'dim' position when the student was flying, preventing the student from 'peeking' at the operable attitude indicator. Examination of the wreckage confirmed that the instructor's light rheostat was in the dim position.

Accident Circumstances

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 of the training methods he was employing.

Probable Cause and Contributing Factors

According to the official findings, the probable cause was the instructor pilot's loss of altitude awareness and possible spatial disorientation, which resulted in a loss of control of the airplane at an altitude too low for recovery. Additionally, company management's lack of involvement in and oversight of its Beechcraft 1900 flight training program was cited. A contributing factor was the instructor pilot's exercise of poor judgment in establishing a flight situation and airplane configuration conducive to spatial disorientation, which afforded the pilots little or no margin for error.