|
National
Transportation
Safety Board
Washington, D.C. 20594 |
AIRCRAFT
ACCIDENT/INCIDENT SUMMARY
Accident No.:
Airplane Owner/Operator:
Airplane Type:
Location:
Date and Time:
Injuries:
Type of Occurrence: |
NYC-92-FA-053
Business Express, Inc.
Beechcraft 1900C, N81IBE
near Block Island, Rhode Island
December 28, 1991, 2147 est
3 Fatal
Loss of Control |
1. THE FLIGHT
On December 28, 1991, about 1845 eastern standard time, a
Beech Aircraft Corporation Beechcraft 1900C, operated by Business Express,
Inc. (BEX), departed the Igor I. Sikorsky Memorial Airport, Bridgeport,
Connecticut. The flight was operated under the provisions of 14 Code of
Federal Regulations (CFR) Part 91 and visual flight rules (VFR). A flight
plan was not filed, nor was one required. An instructor pilot (IP) and
two other pilots were aboard the airplane to conduct training. The location
of the flight was essentially unknown until it was observed in the traffic
pattern at the Block Island Airport about 2000. According to the airport
manager, the flight landed about 2000, and the flightcrew deplaned. The
three pilots discussed the technical aspects of the airplane and seemed
in good spirits. They boarded the airplane and took off from runway 28
sometime between 2045 and 2100. Sometime later, the flight landed again
at the Block Island Airport and remained on the ground for a few minutes
with its engines running; the flight then departed for the second time,
but the airport manager did not observe the direction of flight. N811BE
had been scheduled for a passenger flight from Bridgeport at 1000 on December
29,
1991.
About 0930, company station personnel reported the airplane missing to
the central dispatch department. A search of all company stations disclosed
that N811BE was not at any of the airports serviced by the stations.
Page 2
About 0740, on December 29, 1991, persons aboard a fishing
vessel located part of a wing of an airplane floating in the ocean northeast
of Block Island. The part was later identified as belonging to N811BE.
The U.S. Coast Guard initiated an air and surface search of the area, which
located other small pieces of floating debris, but no survivors or bodies.
Air traffic control (ATC) radar data recorded at the Boston Air Route Traffic
Control Center (ARTCC) was reviewed for possible identification of N811BE.
The December 28 data disclosed air craft activity in the vicinity of the
Block Island Airport between 2113 and 2147. The data reflected an airplane
at various altitudes between 300 feet mean sea level (msl) and 2,500 feet
msl with its transponder providing a code 1200 (VFR code) return. The activity
ceased at 2146:07 at an altitude of 1,800 feet msl at coordinates latitude
°13'34"N and longitude 71°22'48" .Based on the ATC radar data
and the location of the right wing section, an underwater search-and-survey
firm performed a drift analysis of the wing section. The analysis was performed
to determine where the wing section entered the water based on the elapsed
time between the disappearance of the ATC radar target assumed to have
been N811BE and the time and location of the wing section's discovery.
The analysis used surface wind speed and direction for each 20-minute period
during the elapsed time along with oceanographic data on wind-driven and
-tidal
currents for the area. The analysis provided a 12 square mile search area
with the highest probability of wreckage location within a 1.5
square
mile area. Wreckage location efforts began in the 1.5
square mile
area on January 1, 1992. First activation of the underwater receivers for
a cockpit voice recorder (CVR) beacon transmission disclosed faint beacon
signals. A sonar search pattern established along the last ATC radar ground
track of the assumed target of N811BE disclosed a debris field west of
the track. Further search placed the CVR transmitter at the southwestern
end of the debris field. On January 2, underwater video from a remotely-operated
vehicle confirmed the wreckage of N811BE. Poor weather conditions precluded
recovery of the CVR until January 11, 1992. Over about 30 days, salvage
efforts resulted in the recovery of 40 to 50 percent of the airplane. The
bodies of the three pilots aboard were not recovered, and they remain missing.
The accident occurred about 2147 at latitude 41°13'34"N and longitude
°22'48"
Page 3
On December 28, the weather at Providence, Rhode Island,
was reported at 2100 as clear with 20 miles of visibility. The winds were
from 280î at 12 knots, and the altimeter was 30.19 inches of mercury. Providence
is about 60 miles north-northeast of the Block Island Airport. Sunset occurred
at 1624 and twilight ended at 1655 on December 28, 1991. No moon was visible
when the accident occurred at the accident locationí[1].
2. FLIGHT RECORDERS
N811BE was not equipped with a flight data recorder
(FDR), and none was required as per the provisions of 14 CFR 135.2. N811BE
was equipped with a B&D Instrument CVR, Serial No. AOl 165. The recorder
case had minor impact damage. The interior electronic circuits showed signs
of corrosion, and a minor amount of marine life infestation was present.
The recording tape was wet but otherwise undamaged. The underwater beacon
operated properly. The tape contained three channels of excellent quality
audio information, and a transcript was made of the 32 1/2 minutes of recorded
information. No ATC communications were on the tape to provide a correlation
of CVR times with actual times. As noted in the succeeding section, correlation
of the radar data and CVR comments indicates that 49 seconds should be
added to the originally selected CVR times to obtain actual times. A corrected
CVR transcript is contained in Appendix A. All of the comments on the tape
related to training activities with a captain-trainee occupying the left
seat and the IP occupying the right seat. The IP also performed first officer
duties at the request of the captain-trainee. The CVR discussions disclosed
that the captain-trainee was practicing instrument approaches to the Block
Island Airport, during which the IP disabled the trainee's attitude indicator
several times by opening a circuit breaker through which electrical power
was supplied to the indicator. The discussions also disclosed that the
IP simulated a failure of the landing gear extension indicators and a failure
of the flap extension system by opening appropriate circuit breakers. The
first approach was a nondirectional radio beacon approach to runway 10
with a circle to land on runway 28. The airplane landed at 2132:00, and
the pilots took
Page 4
off at 2134.48. About 2135:02, a failure of the left engine
was simulated. At 2135:34, power was restored to the left engine. At 2136:27;
the IP specified a very high frequency omnidirectional radio (VOR) approach
to runway 28 (see Figure 1) and, at 2136:46, the trainee stated, ìhave
a failure on the attitude indicator.î At 2139:04, the descent check was
accomplished, and the approach check was begun. At 2144:22, a failure of
the right engine was simulated by retardation of the power lever to the
flight idle position; at 2144:38, the IP confirmed that the right power
lever was in flight idle. At 2145:15, the trainee said, ìitíll be a single-engine
landing...ref gonna be one oh three.. .thatí1l be one twentyóthree as it
stands now.î At 2146:35, the IP said, ìstop one thing at a time. Youíre
in a bad situation, so correct one thing first.î At 2146:39, the IP said
ìnope,î and at 2146:40, the trainee said, ìWhoaî followed by, ìyour aircraft?î
At 2146:42, the IP replied, ìno take itî followed by the statements ìget
the bankî and ìpower to idle.î At 2146:46, the IP said, ìWhat are you doing
that for?î accompanied by the sound of the landing gear warning, which
continued until the recording ended. At 2146:47, the IP said ìall right.î
The recording ended at 2146:49. All of the above statements were made without
indications of distress or distortion related to physical exertion.
3. RECORDED RADAR STUDY
Recorded ATC radar data were obtained from Boston Center
and the Ocean Terminal Radar Approach Control (TRACON) facility near Providence,
Rhode Island. The TRACON data were processed by the continuous data recording
(CDR) editor program. The data from the two facilities were plotted into
ground tracks and altitude profiles for the 1200 mode C target that represented
N811BE. A time difference error of 4 seconds, as determined by comparing
altitude profiles of the two sets of data, was corrected by adding 4 seconds
to the TRACON data. The Boston Center data were recorded at 12-second intervals,
while the TRACON data were recorded at 4.5-
to 4.7-second intervals.
The radar data were correlated with CVR information to determine actual
times for CVR comments. Because the CVR information contained no communications
with ATC to provide actual times, the correlation was general in
Page 5
Figure 1 - - VOR Instrument Approach Procedure (graphic not
reproduced in this file - see Fig. 3)
Page 6
nature. The correlation indicates that 49 seconds should
be added to CVR times to obtain actual times.The ground track of N811BE
was established by aligning both sets of radar data. Figure 2 shows the
airplaneís ground track as identified by both sets of radar data. The ground
track is related to a grid south ot the Ocean TRACON antenna site and east
and west of a true north-south line through the site. The small open circles
represent N811BEís mode C returns recorded at Boston Center and the cross
marks represent returns recorded at Ocean TRACON. The final portions of
the track are shown in Figure 3. The black dots in Figure 3 show the position
of N811BE with respect to the Ocean TRACON antenna site. The dots represent
every other transponder-reported position, with the related altitude above
each dot, as the airplane was flown into the procedure turn for the VOR
approach to runway 28 at Block Island. The last recorded transponder return
occurred at 2146:24; the reported altitude was 1,900 feet. The actual times
are related to each dot with the hour digits omitted; e.g., 43:47.2 equals
:47.2 eastern standard time. Part of the CVR comments are included
with ìCTî identifying the captain-traineeís comments and ìIPî identifying
the instructor pilotís comments. Radar data from the Ocean TRACON
and local atmospheric conditions were used in a computer program (FLIGHT)
to calculate airplane performance parameters such as ground speed, indicated
airspeed, roll angles, and acceleration loads. This program can calculate
the long-term motions of the airplane, but the short-term motion calculations
are not reliable. Also, the calculated values of parameters, such as roll
angle, should be used with caution. According to the FLIGHT calculations,
N811BE was in level flight between 160 and 180 knots indicated airspeed
(KIAS) when the last radar return was recorded. It was also in a right
bank of about 26o, at a magnetic heading of about 236o,
and
at an altitude of 1,900 feet. Further calculations with a limited-degree-of-freedom
program involving the wreckage location, N811BEís last recorded altitude
and location, an assumed wings-level trim airspeed of 170 KIAS, and an
assumed crash time coincident with the end of the CVR recording indicate
that during the 15 seconds from the time of the last altitude alert until
the end of the CVR recording, the airplane could have reached the wreckage
location intact. This could have been accomplished from a continuous right
turn with the roll angle decreasing from about 75° right
Page 7
Figure 2--Ground Tack of N811BE (graphic not reproduced
in this file - see Fig. 3)
Page 8
Page 9
wing down to about 40 right wing down and with acceleration
loads near 1.7 G increasing to about 2.15 G at impact. The airplaneís rate
of descent would have averaged about 6,800 feet per minute (fpm) in the
process, and its airspeed would have increased to about 240 KIAS. Also,
assuming the airplane began the descent while entering an unusual attitude,
small variations of roll angles and acceleration load time histories would
produce similar results.
4. AIRPLANE AND RELATED INFORMATION
N811BE was owned by the Concord Commercial Corporation of
Park Ridge, New Jersey, and was operated by Business Express, Inc., (BEX).
It had 19 passenger seats and 2 pilot seats. N811BE was equipped with 2
Pratt & Whitney PT-6A-65B engines, each with a Hartzell 4-bladed propeller.
Each powerplant was rated at 1100 horsepower. The airplane had accumulated
,265 hours in service and 13 hours since its last inspection on December
, 1991. The gas generator and the power section of the left engine had
,296 hours and 3,286 hours, respectively, since the last inspection. The
gas generator and power section of the right engine had 1,093 hours and
,600 hours, respectively, since the last inspection, which was an overhaul
for the power section. The maintenance records for N811BE for the year
preceding the accident were reviewed. No discrepancies were noted that
might indicate a chronic problem with the airplaneís systems, flight controls,
or powerplants. Also, there were no discrepancies that might indicate a
potential problem in the airplaneís structure.In April 1987, N811BE was
damaged during a collision with a ground service truck. According to a
damage assessment by the Beech Aircraft Corporation, the truck struck the
right propeller and the right side of the fuselage near the floor level
just aft of the copilotís side window. The fuselage and right propeller
sustained extensive damage.According to further assessments of the damage
to N811BE by the repair station, the airplane was aerodynamically and
structurally straight and undistorted. Repair costs to the airframe and
replacement of the right propeller were estimated at $720,000. The repair/inspection
costs of the right engine were about $141,000. The airplane was repaired
and returned to service in late 1987.
Page 10
The maximum certificated gross takeoff weight for the airplane
was 16,600 pounds, and its maximum landing weight was 16,100 pounds. N811BE
weighed about 12,830 pounds on departure from Bridgeport with an estimated
full load of fuel. Under the circumstances, the airplaneís weight and balance
would have been within limits when the accident occurred.The wreckage of
N811BE was located on the ocean floor in water about 120 feet deep. The
wreckage pattern, as established by sonar, was about 300 feet wide by 600
feet long, and it was oriented on a heading of about 020î magnetic The
approximate center of the wreckage area was at latitude 41°13'34"N
and longitude 71°22'48" W, about 10 miles from the Block Island Airport
on a magnetic bearing of about 077oBoth wings had separated
from the airplane just outboard of the engine nacelles. The right wing
appeared to have failed in downward bending as evidenced by a tension fracture
in the upper cap of the main spar and compression buckling in the lower
cap. The trailing edge flaps were extended about 80..> The
upper panel of the right wing between the fuselage and the engine nacelle
was separated; it and the outboard section of the right wing were found
floating on the ocean surface about 4 miles from the wreckage area.-
The
outboard section of the left wing had failed in two pieces, and its leading
edge was crushed. The lower cap of the main spar was separated at the outer
splice. The inboard portion of the lower cap had separated completely in
an approximate 30-foot section that extended to the main spar separation
in the right wing. The main spar upper cap appeared to have failed in tension.The
nose and cockpit section of the fuselage was separated from the cabin section.
The skin of the upper left quadrant of the nose was dimpled and wrinkled.
The nose gear was attached and in the extended position. The windshields
were in place, but the inner and outer glass panels were shattered; they
were held together by the center plastic laminate: The upper left portion
of the cabin displayed evidence of water impact damage. The passenger door
on the left side was separated from its lower lug attachment fittings.
The door handle was in the locked position, and the alignment markings
for the three aft locking pins indicated a locked position. The alignment
markings for the three forward pins were displaced. The cockpit instruments
were destroyed. The wing flap selector was in the approach position. The
copilotís flight instrument light rheostat
Page 11
was in the dim position.The vertical stabilizer displayed
evidence of water damage on its right side, and the left horizontal stabilizer
was bent upward. The right horizontal stabilizer was missing; its attachment
structure to the vertical stabilizer indicated a failure in aft bending.Both
engines had separated from their nacelles. The right main landing gear
strut was in the extended position; the wheels and tires were separated
from the strut. The left gear strut was bent forward into the nacelle box
structure.The airplane apparently crashed into the water left wing first.
All observed structural failures were from overstress with no evidence
of fatigue in the fractures of critical components.The left engine with
propeller hub and four stub blades was recovered. The right engine was
similarly recovered, but during the transfer form the water to the salvage
barge, the forward part of the right engine including propeller hub, reduction
gears, and exhaust casing separated and sank back into the ocean. These
latter components were not recovered. The four blades on the left propeller
had separated within about 1 foot of the hub. The engines displayed minimal
impact damage but were severely corroded from exposure to ocean water.Both
engines displayed scoring from internal rotating parts indicating that
the engines were developing power when the airplane struck the water. The
scoring was not extensive, and no estimate could be made about the amount
of power the engines were developing. However, since one of the last comments
on the CVR was ìpower to idle,î followed by sounds of the landing gear
warning horn, it appears that the power lever on the left engine was reduced
to match the power from the right engine, which was at a flight idle power
setting to simulate its failure. Nothing in the engines indicated preimpact
distress or anomalies that would have prevented normal operation.The pilotís
attitude indicator was operated by inverters powered by the electrical
system. The power to the attitude indicator could be interrupted by opening
a circuit breaker located on a panel on the right side of the cockpit.
The copilotís attitude indicator was vacuum operated through ejectors
in the airplaneís bleed air pneumatic system. The landing gear warning
horn would sound
Page 12
whenever the landing gear is not extended and locked, and
one or both power levers was retarded to or below the 84 percent to 86
percent N1
(gas generator rated speed) power position. The warning
horn could be silenced by pressing the gear warning horn silence button
adjacent to the landing gear control handle (except when the flaps were
in the landing position) or by extending the landing gear into the down
and locked position.
5. FLIGHTCREW
Instructor Pilot (IP)The IP,
age 28, had an airline transport pilot (ATP) certificate and an IP certificate
with ratings for airplane single-engine and multiengine land. He had type
ratings in the BE 300, BE 1900, and Saab 340 airplanes. His first-class
medical certificate was issued without limitation or waiver on December
, 1991.. According to company records, the IP had about 5,630 hours of
flying time, including 1,128 hours in the BE 1900. During the 24 hours,
days, and 90 days preceding the accident, the IP flew 3, 64, and 203
hours, respectively, all in the BE 1900.The IP was hired by BEX on September
, 1986. He was designated a company line check pilot for captains and
first officers in BE 1900 airplanes on August 18, 1989, and a company proficiency
check pilot in the BE 1900 on March 28, 1991. According to pilots who had
received instruction from the IP, he was a good pilot and a good instructor.
He frequently simulated failures of various systems, such as the landing
gear, wing flaps, attitude indicator, or horizontal situation indicator
by opening circuit breakers or by not moving the appropriate control handle
when requested. On occasion, he would simulate successive failures, such
as an engine failure, followed by a failure in one or more systems.Several
pilots stated that at night, the IP would lower the intensity of the flight
instrument lights on the IPís instrument panel so that the trainee could
not refer to those flight instruments following a simulated failure of
one or more of the trainee's flight instruments. In response to one trainee's
query about why they
Page 13
practiced partial panel[2]
instrument flight when redundant systems were available,
the IP responded that he did not like to practice with partial panel flying,
but that it was required by the training manual.CaptainTraineeThe
captain-trainee, age 28, was occupying the left pilot seat. He was hired
by BEX on October 10, 1990. He had an ATP certificate with ratings for
airplane single engine and multiengine land. He was issued a first-class
medical certificate without limitations or waivers on April 10, 1991. The
trainee had about 2,500 hours of flying time, including about 1,200 hours
in the BE 1900. During the 24 hours, 30 days, and 90 days preceding the
accident, the trainee flew 0 (excluding time in the accident airplane),
, and 112.5 hours, respectively, all in the BE 1900. He was receiving
training for an upgrade check to captain status when the accident occurred.
6. THE COMPANY
BEX began operations in November 1984 with five 8-seat Piper
PA-3 1 airplanes. From 1984 through 1989, the company expanded and purchased
several small commuter airlines in the process. In 1986, the company became
one of Delta Airlineís ìDelta Connectionî carriers. By July 1989,
the company was operating 18 BE 1900, 5
Fokker 27, 7 Saab 340, and
Shorts 360 airplanes with about 266 pilots employed. It was conducting
operations under 14 CFR Parts 121 and 135. When the accident occurred,
BEX was operating 20 BE 1900, 11 Shorts 360, and 25 Saab 340 airplanes
with over 400 pilots employed. On March 2, 1992, BEX added 5 BAC 146-200
airplanes, and by July 1992, the company was operating 19 BE 1900, 37 Saab
, and 5 BAC 146-200 airplanes with 483 pilots employed.During the above
years, BEX expanded its routes significantly in the northeastern United
States; its routes included two cities in CanadaóOntario and Ottawa. In
, BEX carried more than 1.3 million passengers, an increase of
Page 14
more than 18 percent from 1990. The company had no fatal
accidents before this accident.
A review of the company's operations specifications disclosed
that the management officials required by 14 CFR 121.59 and 14 CFR 135.31
were named in the specifications. The same officials were named for the
regulatory designations of director of operations, director of maintenance,
and chief pilot for both Part 121 and Part 135 requirements. The specifications
were issued by the Federal Aviation Administration (FAA) and were signed
by the principal operations inspector (POD. Nothing in the operations specifications
precluded the operation of company training flights under Part 91 of the
Federal Aviation Regulations (FARs) or the operation of those flights under
VFR. According to the specifications, the company's principal base of operations
was Bradley International Airport, Windsor Locks, Connecticut.The company
operations manual required by 14 CFR 121.151 and 135.21 provided guidance
for company personnel. The manual contained a table of organization for
the flight department personnel, which included an assistant chief pilot
position for the Bridgeport domicile. The organizational table showed a
director of training position under the vice president of operations; the
latter was the named director of operations in the operations specifications.
The table also listed a director of system control under the senior vice
president of operations. The latter was responsible for operations, maintenance,
and system control functions. The table of organization did not include
individual names; the names were provided at the request of Safety Board
investigators. The assistant chief pilot position at the principal base
was vacant.According to the manual, the vice president of operations was
responsible for the following:
(1) Determination of training programs;(2) Supervision
of training records;(3) Evaluation and analysis of pilot training and testing;(4)Evaluation
and development of operational procedures and standards;
Page15
(5) (Continuous observance of safety practices; and(6).
Service as the Sr. V.P. of Operations in his absence.
The vice president of operations joined BEX in 1986; he had
previously flown as a pilot with a commuter airline for 9 years. He indicated
that he was responsible for the flight training programs and that he had
established the standards for the programs. He stated that control of the
training programs was the responsibility of the director of training. He
indicated that three to four of the BE 1900 IPís operated the ground and
flight training programs. Before the accident, he was not aware that flight
plans were not filed for training flights or that multiple simulated emergencies
were flown. He stated that opening circuit breakers to simulate a failure
of a system was common practice. He stated that no system had been established
to monitor or to standardize instructional practices.The director of training
joined BEX in 1989. He was a qualified pilot in the Saab 340 but not in
BE 1900. After joining BEX, he taught airplane systems ground school for
the Saab 340 pilots, but he did not know who was responsible for ground
or flight instruction in the BE 1900. He said that BEX formerly had program
managers for each type of airplane but that the managers were eliminated
in late 1990. In April 1991, he requested that the program managers be
returned, but the request was denied. He said that no one was specifically
in charge of monitoring the BE 1900 training program, and no one was assigned
to monitor and standardize instructional methods. According to the BEX
operations manual, the director of training was responsible to the vice
president of operations for the following:
(1) Departmental production of safe and efficient operation
of Company fleet;(2) Construction and revision of aircraft operating manuals,
pilot training manuals, and technical publications and bulletins required
of the flight department;
(3) Determination and coordination of pilot training and
qualification requirements and schedules to support line flying activities;
Page 16
(4) Management of the quality of pilot training programs,
activities, and records, and training department personnel;(5)
Administration
of training of proficiency check airmen and instructors to assure competency,
currency, and standardization;(6) Performance of special projects and other
functions as assigned; and(7) Representation of the Company with government,
industry, and communities in activities related to flying training.
BEX had a training manual that provided policy and guidance
on ground and flight training for flight crewmembers. According to the
manual, the training coordinator, who reported directly to the vice president
of operations, scheduled all flightcrew training. The coordinator was to
maintain a daily check of the pilot training files to ensure that the records
were current and in compliance with FAR requirements. He or she was to
coordinate with the director of training, chief pilot, maintenance department,
and crew scheduling to establish the necessary training schedules.The individual
flight instructors maintained the trainee's file until the assigned training
was completed. The IP involved in this accident had the training files
of the two captain-trainees who were on board the airplane; the files were
not recovered. The training coordinator knew of no difficulties that the
two trainees might have been having with the upgrade training.According
to a parent of one of the trainees, his son had told him that the other
trainee was having difficulty with the upgrade training and that the other
trainee might not complete the training successfully. His son had spent
the evening preceding the accident with the other trainee to help him with
the training requirements. The other trainee was in the left seat of N811BE
when the accident occurred.BEX published the training manual ìto provide
each Instructor, Flight
Page 17
Crewmember.
.
.with
the proper procedures and guidelines necessary to perform their duties
in a standardized, safe and efficient manner.î According to the manual,
ìFlight training may be originated at any airport where an aircraft may
be based, provided an appropriate Flight Instructor conducts such training
in accordance with company procedures and policies.î BEX also used a BE
flight simulator located at Flight Safety International (FSI), La
Guardia Airport, New York, for some of its flight training. The simulator
was evaluated in 1989 by the FAA to the level C (Phase ll) standards of
Part 121, Appendix H. As -such,
it could be used for type rating checks and ATP certificate checks subject
to the flight examiner s discretion concerning certain maneuvers.When the
accident occurred, the FSI flight simulator was the only Phase II BE 1900
simulator in domestic operation. Also, at that time, there were about 150
BE 1900 airplanes in domestic airline operations out of a total fleet of
about 220 airplanes.The training manual also included a flight training
form that listed the items and maneuvers in which training was required
for initial, transition, recurrent, and upgrade flight checks. Two of the
items and maneuvers listed on the form were: (1) normal/abnormal/emergency
operation of the flight instruments, and (2) unusual attitudes.BEX also
had a company operating manual for the BE 1900 that included a chapter
on training. This chapter contained explanations of normal procedures and
techniques to be used in flying the airplane. For instance, the chapter
outlined the procedures and techniques to be used for single-engine precision
and nonprecision approaches, including a circle-to-land procedure. Nothing
in the training chapter addressed partial panel instrument flying directly,
but the chapter did mention flight training on the abnormal operation of
systems. Under some basic rules for training flights, page 13:5:2:2(8)
of
the manual stated, ìDuring training, no multiple emergencies, and in the
event of an actual emergency, the simulated emergency will be restored
to normal if possible before correcting the actual emergency.î
7.
7. FAA SURVEILLANCE The P01 for BEX
was located at the FAA's Flight Standards District Office
Page 18
(FSDO) at Bradley International Airport. The P01 had been
at the same FSDO for his approximate 20-year career with the FAA. The P01
indicated that he had been the P01 for BEX for several years and that he
had previously served as P01 for BEX earlier in his career.The P01 was
qualified in the Saab 340 airplanes but not in the BE 1900. He indicated
that he had visited BEX training sessions for BE 1900 pilots, had performed
en route checks in DE 1900 airplanes, and had visited the BE 1900 flight
simulator at La Guardia Airport, but he could not recall when he had performed
these activities or any of the details related to the activities. The P01
indicated that he had not assigned any of his inspectors to specifically
monitor the BEX pilot training programs. He also stated that following
the accident of December 28, 1991, BEX had contracted with FSI to conduct
the majority of its BE 1900 flight training in the BE 1900 flight simulator.Safety
Board investigators also interviewed two FAA Aviation Safety Inspectors
(Operations) who had given many of the ATP rating and type rating check
flights for BEX pilots in the BE 1900 airplane. When interviewed in May
, each inspector had given 15 to 20 ATP or type rating checks to BEX
pilots; the majority were given after the accident. Neither inspector had
required partial panel instrument flying of any of the ATP 6r type rating
applicants, but one inspector indicated that if an applicant had lost his
attitude indicator during flight, he would have expected the applicant
to be able to fly partial panel without referring to the other attitude
indicator. Both inspectors indicated that they had not reviewed BEXís pilot
training programs nor had they been directed to do so. Neither inspector
was aware that circuit breakers were used to fail various systems during
flight training nor were they aware that the Block Island Airport was used
by BEX pilots for training.A review of the Program Tracking and Reporting
Subsystem (PTRS) records for operational surveillance of BEX from January
, 1991, through January 1, 1992, disclosed about 430 reports. Of these,
four were labelled with the activity code for training and one was labeled
with the activity code for simulator. The latter related to the Saab 340
simulator, which was a part of BEXís 14 CFR Part 121 operation. The majority
of the surveillance reports revealed activity related to ramp, en route
cockpit, and en route cabin inspections.All four of the reports related
to the surveillance of training identified the
Page 19
P01 as having conducted the surveillance. Of the four reports,
two pertained to Part 135 operations at BEX and involved only the BE 1900
airplanes. The two PTRS reports contained no comments about the type of
training observed or the inspectorís opinion of the training.In January
, based on discussions with Safety Board investigators about the operation
of training flights without the knowledge of BEX system control, the company
established a policy that training flight schedules Would be coordinated
with system control and that the IP would report to system control shortly
before takeoff and shortly after termination of the training flight. Based
on similar discussions, the company adopted a policy in April 1992 that
prohibited the opening of circuit breakers during training flights to simulate
the failure of an associated system. Further, in April 1992, BEX established
program managers for each model of airplane in its fleet. The program managers
are responsible for maintaining pilot qualifications in their respective
airplanes and standardizing the training activities related to that model
of airplane.
8. ANALYSIS
The pilots of N811BE were qualified in the airplane in accordance
with FARs and company policies. Although neither autopsies nor post mortem
toxicological tests could be performed because the bodies of the pilots
were not recovered, there was no independent evidence of medical or physiological
problems that might have adversely affected their performance. Further,
the CVR conversations between the pilots suggest that neither had any physical
problems that might have affected their control of the airplane.The Safety
Board concludes that there is no evidence to indicate that the airplane
was not airworthy or that structural failures, or systems defects or malfunctions,
precipitated control difficulties. All critical structural failures observed
were caused by overloads associated with forceful impact with the surface
of the ocean.Although the evidence was not conclusive with regard to when
the outboard section of the right wing separated from the airplane, the
Safety Board believes that the wing was intact when the airplane crashed
into the ocean. The postaccident drift analysis placed the wing section
in the wreckage area when the
Page 20
accident occurred. Metallurgical examination disclosed that
there were no defects in the structural components of the wing in the area
of separation and that separation occurred from overstress.Based on the
airplaneís last transponder-reported position and altitude, the airplane
performance study disclosed that the airplane could have descended to the
wreckage location within the 15 seconds that elapsed between the last altitude
alert recorded on the CVR and the end of the recording. Further, the descent
could have occurred without exceeding performance limitations in terms
of airspeed and acceleration loads that could have caused major structural
failures. Moreover, the descent could have occurred without acceleration
loads that would have made intra cockpit conversation difficult--as noted
before, the pilotsí conversation was not abnormal throughout the descent
and the IP continued to discuss unusual attitude recovery actions with
the captain-trainee almost until the end of the recording.The Safety Board
cannot conclusively exclude the possibility of an event that caused premature
termination of CVR operation before the airplane struck the water because
the CVR events could not be precisely coordinated with the position and
altitude as recorded by ATC radar, nor was there any FDR information available
to establish the airplaneís actual performance during its final descent.
However, throughout the approximate 32-minute CVR transcript there was
no mention by any of the pilots of any airplane systems problems, engine
problems, or instrument problems, other than those created by the IP. Therefore,
considering all of the evidence, the Board believes that any event that
would have caused termination of the CVR must have been sudden and probably
catastrophic, which leads to the conclusion that the event was a high speed
collision with the surface of the ocean.The Safety Board notes that the
ATC radar data show no returns from N811BEís transponder after 2146:24
when an altitude of 1,900 feet was recorded by the Ocean TRACON. Since
altitudes as low as 300 feet in the vicinity of Block Island were reported
previously, efforts were made to determine why there were no further transponder
reports as the airplane descended below 1,900 feet and into the ocean.The
transponder antenna on N811BE was located on the underside of its fuselage.
Therefore, steeply banked attitudes in a right descending turn probably
would have prevented interrogation of N81IBEís transponder by the Ocean
Page 21
TRACON, which would have precluded mode A and C reports of
the airplaneís position and altitude, respectively, to that facility after
:24. Although the Safety Board could not determine with precision the
airplaneís attitude when it struck the water, the airplane may have been
nearly inverted with the outboard section of the left wing striking the
water first and with the longitudinal axis at a fairly substantial angle
with respect to the surface of the water. ëThis attitude probably would
have_been consistent with a loss of control occurring in a right. turn
under conditions of thrust asymmetry; that is, with the left engine/propeller
producing relatively high thrust and the right engine/propeller producing
little or no thrust to simulate its failure. Therefore, the Safety Board
concludes that the loss of mode A and C reports from N811BEís transponder
after 2146:24 was related to the airplaneís unusual attitude as it descended
below 1,900 feet and crashed into the ocean about 2146:49.The evidence
indicates that the trainee's attitude indicator was intentionally disabled,
about 6 minutes after which a failure of the right engine was simulated
by retarding the right power lever to flight idle. Further, the evidence
indicates that as the trainee maneuvered the airplane to align it for a
VOR approach to runway 28 at Block Island Airport, he became spatially
disoriented[3]and
asked the IP to take control of the-airplane. The IP declined the request,
apparently because he failed to recognize the trainee's severe disorientation,
and attempted to coach the trainee through a recovery from an unusual attitude.
In the process, the IP lost awareness of the airplaneís altitude arid rate
of descent and may have become spatially disoriented. As a consequence,
the airplane entered an uncontrolled descent and crashed into the ocean
in less than 15 seconds.The spatial disorientation of the captain-trainee
occurred in large part because the IP exercised poor judgment in exposing
the captain-trainee to a failure of his attitude indicator followed by
the simulated failure of the right engine while the trainee was maneuvering
the airplane at relatively low speeds and a low altitude on a nonprecision
instrument approach on a dark night. The disablement of the trainee's attitude
indicator without a means of covering the indicator, despite the trainee's
specific request, was in itself a significant hazard to the trainee's spatial
orientation because it is difficult to completely ignore the instrument
unless it is covered. As a result, the false indications of airplane attitude
as the speed of the indicatorís operating gyro slowed would have tended
to distract and confuse
Page 22
the pilot. Also, the lapse of almost 6 minutes between
disablement of the attitude indicator and simulated failure of the right
engine would have introduced significant errors in the indicatorís display
of the airplaneís pitch and bank attitudes. Since there was no mention
on the CVR of covering the attitude indicator, the Board believes that
the IP used poor judgment in subjecting the trainee to such conditions.Almost
minutes after disabling the trainee's attitude indicator, the IP compounded
the trainee's problems with spatial orientation by simulating the failure
of the right engine, which would have introduced significant lateral and
directional control problems. Failure of an attitude indicator in the BE
did not constitute an emergency as defined in the pilotís operating
handbook, because of the airplaneís two independently-powered attitude
indicators. Therefore, when he simulated a failure of the right engine,
the IP technically did not introduce multiple emergencies. However, by
not permitting control of the airplane by reference to the IPís operable
attitude indicator, he effectively created multiple emergencies for the
captain-trainee, which again reflected poor judgment on the part of the
IP.Although it appears that none of the companyís operations specifications
or its operating policies and procedures were disregarded by the IP who
was involved in the accident, the Safety Board believes that considerable
more attention and communication by management was needed to assure adherence
to standard instructional methods and to flight safety. Instead, company
management officials relied on the judgment of the IPs.
The evidence indicates that company management officials
were not well informed about the flight training activities within the
company, at least with respect to the BE 1900 airplane and Part 135 training.
This probably occurred. in part because of the lack of a subordinate program
manager for the BE 1900 airplane and lack of an assistant chief pilot at
the principal base. Further, management deficiencies probably were related
to the companyís rapid expansion during the 2 to 3 years that preceded
the accident. ln any event, the result was that all BE 1900 pilot training
activities were apparently delegated to relatively junior IPs, who were
relatively new to the company training procedures and who were inexperienced
as air carrier check pilots.The Safety Board believes that company managers
failed to adequately
Page 23
monitor the BE 1900 flight training program and failed
to recognize that rio one was specifically in charge of the training program.
Also, the managers and the P01 were not aware that, in effect, multiple
simulated emergencies were flown in training and that at least this IP
was exercising judgment that seriously jeopardized flight safety by conducting
partial panel instrument training at low altitude at night.The Safety Board
is aware that many commuter and regional air carriers have had flight training
problems similar to BEXís problems. Because of the lack of airplanes available
during daytime revenue operations and the lack of sophisticated flight
simulators, much of the flight training is conducted in airplanes at night.
ln 1986, following three fatal commuter airline crashes in which the pilots
were flying instrument approaches in instrument meteorological conditions
on regularly scheduled flights, the Safety Board discovered similar problems
related to the training of commuter air carrier pilots. As a result, the
Safety Board issued Safety Recommendation A-86-103, which asked the FAA
to:
Expedite the program which proposes standards
for the use and evaluation of aircraft flight simulator .devices to be
used in training programs of 14 CFR Part 135 operators and in cooperation
with the Regional Airlines Association (RAA), encourage and assist operators
to acquire simulator devices.
The Safety Board also issued Safety Recommendation A-86-
, which asked the RAA to:
Work with its membership to encourage the use
of flight simulators and Advanced Training Devices in the pilot training
programs of commuter airlines.
Safety Recommendation A-86-103 was classified
ìClosed--Acceptable Actionî on February 23, 1989, based on the FAAís December
5,
1988, response, which stated:
The Federal Aviation Administration (FAA) has
granted the petition for exemption from the Regional Airline Association
to allow the use of advanced training devices in crew training and checking
under 14 CFR Part 135. Any Regional Airline Association member who is a
CFR Part 135 certificate holder can apply under this exemption for
Page 24
approval to use FAA-approved advanced training
devices for training and checking. The exemption, along with the advisory
circular which addresses advanced training devices, establishes the basis
to encourage and assist 14 CFR Part 135 operators to incorporate flight
simulator devices into their training programs. Individual principal operations
inspectors will cooperate fully with operators to utilize these devices
in their training programs.
The Safety Board, in its February 23, 4989,
reply that closed Safety Recommendation A-86-103, stated:
We note that the Federal Aviation Administration
has granted the petition for exemption from the Regional Airline Association
to allow the use of advanced training devices in crew training and checking
under 14 CFR Part 135. This exemption, along with advisory circulars 12045
and 120-46, establishes the basis to encourage and assist 14 CFR Part 135
operators to incorporate flight simulator devices into their training programs.
We appreciate the actions taken. Safety Recommendation A-86-103 is now
classified as ìClosed--Acceptable Action. ì
Safety Recommendation A-86-120 was classified
ìClosed--Acceptable Actionî on June 7, 1988, based on the RAAís response
on March 2, 1988, which stated: The RAA has, since 1983, been working on
Advanced Training Devices (ATD) for use by commuter air carriers. The FAA,
responding to an RAA proposal, issued AC 120-45 and 120-46, which recognize
the ATD and establish training and checking authorizations. Those ACs have
been distributed to all member airlines and members are continually being
encouraged to purchase ATDs for use in training programs. Additionally,
more motion base/visual simulators are being installed for commuter use
in training centers and member airlines are using them.The Safety Board
is aware that since the above safety recommendations were closed, the FAA,
in October 1990, adopted Special Federal Aviation Regulation (SFAR) No.
, Advanced Qualification Program (AQP). The AQP provides an
Page 25
alternative method for qualifying, training, certifying,
and otherwise ensuring the competency of crewmembers and others who are
required to be trained and qualified under the provisions of 14 CFR Parts
and 135. The AQP provides for increased use of approved flight simulators
and training devices in air carrier training programs and for the establishment
of training centers with which carriers can contract for the complete training,
qualification, and evaluation of air carrier personnel or for services
that are less comprehensive.The Safety Board is also aware that the FAA
has proposed to establish certification and operating rules for training
centers. The proposal would also provide additional credits for the use
of aircraft flight simulators in formal training, testing, and checking
programs. The Safety Board responded to the FAAís related notice of proposed
rule making (NPRM)[4]
in December 1992, and agrees with the intent of the NPRM to permit a wider
variety of training, testing, and checking to be accomplished in approved
flight simulators and training devices. The Safety Board cautioned, however,
that care must be exercised to prevent excessive use of flight simulators
to meet specified qualification requirements at the expense of operating
experience in the actual flight environment.The Safety Board believes that,
although no air carrier yet has an approved AQP, the FAA and RAAhave focused
well on the crewmember training problems faced by commuter and regional
air carriers, and the availability of flight simulators and advanced training
devices for most types of airplanes used by commuter and regional air carriers
has increased significantly in the past 8 years. However, as this accident
demonstrates, the availability of only one Phase II BE 1900 simulator apparently
has not been sufficient for BEX to cope with its rapid expansion and its
increased number of pilots. As a result, hazardous training maneuvers continued
to be conducted in the companyís airplanes. However, to BEXís credit, it
has recognized the risks and, according to the P01, has made plans to conduct
most of its BE 1900 training in flight simulators. The Safety Board believes,
however, chat similar needs probably continue to exist in the commuter
and regional air carrier industry and, therefore, encourages the RAA again
to assist its membership in obtaining access to appropriate flight simulators
for use in their pilot training programs.
Page 26
The Safety Board also notes that with the significant improvements
made in flight simulators in the last decade, and with the increased size,
complexity, and performance of typical commuter air carrier airplanes,
it may be time to consider the confinement of certain hazardous training
maneuvers to flight simulators for Part 135 commuter operators. ln 1972,
the Safety Board made safety recommendations to the FAA to this effect
for Part 121 operators, and currently, virtually all training, testing,
and checking for pilots of Part 121 operators are conducted in flight simulators.
Therefore, the Safety Board believes that the FAA should consider appropriate
amendments to 14 CFR Part 135 to require that -training,
testing, and checking in the performance of certain hazardous flight maneuvers,
such as engine-out operations and recovery from unusual attitude maneuvers,
be conducted to the maximum extent feasible in approved flight simulators
for Part 135 commuter operators.The Safety Board believes that the FAA
surveillance devoted to BEXís flight training programs was inadequate in
view of the companyís rapid expansion and the commensurate increase in
the number of pilots. When increases of this type occur, the quality of
the companyís training programs becomes more important. Transitional training
is needed as more pilots are brought into the company and its current pilots
upgrade to different positions and different airplanes. The Board believes
that only two surveillance visits to BEXís BE 1900 training program over
a year were not sufflcient to adequately assess the quality of the program
or management's involvement in the program. ln this case, management oversight
of the BE 1900 training program was minimal, particularly after elimination
of the program manager position in late 1990. Appropriate surveillance
could have identified these management deficiencies.ln view of the 430
or so surveillance activities devoted to BEXís operations between January
, 1991, and January 1, 1992, of which only 4 were devoted to BEXís operational
training programs, the Board believes that the P0Iís resources for surveillance
were probably adequate but not distributed properly. The Safety Board realizes
that judgments in this respect are not easy to make and does not regard
the lack of such surveillance as a causal factor in the accident. However,
the Board believes that the companyís steady expansion in terms of airplanes,
pilots, and routes should have suggested to the FAA a need for increased
surveillance of the companyís pilot training programs and its management
of the programs.
Page 27
9.
FINDINGS
1. The flightcrew was qualified and current in accordance
with FARs and company policies.2. There was no evidence of airframe or
powerplant failures prior to impact with the water. There were no airplane
system malfunctions or failures before impact with the water except when
electrical power to the captain-traineeís attitude indicator was
deliberately removed.4. The captain-trainee was flying the airplane in
simulated night instrument conditions on a dark moonless night over the
ocean about 10 miles east-northeast of Block Island, Rhode Island, when
the accident occurred5. The IP disabled the captain-traineeís attitude
indicator, and about 6 minutes later, he simulated a failure of the right
engine by retarding the power level to the flight idle position, which,
in effect, introduced multiple emergencies contrary to the provisions of
the companyís BE 1900 operating manual.6. The IP used poor judgment by
encouraging the captain-trainee to fly the airplane with his attitude indicator
disabled and uncovered, followed about 6 minutes later by a simulated failure
of the right engine under simulated instrument conditions on a dark night.7.
The
IP
h
failed
to recognize in a timely manner that the captain-trainee was spatially
disoriented when the captain-trainee asked the IP to take control of the
airplane (ìYour aircraft?î); instead, the IP attempted to coach the captain-trainee
into a recovery from an unusual attitude.8. The attempted recovery from
an unusual attitude was not successful, apparently because the IP lost
awareness of the airplaneís altitude and rates of descent and may have
become spatially disoriented at an altitude too low for recovery.
Page 28
9. The airplane probably crashed into the ocean in a
near-inverted attitude with the outboard section of the left wing sLriking
the water first and with the longitudinal axis at a substantial angle with
respect to the surface of the ocean.10. Company management personnel did
not adequately supervise the BE1900 flight training program to ensure that
training objectives were met without exposing its pilots to conditions
potentially hazardous to flight safety. The FAA failed to adequately monitor
the companyís flight training programs and failed to recognize that management's
oversight of and involvement in the BE 1900 training program were minimal.
10.
PROBABLE CAUSEThe National Transportation
Safety Board determines that the probable causes of this accident were
the instructor pilotís 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 pilotís 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.
11.
SAFETY RECOMMENDATIONSAs the result
of the investigation of this accident, the National Transportation Safety
Board recommends that the Federal Aviation Administration:Require principal
operations inspectors of commuter airlines to verify that appropriate and
qualified levels of airline management are actively involved in the airlineís
flight training programs. (Class II, Priority Action) (A-93-70)
Page 29
Encourage commuter airline managers to use approved flight
simulators for pilot training, qualification, and competency and instrument
check purposes to the maximum extent feasible. (Class II, Priority Action)
(A-93-7 1)Consider an amendment to 14 CFR Part 135 to require that commuter
air carriers perform certain hazardous training, testing, and checking
maneuvers, -such as engine-out operations and recovery from unusual flight
attitudes, in approved flight simulators to the maximum extent feasible.
(Class III, Longer Term Action) (A-93-72)
The Safety Board also recommends that the Regional
Airline Association:Encourage its members to use approved flight simulators
for required pilot training, qualification, and competency and instrument
check purposes to the maximum extent feasible. (Class II, Priority Action)
(A-93-73)-
BY THE NATIONAL TRANSPORTATION SAFETY BOARD
April 27, 1993 |
Carl VogtChairman
SusanCoughlinVice Chairman
John K. LauberMember
Christopher A. HartMember
John HammerschmidtMember |
Page 31-74
APPENDIX A
Transcript of a B+D Instruments cockpit voice recorder S/N
AOl 165 removed from a Business Express, Inc, Beech 1900C, N811BE, which
was involved in an accident on December 28, 1991, off the coast of Block
Island, Rhode Island. (SEE TRANSCRIPT FILE.)
Page 75
APPENDIX B
An individual's orientation in space, that is, the recognition of whether an individual is upright, supine, etc., is dependent upon visual and vestibular information. Visual information, provided by the eyes and processed by the brain, gives information on the position being maintained. Vestibular information, provided by the organs and fluid in the inner ears, indicates the position or orientation that -the body perceives is maintained. An individual who correctly determines his or her position relative to the earth is said to have proper spatial orientation.
To an individual inside an aircraft, however, vestibular information can be misleading because the body no longer has a fixed reference with which to orient against, as the individual moves when the aircraft moves. Further, steady aircraft motion, or an accelerating or decelerating aircraft, can produce, vestibular sensations that are at odds with the reality of the body's orientation. Generally, visual information in an aircraft can counter misleading vestibular information since either the horizon or aircraft instruments can tell the individual the aircraft's, and thus the individual's, orientation relative to the earth. However, when such visual information is lacking or is not perceived, the individual can be misled by incorrect vestibular information. That individual is spatially disoriented, or is perceiving an orientation in space that is incorrect. A spatially disoriented pilot can believe that a straight and level aircraft is in a turn, or is climbing or descending.
Spatial disorientation is likely to occur when external visual cues are absent. This can occur during instrument meteorological conditions or during nighttime when visual cues are absent, such as on moonless nights over unpopulated areas. Pilots are trained to rely on aircraft instruments to provide correct spatial references when visual cues external to the aircraft are absent.
[1]
According to astronomical data, the moon was about 370
below the
eastern horizon.
[2]
Refers to less than a full complement of flight instruments. Typical instruments
that might fail in flight are gyro-controlled instruments such as the attitude
indicator, turn and bank indicator, or heading indicator.
[3]
See Appendix B for a discussion of spatial disorientation.
[4]Aircraft
Flight simulator Use in Pilot Training, Testing, and checking at Training
centers, Docket No. 26933, Federal Register (page 35888), Vol. 57, No.
, August 11, 1992. |