Individually Owned: 150,657
Corporate Owned: 137,281
Aircraft Accident/Incident Report
Block Island, Rhode Island 02807
Saturday, December 28, 1991 21:46 EST
NTSB Narrative Summary Released at Completion of Accident
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.
NTSB Probable Cause Narrative
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.
Event Information
| Type of Event | Accident |
| Event Date | 12/28/1991 |
| Event Day of the Week | Saturday |
| Time of Event | 2146 |
| Event Time Zone | Eastern Standard Time |
| Event City | BLOCK ISLAND |
| Event State | RHODE ISLAND |
| Event Country | -- |
| Zipcode of the event site | 02807 |
| Event Date Year | 1991 |
| Event Date Month | 12 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | |
| Event Location Longitude | |
| Event Location Airport | |
| Event Location Nearest Airport ID | |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | 0 |
| Degrees magnetic from airport | 0 |
| Airport Elevation | -- |
| Weather Briefing Completeness | Unknown |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 2100 Eastern Standard Time |
| Direction of event from weather observation facility (degrees) | 32 |
| Weather Observation Facility ID | PVD |
| Elevation of weather observation facility | 56 |
| Distance of event from weather observation facility (units?) | 63 |
| Time Zone of the weather observation | EST |
| Lighting Conditions | Night/Dark |
| Lowest Ceiling Height | 0 |
| Lowest Non-Ceiling Height | 0 |
| Sky/Lowest/Cloud Conditions | Clear |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | 0 |
| Visibility Runway Visual Value (Statute Miles) | 0 |
| Visibility (Statute Miles) | 20 |
| Air Temperature at event time (in degrees celsius) | 3 |
| Dew Point at event time (in degress fahrenheit) | -- |
| Wind Direction (degrees magnetic) | 280 |
| Variable Wind Indicator | Unknown |
| Wind Speed (knots) | 12 |
| Wind Velocity Indicator | Unknown |
| Wind Gust Indicator | Unknown |
| Wind Gust (knots) | 0 |
| Altimeter Setting at event time (in. Hg) | 30 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | Unknown |
| METAR weather report | -- |
| Event Highest Injury | Fatal |
| On Ground, Fatal Injuries | 0 |
| On Ground, Minor Injuries | 0 |
| On Ground, Serious Injuries | 0 |
| Injury Total Fatal | 3 |
| Injury Total Minor | -- |
| Injury Total None | -- |
| Injury Total Serious | -- |
| Injury Total All | 3 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 2121 |
| NTSB Notification Source | -- |
| NTSB Notification Date | -- |
| NTSB Notification Time | 0 |
| Fiche Number and/or location -used to find docket information | 46691 |
| Date of most recent change to record | Apr 19 2002 9:59AM |
| User who most recently changed record | NTSB\GIUV |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N811BE |
| NTSB Number | NYC92FA053 |
| Missing Aircraft Indicator | N |
| Federal Aviation Reg. Part | Part 91: General Aviation |
| Type of Flight Plan filed | None |
| Flight plan Was Activated? | -- |
| Damage | Destroyed |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | BEECH |
| Aircraft Model | 1900C |
| Aircraft Series Identifier | 1900C |
| Aircraft Serial Number | UB49 |
| Certified Max Gross Weight | 16600 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | U.S. Registered/U.S. Soil |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 21 |
| Number of Engines | 2 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | Continuous Airworthiness |
| Date of Last Inspection | Dec 24 1991 12:00AM |
| Airframe hours since last inspection | 13 |
| Airframe Hours | 11265 |
| ELT Installed | Yes |
| ELT Activated | No |
| ELT Aided Location of Event Site | No |
| ELT Type | -- |
| Aircraft Owner Name | CONCORD COMMERCIAL CORP |
| Aircraft Owner Street Address | ONE MAYNARD DR |
| Aircraft Owner City | PARK RIDGE |
| Aircraft Owner State | NJ |
| Aircraft Owner Country | |
| Aircraft Owner Zipcode | 07656 |
| Operator is an individual? | -- |
| Operator Name | BUSINESS EXPRESS INC. |
| Operator Same as Owner? | No |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | No |
| Operator Street Address | 285 RIVERSIDE AVE. |
| Operator City | WESTPORT |
| Operator State | CT |
| Operator Country | |
| Operator Zip code | 06880 |
| Operator Code | PLGA |
| Owner has at least one certificate | Yes - certificate holder |
| Other Operator of large aircraft? | No |
| Certified for Part 133 or 137 Operation | Unknown |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | -- |
| Indicates Domestic or International Flight | -- |
| Operator carrying Pax/Cargo/Mail | -- |
| Type of Flying (Per_Bus / Primary) | Instructional |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | No |
| Departure Airport Code | BDR |
| Departure City | BRIDGEPORT |
| Departure State | CT |
| Departure Country | |
| Departure Time | 1845 |
| Departure Time Zone | EST |
| Destination Same as Local Flt | dest & departure same, accident can occur anywhere |
| Destination Airport Code | |
| Destination City | |
| Destination State | |
| Destination Country | |
| Specific Phase of Flight | Descent |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Jan 2 2001 10:30AM |
| User who most recently changed record | dbo |
| Since inspection or accident | -- |
| Event Location Runway Number and Location | 0 |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |