Crash of a Beechcraft B200 Super King in Whatì: 2 killed

Date & Time: Jan 30, 2019 at 0915 LT
Operator:
Registration:
C-GTUC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Yellowknife – Whatì – Wekweèti – Ekati
MSN:
BB-268
YOM:
1977
Flight number:
8T503
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2762
Captain / Total hours on type:
1712.00
Copilot / Total flying hours:
566
Copilot / Total hours on type:
330
Aircraft flight hours:
20890
Aircraft flight cycles:
18863
Circumstances:
At 0851 Mountain Standard Time on 30 January 2019, the Air Tindi Ltd. Beechcraft King Air 200 aircraft (registration C-GTUC, serial number BB-268) departed Yellowknife Airport (CYZF), Northwest Territories, as flight TIN503, on an instrument flight rules flight itinerary to Whatì Airport (CEM3), Northwest Territories, with 2 crew members on board. At 0912, as the aircraft began the approach to CEM3, it departed controlled flight during its initial descent from 12 000 feet above sea level, and impacted terrain approximately 21 nautical miles east-southeast of CEM3, at an elevation of 544 feet above sea level. The Canadian Mission Control Centre received a signal from the aircraft’s 406 MHz emergency locator transmitter and notified the Joint Rescue Coordination Centre in Trenton, Ontario. Search and rescue technicians arrived on site approximately 6 hours after the accident. The 2 flight crew members received fatal injuries on impact. The aircraft was destroyed.
Probable cause:
Findings as to causes and contributing factors:
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
- For undetermined reasons, the left-side attitude indicator failed in flight.
- Although just before take off the crew acknowledged that the right-side attitude indicator was not operative, they expected it to become operative at some point in the flight. As a result, they did not refer to the minimum equipment list, and departed into instrument meteorological conditions with an inoperative attitude indicator.
- The crew’s threat and error management was not effective in mitigating the risk associated with the unserviceable right-side attitude indicator.
- The crew’s crew resource management was not effective, resulting in a breakdown in verbal communication, a loss of situation awareness, and the aircraft entering an unsafe condition.
- The captain did not have recent experience in flying partial panel. As a result, the remaining instruments were not used effectively and the aircraft departed controlled flight and entered a spiral dive.
- The captain and first officer likely experienced spatial disorientation.
- Once the aircraft emerged below the cloud layer at approximately 2000 feet above ground, the crew were unable to recover control of the aircraft in enough time and with enough altitude to avoid an impact with terrain.

Findings as to risk:
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
- If flight crews do not use the guidance material provided in the minimum equipment list when aircraft systems are unserviceable, there is a risk that the aircraft will be operated without systems that are critical to safe aircraft operation.
- If flight crews do not use all available resources at their disposal, a loss in situation awareness can occur, which can increase the risk of an accident.

Other findings:
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
- A review of Air Tindi Ltd.'s pilot training program revealed that all regulatory requirements were being met or exceeded.
Final Report:

Crash of a Beechcraft B200 Super King Air off Kake: 3 killed

Date & Time: Jan 29, 2019 at 1811 LT
Operator:
Registration:
N13LY
Flight Type:
Survivors:
No
Schedule:
Anchorage - Kake
MSN:
BB-1718
YOM:
2000
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
17774
Captain / Total hours on type:
1644.00
Aircraft flight hours:
5226
Circumstances:
The pilot of the medical transport flight had been cleared by the air traffic controller for the instrument approach and told by ATC to change to the advisory frequency, which the pilot acknowledged. After crossing the initial approach fix on the RNAV approach, the airplane began a gradual descent and continued northeast towards the intermediate fix. Before reaching the intermediate fix, the airplane entered a right turn and began a rapid descent, losing about 2,575 ft of altitude in 14 seconds; radar returns were then lost. A witness at the destination airport, who was scheduled to meet the accident airplane, observed the pilot-controlled runway lights illuminate. When the airplane failed to arrive, she contacted the company to inquire about the overdue airplane. The following day, debris was found floating on the surface of the ocean. About 48 days later, after an extensive underwater search, the heavily fragmented wreckage was located on the ocean floor at a depth of about 500 ft. A postaccident examination of the engines revealed contact signatures consistent with the engines developing power at the time of impact and no evidence of mechanical malfunctions or failures that would have precluded normal operation. A postaccident examination of the airframe revealed about a 10° asymmetric flap condition; however, significant impact damage was present to the flap actuator flex drive cables and flap actuators, indicating the flap actuator measurements were likely not a reliable source of preimpact flap settings. In addition, it is unlikely that a 10° asymmetric flap condition would result in a loss of control. The airplane was equipped with a total of 5 seats and 5 restraints. Of the three restraints recovered, none were buckled. The unbuckled restraints could suggest an emergency that required crewmembers to be up and moving about the cabin; however, the reason for the unbuckled restraints could not be confirmed. While the known circumstances of the accident are consistent with a loss of control event, the factual information available was limited because the wreckage in its entirety was not recovered, the CVR recording did not contain the accident flight, no non-volatile memory was recovered from the accident airplane, and no autopsy or toxicology of the pilot could be performed; therefore, the reason for the loss of control could not be determined. Due to the limited factual information that was available, without a working CVR there is little we know about this accident.
Probable cause:
A loss of control for reasons that could not be determined based on the available information.
Final Report:

Crash of a Beechcraft 200 Super King Air in Oscoda: 1 killed

Date & Time: Sep 25, 2018 at 0613 LT
Operator:
Registration:
N241CK
Flight Type:
Survivors:
No
Schedule:
Detroit - Oscoda
MSN:
BB-272
YOM:
1977
Flight number:
K985
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3806
Captain / Total hours on type:
201.00
Aircraft flight hours:
13933
Circumstances:
The airline transport pilot of the multiengine airplane was cleared for the VOR approach. The weather at the airport was reported as 400 ft overcast with 4 miles visibility in drizzle. When the airplane failed to arrive at the airport as scheduled, a search was initiated, and the wreckage was located soon thereafter. Radar data indicated that the pilot was provided vectors to intercept the final approach course. The last radar return indicated that the airplane was at 2,200 ft and 8.1 miles from the runway threshold. It impacted terrain 3.5 miles from the runway threshold and left of the final approach course. According to the published approach procedure, the minimum descent altitude was 1,100 feet, which was 466 ft above airport elevation. Examination of the wreckage revealed that the airplane had impacted the tops of trees and descended at a 45° angle to ground contact; the airplane was destroyed by a postcrash fire, thus limiting the examination; however, no anomalies were observed that would have precluded normal operation. The landing gear was extended, and approach flaps had been set. Impact and fire damage precluded an examination of the flight and navigation instruments. Autopsy and toxicology of the pilot were not performed; therefore, whether a physiological issue may have contributed to the accident could not be determined. The location of the wreckage indicates that the pilot descended below the minimum descent altitude (MDA) for the approach; however, the reason for the pilot's descent below MDA could not be determined based on the available information.
Probable cause:
The pilot's descent below minimum descent altitude during the non precision instrument approach for reasons that could not be determined based on the available information.
Final Report: