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Crash of a Beechcraft B250GT Super King Air in Piracicaba: 7 killed
Date & Time:
Sep 14, 2021 at 0835 LT
Operator:
Registration:
PS-CSM
Survivors:
No
Schedule:
Piracicaba - Fazenda Tarumã
MSN:
BY-364
YOM:
2019
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total hours on type:
297.00
Copilot / Total hours on type:
85
Aircraft flight hours:
268
Circumstances:
Shortly after takeoff from Piracicaba Airport Runway 35, while in initial climb, the stall warning alarm sounded in the cockpit and the twin engine airplane encountered difficulties to gain height. It entered a right turn then descended to the ground and crashed in a eucalyptus forest located about 1,5 km north of the airport. The airplane disintegrated on impact and all seven occupants were killed, among them the Brazilian businessman Celso Silveira Mello Filho aged 73 who was travelling with his wife and three kids.
Crew:
Celso Elias Carloni, pilot,
Giovani Dedini Gulo, copilot.
Passengers:
Celso Silveira Mello Filho,
Maria Luiza Meneghel,
Celso Meneghel Silveira Mello,
Camila Meneghel Silveira Mello Zanforlin,
Fernando Meneghel Silveira Mello.
Crew:
Celso Elias Carloni, pilot,
Giovani Dedini Gulo, copilot.
Passengers:
Celso Silveira Mello Filho,
Maria Luiza Meneghel,
Celso Meneghel Silveira Mello,
Camila Meneghel Silveira Mello Zanforlin,
Fernando Meneghel Silveira Mello.
Probable cause:
Contributing factors:
- Attention - a contributor.
The analysis of the pilots' performance during the flight of the previous day revealed episodes of inattention, such as those related to the lowering of the landing gear. In the accident flight, the crew fixated on the excessive RPM, failing to notice in a timely manner that the speed was decreasing, something that limited their ability to promptly respond to the stall condition.
- Attitude - a contributor.
During the accident flight, it was noted that the aircraft rotated at a speed of 102 knots, being such speed consistent with the prescribed aircraft’s maximum takeoff weight. However, because the aircraft’s weight was 1,374 pounds above the MTOW, when it rotated at the referred speed, a continuous 1 kHz alarm sounded, indicating that it had entered a pre-stall condition. Such improvisational approach regarding the MTOW exacerbated the situation, contributing to the outcome of the accident.
Training - undetermined.
The classification of the aircraft by the Brazilian Regulatory Agency as a “class aircraft” may have contributed to the training required from pilots being insufficient to ensure their proficiency in handling emergencies on the B200GT aircraft.
- Work-group culture - undetermined.
According to reports, the belief that the King Air aircraft was capable of taking off with a weight greater than the one specified by the manufacturer was common among operators to whom the investigators had access. This belief may have contributed to the decision made to conduct the flight under those conditions, influencing the takeoff performance.
- Handling of aircraft flight controls - undetermined.
After the retraction of the landing gear, a command to reduce aircraft power was applied by the PIC, which preceded the stall warning. Following this warning, a possible command for feathering one of the propellers may have triggered loss of control of the aircraft.
- Piloting judgment - a contributor.
The takeoff in which the accident occurred was performed 1,374 pounds above the weight limit prescribed in the AFM. Speeds and parameters of a typical takeoff were used, with power being reduced shortly after the landing gear retraction. In this context, there was no adequate assessment of the flight parameters, culminating in the aircraft’s stall condition.
- Aircraft maintenance - undetermined.
Although one engine N2 maximum of 25 RPM greater than the Takeoff and Max Continuous value of 2,000 RPM verified at takeoff cannot be directly linked to the adjustments made to the propellers during the last inspection, the early release of the aircraft may have prevented a sufficiently thorough check of the maintenance tasks performed. This was found to have occurred the day before the accident after the first attempt to start up the engines. There were erasures on the record sheet that documented the engine parameters at entry and exit, leading to discrepancies in relation to the records made in the corresponding Service Order.
- Memory - undetermined.
The analysis of the Cockpit Voice Recorder’s audio spectrum revealed that the propellers were adjusted after the “propeller overspeed” callout was made by the PIC. Although this procedure was not prescribed for the B200GT, it was found to be practiced in the E110 aircraft, in which the PIC had developed much of his professional experience. It is possible that this action originated from the retrieval of previous conditioning, characterizing what is known as “negative transfer”.
- Perception - a contributor.
The stall condition, likely related to the gradual reduction in speed that followed the reduction of the power levers, was not perceived in a timely manner for a reaction to be planned. In that context, there was exclusively a perception of the slightly excessive propeller RPM, a maximum amount of 25 RPM, which impaired the situational awareness regarding the other aspects of the flight.
- Attention - a contributor.
The analysis of the pilots' performance during the flight of the previous day revealed episodes of inattention, such as those related to the lowering of the landing gear. In the accident flight, the crew fixated on the excessive RPM, failing to notice in a timely manner that the speed was decreasing, something that limited their ability to promptly respond to the stall condition.
- Attitude - a contributor.
During the accident flight, it was noted that the aircraft rotated at a speed of 102 knots, being such speed consistent with the prescribed aircraft’s maximum takeoff weight. However, because the aircraft’s weight was 1,374 pounds above the MTOW, when it rotated at the referred speed, a continuous 1 kHz alarm sounded, indicating that it had entered a pre-stall condition. Such improvisational approach regarding the MTOW exacerbated the situation, contributing to the outcome of the accident.
Training - undetermined.
The classification of the aircraft by the Brazilian Regulatory Agency as a “class aircraft” may have contributed to the training required from pilots being insufficient to ensure their proficiency in handling emergencies on the B200GT aircraft.
- Work-group culture - undetermined.
According to reports, the belief that the King Air aircraft was capable of taking off with a weight greater than the one specified by the manufacturer was common among operators to whom the investigators had access. This belief may have contributed to the decision made to conduct the flight under those conditions, influencing the takeoff performance.
- Handling of aircraft flight controls - undetermined.
After the retraction of the landing gear, a command to reduce aircraft power was applied by the PIC, which preceded the stall warning. Following this warning, a possible command for feathering one of the propellers may have triggered loss of control of the aircraft.
- Piloting judgment - a contributor.
The takeoff in which the accident occurred was performed 1,374 pounds above the weight limit prescribed in the AFM. Speeds and parameters of a typical takeoff were used, with power being reduced shortly after the landing gear retraction. In this context, there was no adequate assessment of the flight parameters, culminating in the aircraft’s stall condition.
- Aircraft maintenance - undetermined.
Although one engine N2 maximum of 25 RPM greater than the Takeoff and Max Continuous value of 2,000 RPM verified at takeoff cannot be directly linked to the adjustments made to the propellers during the last inspection, the early release of the aircraft may have prevented a sufficiently thorough check of the maintenance tasks performed. This was found to have occurred the day before the accident after the first attempt to start up the engines. There were erasures on the record sheet that documented the engine parameters at entry and exit, leading to discrepancies in relation to the records made in the corresponding Service Order.
- Memory - undetermined.
The analysis of the Cockpit Voice Recorder’s audio spectrum revealed that the propellers were adjusted after the “propeller overspeed” callout was made by the PIC. Although this procedure was not prescribed for the B200GT, it was found to be practiced in the E110 aircraft, in which the PIC had developed much of his professional experience. It is possible that this action originated from the retrieval of previous conditioning, characterizing what is known as “negative transfer”.
- Perception - a contributor.
The stall condition, likely related to the gradual reduction in speed that followed the reduction of the power levers, was not perceived in a timely manner for a reaction to be planned. In that context, there was exclusively a perception of the slightly excessive propeller RPM, a maximum amount of 25 RPM, which impaired the situational awareness regarding the other aspects of the flight.
Final Report:
Crash of a Beechcraft B250GT Super King Air in Gwalior
Date & Time:
May 6, 2021 at 2115 LT
Operator:
Registration:
VT-MPQ
Survivors:
Yes
Schedule:
Indore - Gwalior
MSN:
BY-373
YOM:
2020
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
9362.00
Copilot / Total hours on type:
50
Aircraft flight hours:
49
Circumstances:
Beechcraft Super King Air B200GT aircraft, VT-MPQ belonging to the Directorate of Aviation, Government of Madhya Pradesh (DoA,GoMP) was involved in an accident on 06.05.2021 while operating a flight from Indore Airport to Gwalior. The flight was under the command of an ATPL holder with another CPL holder as Co-Pilot. There was one passenger on board in addition. The flight crew contacted ATC Indore for clearance to operate the flight to Gwalior. The aircraft was cleared for Gwalior via airway W10N and FL270. Aircraft departed from RWY25 at Indore and climbed to FL 270. Aircraft descended into Gwalior in coordination with Delhi and Gwalior. Approaching Gwalior the crew were advised by the ATC that RWY24L was in use. ATC then asked the crew if they would like to carry out a VOR approach for the opposite RWY 06R. The crew requested for a visual approach for RWY 06R in the night time and were cleared to descend 2700 ft and called field in sight at 25 NM. Crew then requested for right base RWY 06R and were cleared to circuit altitude. Crew called turning right base with field visual and were cleared to land which the crew acknowledged. Just before landing the aircraft and short of the threshold, the main gear collided with the raised arrester barrier and came to a halt on the Runway 06R just beyond the threshold markings at 1515 UTC. The aircraft was substantially damaged, however there was no post impact fire. The 2 crew and 1 passenger received minor to serious injuries.
Probable cause:
The PIC (PF) carrying out a visual approach at night and knowingly deviated below the visual approach path profile (3°) while disregarding the PAPI indications, thereby the aircraft collided with the raised Arrester Barrier. Lack of assertiveness on the part of the copilot (PM).
The following contributing factors were identified:
- Non-Compliance to the SOP of “Change of Runway Checklist” by the ATC staff leading to the 'Arrester Barrier' remaining in a 'Raised Position' while the aircraft (VT-MPQ) came in for landing on runway 06R.
- Non-essential conversation by the flight crew during the final approach for landing causing distraction leading to a delayed sighting of the raised Arrester Barrier.
- Systemic failure at various levels at the Gwalior Air Force Base to ensure that the 'Arrester Barrier Position Indicator Lights and Integral Panel Lights' were not rectified in a stipulated time period.
- A robust alternate procedure was not defined when the 'Arrester Barrier Position Indicator Lights and Integral Panel Lights' were unserviceable.
- The Gwalior Airforce Base authorities did not install 'Red Obstacle Lights' on the Arrester Barrier Poles to indicate the position of the obstacle on the date of the accident as per the DGCA requirements (CAR Section 4, Series B, Part 1).
The following contributing factors were identified:
- Non-Compliance to the SOP of “Change of Runway Checklist” by the ATC staff leading to the 'Arrester Barrier' remaining in a 'Raised Position' while the aircraft (VT-MPQ) came in for landing on runway 06R.
- Non-essential conversation by the flight crew during the final approach for landing causing distraction leading to a delayed sighting of the raised Arrester Barrier.
- Systemic failure at various levels at the Gwalior Air Force Base to ensure that the 'Arrester Barrier Position Indicator Lights and Integral Panel Lights' were not rectified in a stipulated time period.
- A robust alternate procedure was not defined when the 'Arrester Barrier Position Indicator Lights and Integral Panel Lights' were unserviceable.
- The Gwalior Airforce Base authorities did not install 'Red Obstacle Lights' on the Arrester Barrier Poles to indicate the position of the obstacle on the date of the accident as per the DGCA requirements (CAR Section 4, Series B, Part 1).
Final Report:
