Friday, March 23, 2018

Fatal BSF B-200 twinprop crash attributed to inexperienced crew


The fatal crash of a Beechcraft Super King Air B-200 twin turboprop aircraft belonging to Indian Border Security Force on 22 December 2015 has been attributed to the inexperienced flight crew.

The aircraft was flying from IGI Airport, Delhi to Ranchi, carrying technical personnel and equipments supposed to carry out scheduled maintenance of a BSF Mi-17 helicopter.

All the ten on board including the 2 pilots died in the accident.

The probe panel also concluded “there was non-existence of safety culture, non-existence of SMS (safety management systems) and nil supervision of the operations at ground level.”

Shortly after take-off and attaining a height of approximately 400 feet AGL, the aircraft progressively turned left with simultaneous loss of height. It had taken a turn of approximately 180 degree and impacted some trees before hitting the outside perimeter road of the airport in a left bank attitude.

Finally it came to rest in the holding tank of the water treatment plant of the airport. The crash occurred 50 seconds after aircraft rotation.

Both the Pilot-in-Command and the Co-pilot were qualified to operate the B-200 aircraft, holding valid CPL license with Type endorsement.

The total PIC experience of the PF on the B-200 aircraft was 77:00 hours and that of the PM was 196:35 hours as PIC.

The PF was released as PIC after 620:35 hours of co-pilot experience on Type, while the PM was released as PIC after 183 hours of co-pilot experience on Type.

They were pairing with each other to operate flights on B-200 aircraft after being released to fly as PIC.

In the present case flying undertaken by the flight crew wherein both, the PF and the PM, were neither possessing adequate flying experience nor could mutually add or impart quality flying experience in the real sense of the terms.

The combination of this flight crew was continued over other Type qualified Pilots in the Organisation. Therefore, though the numbers of flying hours flown by this flight crew were increasing, but whether it added to qualitative improvement in their flying skills is questionable.

Despite written instructions of the Accountable Manager that an experienced pilot should be on board as the second pilot whenever the PF or PM were flying as PIC, these low experienced pilots did not fly under supervision of an experienced pilot while building their respective PIC experience.

Therefore, in such a scenario there was no opportunity available to this flight crew to identify their deficiencies in flying techniques, operational procedures, correct interpretation of the effects of weather, airmanship, etc. and applicable appropriate correction/ response even though a well experienced and seasoned Senior Pilot on Type was available in-house.

Engine wreckage
For operating the accident flight, it appears that the flight crew were not confidant due to the poor foggy condition prevailing at the time of planned departure. With an understanding that immediately after take-off, autopilot will be engaged and the aircraft will fly away on the autopilot, the crew cancelled the taxi clearance and carried out the serviceability checks of the operation of (engagement/ disengagement) the autopilot.

The flight crew during discussion among themselves regarding the conduct of flight had decided to rotate after 120 knots (additional 10 knots) considering tail wind component of 06 knots. The take-off roll and rotation of the aircraft was carried out as discussed.

Their decision to increase the rotation speed by 10 knots to allow for the tail wind of 06 knots itself shows that they were ignorant of the fact that the tailwinds do not affect the rotation speeds of the aircraft at all.

Just after lift-off, even without retracting the landing gear, the crew engaged the autopilot but did not engage the Heading Mode‘ of the autopilot.

This hurried and non-standard action by the flight crew by engaging the auto-pilot immediately after lift-off reveals their eagerness to let the aircraft be flown by the autopilot and underlines their inability to fly the aircraft manually until autopilot engagement height was achieved.

As per the Pilot Operating Handbook procedure, after lift–off and establishing of positive rate of climb, the landing gear is retracted. Thereafter the climb power is set and the autopilot should be engaged only after attaining the height of 500 feet AGL.

Engagement of the autopilot without engaging the Heading Mode resulted in the aircraft turning left probably due to the existing left bank or inadvertent manual input by the flight crew at the time of engagement of the autopilot.

The bank angle increased progressively and beyond 45 degree, a situation the flight crew could not decipher because of their disorientation. After disengagement of the autopilot, probability exists that the flight crew had further increased the bank instead of taking corrective action to decrease the bank.

This allowed the bank angle to increase beyond 45 degree resulting in multiple altitude warning and stalling of the aircraft. The aircraft crashed after turning almost 180 degree from the direction of the take-off.

The aircraft was also slightly overloaded. As per the weight & load data sheet there were 8 passengers with 20 Kgs of baggage in the aft cabin compartment. But weight of personal baggage recovered from the wreckage was 152 kg.

The actual take-off weight shown was 5668.85 Kgs as against the maximum take-off weight of 5669.9 Kgs.

The Beechcraft Super King Air aircraft with registration VT-BSA (MSN BB-1485) was manufactured in 1994.

The aircraft was powered by two PT6A-42 turboprop engines rated at 850 SHP and equipped with Collins FCS-65 Automatic Flight Control System and Collin EFIS-85B Electronic flight instrument system.

Read the complete report here.