Beechcraft B58 Post Report Considerations (Brazil)

PP-KST post accident CENIPA Report considerations

According to the CENIPA Report the accident happened following a flat spin maneuver which occurred 14 minutes after take-off.

Data of the pre-accident reported information (before the occurrence itself) is somewhat inaccurate as well as inconsistent, as I’ll try to summarize (italics underlined red information is from the CENIPA Report and blue typed ones are from the AIR CRASH CONSULTANTS ANONYMOUS EXPERTS investigator, based on the Beechcraft 58 FLIGHT CREW OPERATIONS MANUAL).

On Page 7, item 1.5.1, the report mentioned that the Pilot, albeit qualified, had logged only 35 minutes flying time on the Baron 58.

On Page 9, item 1.12, § 2, the report mentioned that witnesses observed the aircraft was descending, turning itself on its vertical axis in a horizontal attitude.

On Page 9, item 1.12, § 4, the report concluded that the aircraft was stalled before the impact.

On Page 9, item 1.12, § 7, the report mentioned that the engine power output was asymmetrical (left propeller turning slowly, likely in idle, and the right one at low rotation) and that the spin occurred counter-clockwise.

On Page 11, item 1.16.2, the report mentioned that an information download was made from the GARMIN AEREA 500 from the airplane and on Page 16, item 1.16.9, § 1, the report also informed that the pilot had “very little experience on GARMIN 1000”.

Page 15, item 1-18, § 16:

1. Basic Operating Weight: 4.015 Lb
2. Pilot and right seat passenger weight: 330 Lb
3. Seat nr. 4 passenger weight: 220 Lb
4. Front cargo hold baggage weight: 45 Lb
5. Rear cargo hold baggage weight: 50 Lb
6. Fuel Load: 1.111 Lb (700 L of AVGAS)
7. Taxi fuel: 24 Lb (presumed information for a 10 minute taxi-out time)
8. Initial climb-out fuel (14 minutes flight): 26 Lb – Real: 84.12 Lb *

Actual TAKEOFF WEIGHT according to the above mentioned information:  5,771 Lb

MAXIMUM TAKEOFF WEIGHT (FCOM): ….…………....5,524 Lb

ACTUAL WEIGHT after 14 minutes flying time:…………..…………….….5,687 Lb *

*BEECHCRAFT Baron 58 Flight Crew Operating Manual, SECTION 5-PERFORMANCE, page 5-29

AIR CRASH CONSULTANTS ANONYMOUS EXPERTS considerations

Regarding the item “h”, my observation for the mistakenly reached conclusion was due to the fact that the mentioned climb-out fuel was assumed to be only 26 Lb. A considerable disagreement between the written report and the actual data provided by the FCOM (84.12 Lb).

On page 14, item 1-18, § 1, the report states that the aircraft was transporting a 50 Kg (110.23 Lb) Nitrogen Canister of cattle semen but that was not taken into account in the mentioned weight calculation, as observed.

Regarding a possible (although unlikely) Nitrogen gas leak from the canister:

That fact could not have played any immediate role in the accident due to the fact that a possible gas inhalation intoxication effects would had been felt approximately 30 hours AFTER its occurrence. The symptoms would include cough, Dyspnea, fever, mucoid frothy sputum, decreased pulmonary function, bronchitis, among others (© UNIVERSITY OF KANSAS - Poison Facts: Medium Chemicals: Nitrogen Dioxide).

The previously mentioned misinterpretations or mistakes found in the report do not disqualify it.

However, other factors might have played important roles as contributing factors to the accident as follows:

1-Maximum Takeoff  Weight exceedance, although small is a definite contributing factor.

2-Pilot’s lack of experience in the respective type of aircraft and its spin characteristics is a definite contributing factor.

According to Page 19, item 3.2.1.2.1, sub-item a, the pilot had never had any formal training in the respective aircraft and also possessed very little experience on type (00:35 hours total time). The fact of the lack of formal training, therefore, leads to the conclusion that the pilot could eventually not be aware of the existence of a document of utmost importance from RAYTHEON (Safety Communiqué No. 192, regarding the Beechcraft Baron 58 spin characteristics and its avoidance).

3-No GARMIN 1000 formal training (Page 16, item 1.19, § 8)  therefore preventing the pilot-operator to use its full capabilities. Likelihood mishandling and the possibility of its unsafe operation as a whole is a definite contributing factor.

4-Apparently, no attempted maneuver to recover from the flat spin was performed by the pilot. The CENIPA report also fails to mention important information:

Did the pilot have the information, the experience, the appropriate skills as well the knowledge of the appropriate technique to recover from spins?

If not, that might be proven to be the one of the most important contributing factors to the occurrence of the accident.

Sources:

-        RAYTHEON Safety Communiqué No. 192

-        Report RF A-022/CENIPA/2013

-        BEECHCRAFT Baron 58 Flight Crew Operating Manual

-        UNIVERSITY OF KANSAS - Poison Facts: Medium Chemicals: Nitrogen Dioxide

© ANTONIO CARLOS ARANTES DE BIASI