Beech 1900C accident near Block Island, Rhode Island, December 29, 1991
On December 29, 1991 at about 2:46 am local time, a Beech 1900C, registered N811BE, was destroyed in an accident near Block Island, Rhode Island. It was an instructional flight under general aviation rules (Part 91). 3 people were killed. The weather was visual conditions (good weather).
The NTSB's probable cause their words, unchanged
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.
Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.
What the record shows
- Date
- December 29, 1991 · about 2:46 am local time
- Place
- Block Island, Rhode Island
- Type
- Accident
- Injuries
- 3 people were killed.
- Weather
- visual conditions (good weather)
- Aircraft
- Beech 1900C · all 1900Cs on the register
- Registration
- N811BE · no longer on the register · serial UB49
- Damage
- Destroyed
- Flight
- Instructional flight · general aviation rules (Part 91)
The NTSB's narrative final · quoted from the NTSB record
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.
The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.
The factual record from the NTSB's investigation tables, in plain English
Pilot
- Certificate: airline transport pilot, flight instructor, commercial pilot
- Ratings: multi-engine land; single-engine land; instructor: airplane multi-engine; instructor: airplane single-engine; instrument: airplane
- Flight time: 5,628 hours in all; 2,200 in this make and model; 203 in the last 90 days; 64 in the last 30 days
- Medical certificate: Class 1 (valid medical--no waivers/lim.)
- Seat: rgt
The aircraft
- Airframe total time: 11,265 hours
- Last inspection: continuous airworthiness programme, December 24, 1991; 13 hours since
- Maximum gross weight: 16,600 lb
- Seats: 21
- Landing gear: retractable
- Engine: P&W PT-6A-65B (turboprop); 0 hours total
- Operator: Business Express INC.
The flight
- Departed from: BDR Bridgeport CT at 11:45 pm
- Flight plan: none
- Runway 0
- A second pilot was aboard
Weather at the time
- Light: night, dark
- Wind: from 280° at 12 knots
- Visibility: 20 statute miles
- Sky: clear
- Temperature: 37°F (3°C), dew point 0°F (-18°C)
- Altimeter: 30.00 inHg
- Observation at 2:00 am from PVD, 63 miles away
Injuries
| Fatal | Serious | Minor | None | |
|---|---|---|---|---|
| Crew | 3 |
Documents from the investigation the NTSB's docket: the evidence folder behind the report
The docket, the folder of records gathered during an investigation (maintenance records, photographs, witness statements, examinations), has not been read from the NTSB for this case yet; the list appears here once it has. Open the docket at the NTSB.
Other NTSB records under N811BE the same tail number, which may have belonged to a different aircraft at the time
Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.