Accident Beechcraft 100 King Air C-GJSU,

ASN Wikibase Occurrence # 320735

Date:	Monday 10 June 2013
Time:	17:26
Type:	Beechcraft 100 King Air
Owner/operator:	Aviation Flycie
Registration:	C-GJSU
MSN:	B-88
Year of manufacture:	1971
Total airframe hrs:	13616 hours
Cycles:	10999 flights
Engine model:	Pratt & Whitney Canada PT6A-28
Fatalities:	Fatalities: 0 / Occupants: 4
Aircraft damage:	Substantial, written off
Category:	Accident
Location:	0,9 km W of Saint-Mathieu-de-Beloeil Airport, QC - Canada
Phase:	Approach
Nature:	Test
Departure airport:	Montreal-St. Hubert Airport, QC (YHU/CYHU)
Destination airport:	Montreal-St. Hubert Airport, QC (YHU/CYHU)
Investigating agency:	TSB
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
The Beechcraft King Air 100 took off from the Montréal/St-Hubert Airport, Quebec, Canada at 17:00, on a local flight under visual flight rules with 1 pilot and 3 passengers on board. The purpose of the flight was to check the rudder trim indicator and to confirm a potential synchronization problem between the autopilot and the global positioning system (GPS).
At approximately 17:14, once the tests were completed, the aircraft, which was about 25 nautical miles (nm) south of St-Hubert Airport, set a direct course for St-Hubert Airport. At 17:16, the pilot advised air traffic control (ATC) that the tests had been completed and asked to return to St-Hubert Airport with a simulated instrument landing system (ILS) approach to runway 24R.
At 17:22:52, the propeller sound fluctuated, as the fault warning light and RH FUEL PRESSURE light illuminated. The pilot noted that the engine nacelle fuel tank gauges showed E (empty). The pilot activated the left and right auxiliary boost pumps and opened the crossfeed valve. At 17:23:44, the aircraft intercepted the localizer of runway 24R at St-Hubert Airport at an altitude of 2800 feet asl. At 17:23:58, the propeller sound fluctuated again, and the right engine stopped.
At 17:24:04, when the aircraft was 2.5 nm northwest of Saint-Mathieu-de-Beloeil Airport and 2600 feet asl with a ground speed of 190 knots, the pilot advised the controller they were going to land at there instead of St-Hubert. At 17:24:34, when C-GJSU was 2400 feet asl, 7.4 nm away from the runway and on a path toward St-Hubert, the left engine stopped. The pilot initiated a left turn toward the new destination. Over the next 40 seconds, C-GJSU's ground speed dropped from 180 knots to 110 knots.
At 17:24:47, the controller provided traffic information to C-GJSU and cleared C-GJSU to the enroute frequency. The pilot acknowledged immediately. There was no further communication by C-GJSU.
During the turn, when the aircraft was at the highest point of the turn at 1600 feet asl, the pilot lowered the landing gear. When C-GJSU was 1000 feet asl, the stall warning horn sounded, then sounded 3 more times over the next 10 seconds. When the aircraft was approximately 450 feet above ground level (agl) and 0.85 nm from the threshold of runway 15, the pilot decided to land in a field to the right. Twelve seconds before impact, the pilot warned the maintenance engineer, who was seated in the co-pilot seat, that a forced landing was imminent. At that point, the engineer was not aware that the engines had stopped. The engineer immediately alerted the other 2 passengers that a forced landing was imminent and warned them to hold on tight.
Four seconds later, C-GJSU experienced an aerodynamic stall. The right wing touched the ground at an angle of approximately 45°, then the aircraft hit a fence and a tree before severing 2 electrical wires and violently striking the grass-covered ground. The aircraft kept moving for another 120 feet before coming to a stop on its belly. The 4 occupants, who sustained minor injuries, egressed by means of the emergency exit on the right side of the aircraft, which was extensively damaged.

Th investigation learned that, while preparing for the flight, the pilot relied exclusively on the fuel gauges, misread them, and assumed that the aircraft had enough fuel on board for the flight. During the flight, the pilot did not monitor the fuel gauges and, when returning to the airport, decided to extend the flight to practice a simulated instrument landing approach, without noticing there was insufficient fuel to complete it.
The investigation found the pilot had a history of performance that did not meet expected standards to act as pilot-in-command for that aircraft type. Despite a marginal performance during the check flight, the pilot had successfully passed a pilot proficiency check, and TC had approved the individual's appointment to the position of chief pilot.
Meanwhile, the company's operations manager, who had no previous experience in commercial air carrier operations, was unable to fully appreciate the significance of the chief pilot's marginal performance or to detect deviations from regulations in the commercial flights performed over the company's first three months of operations, which preceded the accident. The regulator, Transport Canada, had also approved the appointment of the operations manager.
In addition, the investigation revealed that the person responsible for maintenance (PRM), a new co-pilot on the company's BE10, had no previous experience in maintenance or in air taxi flight operations. Transport Canada had also approved the appointment of the PRM.
The TSB determined that Transport Canada's appointment approval process was not effective and that, once the appointments had been approved, the management team's inability to perform the duties and responsibilities was not grounds for Transport Canada to revoke them.

Findings as to causes and contributing factors:

1. The pilot relied exclusively on the gauge readings to determine the quantity of fuel on board, without cross-checking the fuel consumption since the last fuelling to validate those gauge readings.
2. The pilot misread the fuel gauges and assumed that the aircraft had enough fuel on board to meet the minimum fuel requirements of the Canadian Aviation Regulations for this visual flight rules flight, rather than adding more fuel to meet the greater reserves required by the company operations manual.
3. The pilot did not monitor the fuel gauges while in flight and decided to extend the flight to carry out a practice instrument approach with insufficient fuel to complete the approach.
4. The right engine stopped due to fuel exhaustion.
5. The pilot did not carry out the approved engine failure procedure when the first engine stopped, and the propeller was not feathered, resulting in significant drag which reduced the aircraft's gliding range after the second engine stopped.
6. The pilot continued flying toward Montréal/St-Hubert Airport (CYHU), Quebec, despite having advised air traffic control of the intention to divert to the St-Mathieu-de-Beloeil Airport (CSB3), Quebec, and without communicating the emergency. The priority given to communications resulted in the aircraft moving farther away from the intended diversion airport.
7. The left engine stopped due to fuel exhaustion 36 seconds after the right engine stopped, when the aircraft was 7.4 nautical miles from Runway 24R at Montréal/St-Hubert Airport (CYHU), Quebec, and 2400 feet above sea level.
8. The pilot's decision to lower the landing gear while the aircraft was still at 1600 feet above sea level further increased the drag, reducing the aircraft's gliding range. As a result, the aircraft was not able to reach the runway at St-Mathieu-de-Beloeil Airport (CSB3), Quebec.
9. The operations manager was unable to perform the duties and responsibilities of the position related to monitoring and supervision of flight operations. As a result, the safety of more than half of the flights was compromised.

Accident investigation: