Aviation Accident Summaries

Aviation Accident Summary CHI08FA053

Springfield, IL, USA

Aircraft #1

N17784

Beech V35B

Analysis

The pilot departed on the cross-country flight under visual flight rules and obtained flight following from several air traffic control facilities located along the intended route of flight. While enroute, he obtained an instrument flight rules (IFR) clearance after encountering instrument conditions at 2,500 feet. The accident flight was provided radar vectors to intercept the instrument landing system (ILS) runway 4 approach for the intended destination. Radar track data showed the accident airplane passed through the localizer centerline at 2,400 feet and then it made a rapid right turn back toward the centerline. The airplane then performed a series of rapid descents and climbs, and several course reversals over a period of 75 seconds. During this time period, the pilot reported having an unspecified problem and his last communication was "I can go out now ... flying eastbound." A witness reported seeing the accident airplane flying about 20 feet above the ground before it entered a steep climb. He then heard an increase in engine noise, which was followed by a loud boom. The airplane impacted about 3.5 miles outside the locator outer marker along the localizer centerline. Instrument meteorological conditions prevailed at the destination airport with a ground visibility of 2-1/2 miles in mist and a 500 foot overcast ceiling. Based on available information, the pilot had not recorded an instrument approach in over 6 months and his last flight review was completed more than 24 months before the accident. No additional dual flight instruction or instrument proficiency checks were uncovered during the investigation. A review of the maintenance records found no history of unresolved airworthiness issues. Examination of the recovered wreckage revealed no evidence of a pre-impact mechanical malfunction.

Factual Information

HISTORY OF FLIGHT On December 20, 2007, at 1517 central standard time, a Beech V35B airplane, N17784, piloted by a private pilot was destroyed during impact with terrain near Springfield, Illinois. Instrument meteorological conditions prevailed at the time of the accident. The personal flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91 while on an instrument flight plan. The pilot and his two passengers were fatally injured. The flight departed Clermont County Airport (I69), Batavia, Ohio, about 1430 eastern standard time and was enroute to Abraham Lincoln Capital Airport (KSPI), near Springfield, Illinois. The accident flight departed I69 under visual flight rules (VFR) and obtained flight following from several air traffic control facilities located along the intended route of flight. At 1437, the pilot established radio contact with Champaign approach control. He asked the controller what the current weather conditions were at Decatur Airport (KDEC). The controller replied that they were VFR, but there was precipitation in the area. At 1441, the pilot told the controller that he could accept an instrument flight rules (IFR) clearance if needed. The controller asked the pilot if he was requesting an IFR clearance. The pilot stated that he wanted to remain VFR at 2,500 feet. The controller told the pilot that he would have to climb to 3,000 feet to accept an IFR clearance. The pilot reiterated that he would remain VFR at 2,500 feet. At 1449, the pilot reported that the airplane was entering instrument meteorological conditions and requested an IFR clearance to KSPI. The pilot was issued an IFR clearance and told to climb to 3,000 feet. At 1455, the pilot was told to contact Springfield approach control. At 1455:51 (hhmm:ss), the pilot established contact with Springfield approach control and reported being level at 3,000 feet. The approach controller told the pilot to expect the instrument landing system (ILS) runway 4 approach into KSPI. At 1457:34, the pilot reported having the current KSPI weather and asked for radar vectors to the final approach course. The approach controller issued radar vectors to join the localizer and cleared the pilot to descend to 2,300 feet. Between 1505:18 and 1509:54, the approach controller attempted to contact the pilot unsuccessfully. At 1509:54, the pilot reestablished two-way communications stating "I hear you loud and clear now, I've got I flipped off a switch a while ago, and I was (unintelligible) direct getting a little bit nervous ... and suppose you were to." At 1510:03, the approach controller told the pilot that he was on an extended right base for the localizer and to maintain 2,300 feet while on a 300 degree heading. At 1514:29, the pilot was told to turn right to a heading of 360 degrees. At 1515:03, the approach controller cleared the flight for the ILS runway 4 approach. The pilot did not initially respond to the clearance and the controller inquired if the pilot had copied the approach clearance. At 1515:29, the pilot read back the approach clearance and then was told to contact Springfield control tower. At 1516:24, the pilot stated on the Springfield control tower frequency, "Springfield tower, bonanza one seven seven eight four is got a problem." At 1516:30, the tower controller asked the pilot to "say request." At 1516:38, the tower controller asked the pilot if he was "having a problem" and the pilot replied "that's affirm." At 1516:44, the tower controller asked the pilot if he was "able to fly the aircraft." At 1516:47, the pilot replied "I can go out now seven eight four is flying eastbound." There were no additional communications received from the accident airplane. At 1515:38, radar track data showed the accident airplane passing through the localizer centerline at 2,400 feet and then make a rapid right turn back toward the centerline. During the right turn, between 1515:47 and 1516:01, the airplane descended from 2,400 feet to 1,300 feet. The airplane then entered a rapid climb to 2,900 feet over a period of 14 seconds. Between 1516:15 and 1516:34, the airplane descended from 2,900 feet to 1,800 feet. Between 1516:34 and 1516:58, the airplane climbed from 1,800 feet to 2,700 feet. At 1517:02, the final radar return was recorded at 2,500 feet. A witness reported seeing the accident airplane flying about 20 feet above the ground before it entered a steep climb. He then heard an increase in engine noise, which was followed by a loud boom. PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) records, the pilot of N17784, age 71, held a private pilot certificate with airplane single engine land and instrument ratings. A search of FAA records showed no previous accidents or enforcement actions. The pilot's last aviation medical examination was completed on June 5, 2007, when he was issued a third-class medical certificate with the limitation that he wear corrective lenses for near and distant vision. A pilot flight logbook was not recovered during the investigation. According to an aviation insurance application, dated August 14, 2006, the pilot reported having a total flight experience of 4,075 hours, of which 3,075 hours were in a Beech V35B. When applying for his previous aviation medical certificates, the pilot reported his total civilian flight experience and flight time completed within the previous six months. As of June 5, 2007, he reported having 3,400 hours total flight experience and that he had flown 50 hours during the previous six months. An aircraft trip logbook was found within the wreckage, detailing the pilot's flights in the accident airplane. The first logbook entry was dated June 20, 2002, at which time the airplane's tachometer read 1,809.4 hours. The most recent logbook entry was dated December 6, 2007, at which time the airplane's tachometer read 2,472.2 hours. According to the aircraft trip logbook, the pilot had flown 211.1 hours during the previous 2 years, 89.5 hours during the prior 12 months, 41.2 hours during the past 6 months, and 21.2 hours during the previous 3 months. No instrument approaches were recorded in the aircraft trip logbook during the previous 6 months. According to available information, the pilot's last flight review was completed on June 16, 2005. No additional dual flight instruction or instrument proficiency checks were uncovered during the investigation. AIRCRAFT INFORMATION The accident airplane was a 1977 Beech V35B (Bonanza), serial number (s/n) D-10007. The Bonanza was a low wing, all-metal, single-engine, V-tailed, four-place monoplane. The airplane had a certified maximum takeoff weight of 3,400 lbs. The airplane was equipped for operation under instrument flight rules (IFR). A Teledyne Continental Motors model IO-520-BB-8 reciprocating engine, s/n 285500-R, powered the airplane. The 285-horsepower engine provided thrust through a McCauley model 3A32C406-C, hub s/n 900896, constant speed, three-blade, metal propeller. The airplane was issued a standard airworthiness certificate on March 14, 1977. The last annual inspection was completed on June 26, 2007, at 2,431 hours total service time. The engine was rebuilt on June 13, 1991, at a tachometer time of 1,249 hours. On October 19, 2007, tests on the static system, altimeter system, automatic pressure altitude reporting system, and transponder were completed. The airplane was topped off with 29.9 gallons of 100 low-lead aviation fuel at the departure airport. The accident occurred during the first flight after being refueled. A review of the maintenance records found no history of unresolved airworthiness issues. METEOROLOGICAL INFORMATION The closest weather reporting facility to the accident site was at KSPI, located about 8.5 miles northeast of the accident site. The airport was equipped with an automated surface observing system (ASOS). At 1529, the KSPI ASOS reported: Wind 120 degrees true at 11 knots; visibility 2 1/2 miles with mist; sky overcast at 500 feet above ground level (agl); temperature 3 degrees Celsius; dew point 2 degrees Celsius; altimeter setting 29.84 inches-of-mercury. At 1507, a Cessna 414 that had departed KSPI provided a Pilot Weather Report (PIREP) to Springfield approach control. The Cessna 414 pilot reported that the cloud tops were at 6,000 feet, the outside temperature was 7 degrees Celsius at 6,000 feet, and that he did not encounter any icing during his climb. AIDS TO NAVIGATION The published inbound course for ILS runway 4 approach was 043 degrees magnetic, with the published decision height of 792 feet (200 feet above ground level). The crossing altitude for the locator outer marker (HUSKK) was 2,297 feet. The distance between HUSKK and the touchdown zone was 5.1 nautical miles (nm). The touchdown zone elevation was 592 feet. The published weather minimums for the ILS runway 4 approach were a 200-foot ceiling and one-half mile visibility for category A, B, C, and D aircraft. FLIGHT RECORDERS The accident airplane was not equipped, nor was it required to be equipped, with a cockpit voice recorder or flight data recorder. A handheld aviation global positioning system (GPS) receiver was found in the wreckage; however, the GPS receiver was substantially damaged in the accident, which precluded any data recovery from its non-volatile FLASH memory devices. WRECKAGE AND IMPACT INFORMATION The aircraft impacted in an open, level, harvested agricultural field. The accident site was about 3.5 miles outside the locator outer marker (HUSKK) along the localizer centerline. There were no trees or other obstructions in the general vicinity of the accident site. The aircraft wreckage was orientated on a 150 degree magnetic heading. No wreckage propagation from the initial impact location was noted. A majority of the airframe's primary structure exhibited severe impact damage and fragmentation. The cockpit and main cabin were destroyed. All airframe structural components were located at the accident site and all flight control surfaces remained attached at their respective airframe positions. Both wings remained attached to the fuselage structure. The leading edges of both wings were crushed aft. Both flap actuators were extended approximately 2 inches, consistent with a flap position between 0 and 5 degrees. The landing gear selector handle was in the up position. The left and right main landing gear remained attached, and were stowed in their respective wheel wells. The nose landing gear was separated from the fuselage structure. Both stabilizers remained attached to the empennage structure. Flight control cable continuity was established from the flight controls to the main cabin carry-through structure. All observed flight control cable separations were consistent with an overload failure. The engine was found separated from the airframe. The propeller hub assembly was found separated from the crankshaft. All six cylinders remained attached to the crankcase and exhibited normal combustion signatures when inspected with a lighted borescope. The right and left magnetos remained partially attached to the engine and were removed for a functional test. Both magnetos produced a blue spark on all leads when rotated by hand. The engine crankshaft was rotated by hand at the right magneto accessory drive gear and thumb compression was obtained from all cylinders at the upper spark plug holes. Crankshaft and camshaft continuity was confirmed throughout the engine. Both upper and lower sparkplugs exhibited wear signatures consistent with normal operation. The fuel manifold valve remained attached to the engine and contained a blue-colored liquid consistent with aviation fuel when it was disassembled. The fuel control unit, oil filter, oil sump, and vacuum pump separated from the engine. The oil filter element and oil pick-up tube/screen were free of obstructions and debris. Oil was present throughout the engine assembly. The vacuum pump exhibited impact damage and could not be rotated by hand. The vacuum pump drive coupling was intact. The vacuum pump was disassembled and its rotor was fractured consistent with impact damage. Two of the three propeller blades remained attached to the hub assembly. All three propeller blades exhibited chordwise scratches, blade twist, and leading edge damage. Examination of the recovered wreckage revealed no evidence of a pre-impact mechanical malfunction. MEDICAL AND PATHOLOGICAL INFORMATION On December 21, 2007, an autopsy was performed on the pilot at the Memorial Medical Center in Springfield, Illinois. The pilot's cause of death was attributed to blunt force injuries sustained in an aircraft accident. The FAA's Civil Aeromedical Institute in Oklahoma City, Oklahoma, performed toxicology tests on the pilot. Triamterene was present in liver and kidney samples. Triamterene is a potassium-sparing diuretic commonly used for the treatment of hypertension and edema. The pilot had disclosed the use of Triamterene for the treatment of hypertension during a previous aviation medical examination.

Probable Cause and Findings

The loss of control during an instrument approach due to spatial disorientation.

 

Source: NTSB Aviation Accident Database

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