CHI00FA276

NTSB accident investigation · Beech E-55 · Grafton, IL · August 30, 2000

Accident · FatalField investigationFinal report
Date
August 30, 2000, 09:54 local (14:54 UTC)
Place
Grafton, IL
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N9047VBeech E-55
Weather
Instrument (IMC) · Day
Status
Completed · report June 18, 2002
Report
Approved by Office Director
Parties
Federal Aviation Administration - Springfield FSDO, Teledyne Continental Motors, Raytheon Aircraft Company
FAA report
20000830036339A
Case key
50213

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot not maintaining aircraft control and altitude/clearance from the river. Factors to the accident included the pilot not obtaining an air traffic control clearance prior to departure into instrument meteorological conditions, the pilot becoming spatially disoriented, the low ceiling, and the mist.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - in flightTakeoff - initial climb
Weather condition - low ceilingFactor
Weather condition - drizzle/mistFactor
Atc clearance - not obtainedPilot in commandFactor
Aircraft control - not maintainedPilot in commandCause
Spatial disorientationPilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled
Altitude/clearance - not maintainedPilot in commandCause

Analysis

During climb after takeoff the pilot became disorientated, lost aircraft control, and the airplane impacted the Mississippi River. The instrument rated pilot departed into known instrument meteorological conditions without an instrument flight rules (IFR) air traffic control (ATC) clearance. After takeoff the pilot contacted ATC to obtain an IFR clearance to his intended destination. The ATC controller instructed the pilot to make a right turn to avoid opposite direction traffic. The traffic was on an instrument approach to the airport from which the accident airplane had just departed. During the turn the accident airplane impacted the Mississippi River approximately 2.2 nm north-northeast of the departure airport. Instrument meteorological conditions prevailed at the time of the accident with a visibility of 1-1/2 statute miles and an overcast ceiling of 300 feet above ground level. No anomalies were found with the recovered portions of the airplane that could be associated with a pre-impact condition.

Factual narrative

History of flight

On August 30, 2000, at 0954 central daylight time, a Beech E-55 Baron, N9047V, owned and piloted by a private pilot, was destroyed during an in-flight collision with the Mississippi river near Grafton, Illinois. Instrument meteorological conditions prevailed at the time of the accident. The personal flight was operating under the provisions of 14 CFR Part 91 and had an instrument flight rules (IFR) flight plan on-file. The pilot and his single passenger were fatally injured. The flight departed St. Charles County Smartt Airport (SET), St. Charles, Missouri, at approximately 0952 and had the intended destination of Zanesville Municipal Airport (ZZV), Zanesville, Ohio.

According to a Federal Aviation Administration (FAA) Air Traffic Control (ATC) accident report, the accident airplane departed SET without an IFR clearance. After takeoff N9047V contacted St. Louis TRACON to obtain an IFR clearance to ZZV. The ATC controller instructed N9047V to make a right turn and issued a traffic advisory for opposite direction traffic, a Cessna 421B, N968J, that was inbound on the VOR 18 instrument approach to SET. The controller issued N9047V a transponder squawk code and N9047V repeated back the squawk code. No further contact with N9047V was reported.

Aircraft radar track data for the period before and after the reported accident time was obtained from FAA. The aircraft radar track data was plotted using commercial software. Copies of the plots are appended to this factual report along with a copy of the source data.

The accident airplane's first radar return was a primary radar return 0.701 nautical miles (nm) north-northwest of SET at 0953:01 (hhmm:ss). At 0953:06 a visual flight rules (VFR) transponder beacon code was recorded 0.788 nm north-northwest of SET and continued heading north until 0953:29 when a right turn was initiated. At 0953:29 the airplane was 1.521 nm north-northwest of SET at 1,200 feet pressure altitude. Only primary radar returns were recorded during the right turn and the last radar return was recorded 2.218 nm north of SET. The point of impact was approximately 2.2 nm north-northeast of SET in the Mississippi River.

According to a police incident report, a witness reported seeing the airplane, "... flying very low over the Mississippi River then it skimmed the water and turned nose down and went into the water." The police incident report is appended to this factual report.

Personnel information

The pilot held a private pilot certificate with ratings for airplane multi-engine land, airplane single engine land, and instrument airplane operations. The pilot's last medical examination was conducted on March 3, 2000, and he was issued a third-class medical certificate with no limitations or restrictions.

According to the pilot's flight logbooks, the pilot had a total flight time of 444.8 hours, of which 122.8 hours were in multi-engine airplanes and 322.0 hours were in single engine airplanes. The pilot had flown 122.8 hours in the Beech E-55 Baron, of which 97.8 were as pilot-in-command and 25.0 hours were as dual instruction. The pilot had flown a total of 35.1 hours in actual instrument meteorological conditions (IMC) and 84.8 hours as simulated IMC. The pilot had completed 126 instrument approaches.

The pilot had flown 33.4 hours in the last 90 days, all of which were in the multi-engine Beech E55 Baron. During the last 90 days the pilot had flown 11.2 hours in actual IMC and completed 5 instrument approaches.

The pilot had flown 33.4 hours in the last 60 days and 28.8 hours in the last 30 days. The pilot flew 11.2 hours in actual IMC during the last 60 days and 9.1 hours in the last 30 days. The pilot completed 5 instrument approaches during the last 60 days and 0 approaches during the last 30 days.

There were no flight logbook entries within 24 hours of the accident.

Aircraft information

The airplane was a Beech E-55 Baron, serial number TE-938. The Beech E-55 Baron is a multi-engine, low-wing, all-metal airplane of semimonocoque design, powered by two reciprocating engines. The airplane can be configured to carry a maximum of six occupants.

The airplane was issued a Standard Airworthiness Certificate on April 15, 1974, and was certified for normal category operations. The airframe had accumulated a total flight time of 5,903.3 hours as of the last maintenance logbook entry dated August 7, 2000. The last annual inspection was performed on February 17, 2000, at 5,810.8 hours total time. The Hobbs hour-meter was not recovered subsequent to the accident.

The left engine was a 285 horsepower Teledyne Continental IO-520-C-7B, serial number 287072-R. The last inspection of the left engine was on February 17, 2000, at which time the engine had accumulated 776.3 hours since the last factory rebuild which was completed on December 3, 1992.

The right engine was a 285 horsepower Teledyne Continental IO-520-C-16B, serial number 810999-R. The last inspection of the right engine was on February 17, 2000, at which time the engine had accumulated 43.3 hours since the last factory rebuild which was completed on September 15, 1998.

The left propeller was a three-bladed Hartzell PHC-C3YF-2UF/FC7663-2R, serial number EB168. The last inspection of the left propeller was on February 17, 2000, at which time the propeller had accumulated 1,171.6 hours since the last overhaul.

The right propeller was a three-bladed Hartzell PHC-C3YF-2UF/FC7663B-2R, serial number EB1706. The last inspection of the right propeller was on February 17, 2000, at which time the propeller had accumulated 43.3 hours since the last overhaul.

Meteorological information

A weather observation station, located at the St. Charles County Smartt Airport (SET), about 2.2 nautical miles (nm) from the accident site on a 194 degrees magnetic heading, recorded the weather at 0954 cdt as:

Wind: 030 degrees magnetic at 4 knots

Visibility: 1.5 statute miles (sm) with mist

Sky Condition: 300 feet above ground level (agl) overcast

Temperature: 26 degrees Celsius

Dew Point: 24 degrees Celsius

Pressure: 30.01 inches-of-mercury

A weather observation station, located at the Lambert - St. Louis International Airport (STL), about 13.3 nm from the accident site on a 167 degrees magnetic heading, recorded the weather approximately one minute prior to the accident as:

Observation Time: 0953 cdt

Wind: 020 degrees magnetic at 4 knots

Visibility: 1.0 sm with mist

Sky Condition: 400 feet agl scattered

Temperature: 27 degrees Celsius

Dew Point: 26 degrees Celsius

Pressure: 30.01 inches-of-mercury

A weather observation station, located at the St. Louis Regional Airport (ALN), about 17.9 nm from the accident site on a 104 degrees magnetic heading, recorded the weather approximately 10 minutes prior to the accident as:

Observation Time: 0945 cdt

Wind: Variable direction at 6 knots

Visibility: 0.5 sm with fog

Sky Condition: 300 feet agl overcast

Temperature: 25 degrees Celsius

Dew Point: 25 degrees Celsius

Pressure: 30.01 inches-of-mercury

At 0742:25 (hhmm:ss) a pilot representing the accident airplane contacted the St. Louis Automated Flight Service Station (AFSS) and requested a weather briefing. The AFSS briefer issued a standard weather briefing and at the completion of the weather briefing the pilot filed an IFR flight plan. A transcription of the weather briefing is appended to this factual report.

Communications

The communications between N9047V, N968J, and the St. Louis TRACON were transcribed as follows:

0953:29 (hhmm:ss)

N9047V: saint louis approach this is baron nine zero four seven victor

0953:35

St. Louis TRACON: baron uh nine seven four seven victor was it nine zero four seven victor

0953:41

N9047V: uh affirmative nine zero four seven victor we are i f r to zulu zulu victor

0953:46

St. Louis TRACON: allrig

Aircraft

Registration
N9047V
Reported as
Beech E-55 (E55)
Category
Airplane
Serial number
TE-938
Airframe hours
5,810.8
Engines
Teledyne Continental IO-520-C-16B, 285 horsepower, reciprocatingTeledyne Continental IO-520-C-7B, 285 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Roby Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 17, 2000
Departed
SET · St. Charles, MO
Destination
ZZV · Zanesville, OH
Flight plan
IFR
Airport
SET · St. Charles County Smartt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
47
Injuries
Fatal
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--no waivers/lim.
Last flight review
March 6, 2000
Toxicology
Performed
Flight hours
445 total · 123 in this make and model · 414 as pilot in command · 33 in the last 90 days · 29 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
30° at 4 knots
Visibility
1.5 statute miles
Lowest ceiling
300 ft overcast
Temperature
79 °F, dew point 75 °F
Altimeter
30.00 inHg
Observed at
SET, 2 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N9047V · 1

Matched to the same aircraft by N-number and date.