# NTSB CHI08FA053: Beech V35B, N17784, Springfield, IL, December 20, 2007 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 20, 2007, 15:17 local (21:17 UTC) - Place: Springfield, IL - Coordinates: 39.736389, -89.804443 - Nearby events: https://openairdocs.org/map.md?lat=39.7364&lon=-89.8044&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report May 11, 2010 - Report: Approved by Office Director - Parties: Teledyne Continental Motors, Hawker Beechcraft, Federal Aviation Administration - Springfield FSDO - NTSB case key (mKey): 67306 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI08FA053 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67306/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=67306 - Page: https://openairdocs.org/ntsb/CHI08FA053 ## Probable cause The loss of control during an instrument approach due to spatial disorientation. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - iaf to faf/outer marker (ifr) - spatial disorientation, pilot in command (cause) - aircraft control - not maintained, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled ## 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 narrative 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 surfa ## Aircraft - Registration: [N17784](https://openairdocs.org/deregistered/N17784-2011-11-22), registration cancelled 2011-11-22, S/N D-10007, built 1977 (OpenAirDocs) - Reported make and model: Beech V35B - Registry model: [Beech V35B](https://openairdocs.org/model/beech-v35b) (registry code 1151548) (OpenAirDocs) - Registry engine: [Continental IO-520-BA](https://openairdocs.org/engine/continental-io-520-ba) (registry code 17230, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-10007 - Airframe hours: 2431 - Engines: Teledyne Continental Motors IO-520-BB-8 285 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Ray L. Wright Construction Equipment Sales - Registered owner: Ray L. Wright Construction Equipment Sales - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: Annual, June 26, 2007 - Departed: I69, Batavia, OH - Destination: KSPI, Springfield, IL - Flight plan: IFR - Airport: KSPI, Abraham Lincoln Capital Arpt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 71; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review June 16, 2005; seat: left; toxicology performed; flight hours: 4,075 total, 3,075 in this make and model ## Weather - Conditions: Instrument (IMC), Day - Wind: 120° at 11 knots - Visibility: 2 statute miles - Lowest ceiling: 500 ft overcast - Temperature: 37 °F, dew point 36 °F - Altimeter: 29.84 inHg - Observed at: KSPI, 8 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 (OpenAirDocs). - [Accident 20071220832089A](https://openairdocs.org/incident/20071220832089A), Dec 20, 2007: Beech V35B, Springfield, IL, Destroyed, 3 fatal. (-23) While on an instrument flight plan and in instrument meteorological conditions, N17784 was being radar vectored by Springfield ATC for the final approach… ## Docket (24 files) The files NTSB released with the investigation on March 4, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=67306. - Air Traffic Control Communications (item 1, .PDF, 870 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326483&FileExtension=.PDF&FileName=Air%20Traffic%20Control%20Communications-Redacted.PDF - ILS Runway 4 Approach Chart (item 2, .PDF, 285 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326484&FileExtension=.PDF&FileName=ILS%20Runway%204%20Approach%20Chart-Master.PDF - Radar Data Plots (ILS Runway 4 Instrument Approach Chart) (item 3, .PDF, 950 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326485&FileExtension=.PDF&FileName=Radar%20Data%20Plots%20(ILS%20Runway%204%20Instrument%20Approach%20Chart)-Master.PDF - Tabluar Radar Data - Springfield Approach (item 4, .PDF, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326487&FileExtension=.PDF&FileName=Tabluar%20Radar%20Data%20-%20Springfield%20Approach-Master.PDF - GPS 17 - Factual Report of Group Chairman (item 5, .PDF, 389 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40300072&FileExtension=.PDF&FileName=GPS%2017%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Weather Products (item 6, .PDF, 118 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326488&FileExtension=.PDF&FileName=Weather%20Products-Redacted.PDF - Witness Information (item 7, .PDF): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326491&FileExtension=.PDF&FileName=Witness%20Information-Redacted.PDF - Cessna 414 Pilot Statement (item 8, .PDF, 199 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326492&FileExtension=.PDF&FileName=Cessna%20414%20Pilot%20Statement-Redacted.PDF - Pilot Toxicology Report (item 9, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326493&FileExtension=.PDF&FileName=Pilot%20Toxicology%20Report-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 10, .PDF, 211 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326494&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 11, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326495&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Aircraft Wreckage Overview -- Front (item 12, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326496&FileExtension=.PDF&FileName=Aircraft%20Wreckage%20Overview%20--%20Front-Master.PDF - Aircraft Wreckage Overview -- Front/Left (item 13, .PDF, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326498&FileExtension=.PDF&FileName=Aircraft%20Wreckage%20Overview%20--%20Front%2FLeft-Master.PDF - Aircraft Wreckage Overview -- Aft/Left (item 14, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326499&FileExtension=.PDF&FileName=Aircraft%20Wreckage%20Overview%20--%20Aft%2FLeft-Master.PDF - Aircraft Wreckage Overview -- Aft/Right (item 15, .PDF, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326500&FileExtension=.PDF&FileName=Aircraft%20Wreckage%20Overview%20--%20Aft%2FRight-Master.PDF - Aircraft Wreckage Overview -- Left Empennage (item 16, .PDF, 108 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326501&FileExtension=.PDF&FileName=Aircraft%20Wreckage%20Overview%20--%20Left%20Empennage-Master.PDF - Aircraft Wreckage Overview -- Aft Empennage (item 17, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326502&FileExtension=.PDF&FileName=Aircraft%20Wreckage%20Overview%20--%20Aft%20Empennage-Master.PDF - Aircraft Wreckage Overview -- Right Empennage (item 18, .PDF, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326503&FileExtension=.PDF&FileName=Aircraft%20Wreckage%20Overview%20--%20Right%20Empennage-Master.PDF - Aircraft Wreckage Overview -- Cockpit/Main Cabin (item 19, .PDF, 193 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326504&FileExtension=.PDF&FileName=Aircraft%20Wreckage%20Overview%20--%20Cockpit%2FMain%20Cabin-Master.PDF - Engine - Front (item 20, .PDF, 147 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326505&FileExtension=.PDF&FileName=Engine%20-%20Front-Master.PDF - Engine - Right (item 21, .PDF, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326506&FileExtension=.PDF&FileName=Engine%20-%20Right-Master.PDF - Engine - Left (item 22, .PDF, 131 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326507&FileExtension=.PDF&FileName=Engine%20-%20Left-Master.PDF - Engine - Rear (item 23, .PDF, 169 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326509&FileExtension=.PDF&FileName=Engine%20-%20Rear-Master.PDF - Propeller (item 24, .PDF, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326513&FileExtension=.PDF&FileName=Propeller-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.