# NTSB CHI08FA066: Hawker Beechcraft 58, N3217L, Cleveland, OH, January 17, 2008 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 16, 2008, 19:22 local (Jan 17, 2008, 00:22 UTC) - Place: Cleveland, OH - Coordinates: 41.517501, -81.683334 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.5175&lon=-81.6833&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report July 28, 2009 - Report: Approved by Office Director - Parties: Hawker Beechcraft Corp., Teledyne Continental Motors, Transportation Safety Board of Canada, Federal Aviation Administration - NTSB case key (mKey): 67392 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI08FA066 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67392/pdf - Page: https://openairdocs.org/ntsb/CHI08FA066 ## Probable cause The pilot experienced spatial disorientation during the inital climb causing him to lose control of the airplane. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Health/Fitness: use of medication/drugs](https://openairdocs.org/ntsb-findings/02013020): Personnel issues › Physical · Pilot; cases with it: [Raytheon 58, 1 case](https://openairdocs.org/ntsb-findings/02013020/cases.md?model=7150003), [All aircraft, 73 cases](https://openairdocs.org/ntsb-findings/02013020/cases.md) - [Performance/control parameters: pitch control](https://openairdocs.org/ntsb-findings/01062022): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Raytheon 58, 1 case](https://openairdocs.org/ntsb-findings/01062022/cases.md?model=7150003), [All aircraft, 526 cases](https://openairdocs.org/ntsb-findings/01062022/cases.md) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Effect on personnel; cases with it: [Raytheon 58, 1 case](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=7150003), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) - [Perception/orientation/illusion: visual illusion/disorientation](https://openairdocs.org/ntsb-findings/02022015): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Raytheon 58, 1 case](https://openairdocs.org/ntsb-findings/02022015/cases.md?model=7150003), [All aircraft, 51 cases](https://openairdocs.org/ntsb-findings/02022015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Raytheon 58, 7 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7150003), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis The pilot was hired by the airplane operator for a positioning flight. The pilot departed at night in a northerly right turn over Lake Erie from a lake shore airport. The moon and city associated with the airport were south of his flight path. The airplane was observed descending in the right hand turn and subsequently impacting the lake. An examination of the recovered wreckage revealed no preimpact anomalies, and an engine monitor recorded sensor readings consistent with both engines being at a high power until the recorded data stopped. The pilot had a history of back pain and had been regularly and recently using a potentially sedating muscle relaxant, which could cause impairment. He had heart disease identified during the autopsy that may have increased his risk of sudden cardiac death. He was also at high risk for obstructive sleep apnea, which commonly causes fatigue and cognitive impairment; however, the investigation could not conclusively identify that the pilot was impaired. The maneuvering of the aircraft and lack of outside visual references soon after takeoff made the situation conducive to spatial disorientation. ## Factual narrative "THIS CASE WAS MODIFIED FEBRUARY 12, 2009." HISTORY OF FLIGHT On January 16, 2008, about 1922 eastern standard time, N3217L, a Hawker Beechcraft Corp. 58 airplane, owned by Everair LLC, sustained substantial damage on impact with Lake Erie during its climb after takeoff from the Burke Lakefront Airport (BKL), Cleveland, Ohio. The 14 CFR Part 91 positioning flight was operating in night visual meteorological conditions. No flight plan was on file. The airline transport rated pilot received fatal injuries. The flight originated from BKL and was destined for the Niagara Falls International Airport (IAG), near Niagara Falls, New York. About 1850, a pilot representing N3217L requested a standard visual flight rules weather briefing from BKL to IAG. A witness, who was a lineman, observed the pilot preflight the accident airplane. The witness saw the airplane's engines rev up at its parking spot on the ramp and saw the airplane jump the chocks. The airplane then taxied out for departure. According to an air traffic controller, the pilot of N3217L was given a clearance to taxi to runway 24L and the pilot asked for flight following to IAG. The pilot reported that he was ready for departure and was given a takeoff clearance by the controller that included an approved right turn on course. The controller reported that he observed the airplane in the right turn, saw the airplane descend in the right turn, and saw the airplane impact the lake. The controller reported that he called the airport fire and rescue facility and Coast Guard contacts and informed them of the accident. Another witness at the airport, in part, stated: At about 7:20 PM on Jan. 16, 2008 I was on the Business Aircraft ramp at Burke Lakefront Airport, I had just checked the maintenance release on a[n] Embraer 120 that was to launch at 7:30 PM. While talking with the lineman, and facing north, lights of an aircraft caught my attention, for two reasons, the lights were not in a normal Nav [navigation] light configuration for a fixed wing aircraft and second was the angle and rate of descent. The angle was about 45 degrees. The direction of travel was west to east. Since there are a large number of helicopters in the area, my next thought was that it was a helicopter coming in. A fuel truck blocked my line of sight for a split second and after it passed I expected to see a helicopter leveling off, but instead the aircraft continued [its] descent into the lake. Instantly there was a line of fire about 20 to 30 yards long and burned for about 4 or 5 minutes. ... I couldn't hear if there was an explosion, I could only see the fire. PERSONNEL INFORMATION The pilot was employed as a pilot by the accident airplane's operator, Aitheras Aviation Group, LLC. The 68 year old pilot held an airline transport pilot certificate with an airplane multiengine land rating and held rotorcraft helicopter and airplane single engine land and sea commercial privileges. He also held a helicopter instrument rating. He held a certified flight instructors certificate with single engine, multiengine, and instrument airplane ratings and rotorcraft helicopter, and instrument helicopter ratings. The operator reported that the pilot had accumulated about 18,600 hours of total flight experience, which included 350 hours in the same make and model airplane as the accident airplane. The operator reported that the pilot's last flight review was completed on April 13, 2007, and the pilot's most recent Federal Aviation Administration (FAA) second class medical certificate was issued on October 4, 2006. AIRCRAFT INFORMATION N3217L, a 1999 Hawker Beechcraft Corp. 58, was a six place, retractable tri-cycle landing gear, twin-engine monoplane of predominately aluminum construction. The airplane's serial number was TH-1927. The airplane was powered by two 300-horsepower Teledyne Continental Motors model IO-550-C (31) engines. The left engine serial number was 690172 and the right engine serial number was 684330. Each engine drove its own three-bladed Hartzell propeller. According to the aircraft maintenance records, the most recent annual inspection was performed on September 20, 2007, and the airplane Hobbs meter read 2,022.3 hours on that date. The operator reported that the airplane was flown 6.4 hours on January 15, 2008, and indicated that the airplane flew "perfectly" and had no squawks. Records show that the airplane was equipped with an Insight Instrument Corp. (Insight) Gemini 1200 engine monitor, serial number 02118. According to Insight, the monitor automatically records parameters during every flight. The monitor watches engine temperatures and stores each flight data as an individual log file in non-volatile memory. The monitor can store up to 50 hours of data. METEOROLOGICAL INFORMATION At 1853, the recorded weather at BKL was: Wind 120 degrees at 6 knots; visibility 10 statute miles; sky condition broken 25,000 feet; temperature 0 degrees C; dew point -7 degrees C; altimeter 30.25 inches of mercury. According to the United States Naval Observatory, at 1920 the position of the moon was 183.4 degrees east of north, 68.3 degrees above the horizon, and was in its waxing gibbous phase with about 60 percent of the its visible disk illuminated. AIRPORT INFORMATION BKL was located on the lakeshore of Lake Erie north of downtown Cleveland, Ohio, and was owned and operated by the city of Cleveland, Ohio. BKL was a certificated airport under 14 CFR Part 139. BKL's field elevation was 583 feet above mean sea level. BKL had 2 runways: Runway 6L/24R -6,198 feet by 150 feet, asphalt/grooved; runway 6R/24L - 5,197 feet by 100 feet, asphalt/grooved. The airport met airport rescue and firefighting index A. WRECKAGE AND IMPACT INFORMATION According to the underwater salvage company, the pilot and wreckage were found and recovered about a mile off the shore by BKL near 41 degrees 31.8 minutes north latitude and 81 degrees 42.7 minutes west longitude from about 30 feet of water. Sections of the right outboard wing and left engine propeller were not recovered. The recovered wreckage was relocated to a hangar at BKL for examination. MEDICAL AND PATHOLOGICAL INFORMATION On the application for that medical certificate, the pilot indicated "Yes" for "Do you currently use any medication" and he noted only atorvastatin. The application showed "No" for all items under "Medical History," including specifically "High or low blood pressure" and "Other illness, disability, or surgery." The pilot's height was noted as 72 inches, weight as 220 lbs, and blood pressure as 120/80. His total flight time was reported as 16,100 hours "To Date" with 150 hours in the "Past 6 months." The pilot's personal medical records were reviewed by the NTSB medical officer. On May 24, 2005, the records indicated that the pilot had injured his back and was prescribed cyclobenzaprine 10mg three times a day as needed for muscle spasm. The pilot's physician noted that the cyclobenzaprine "will cause drowsiness so careful if flying a plane." On October 5, 2006, the pilot was noted as being treated, in part, for back pain, high blood pressure, gastroesophageal reflux disease, and elevated triglycerides and cholesterol. On January 11, 2008, the pilot was noted to also have diet controlled diabetes and to be regularly taking cyclobenzaprine, losartan, metoprolol, and naproxen, among other medications. His blood pressure was noted at that time to be 146/86, his height as 72 inches, and his weight as 234.7 pounds. An autopsy was performed on the pilot for the Cuyahoga County Coroner. The autopsy report indicated "hypertensive and atherosclerotic cardiovascular disease," noting cardiomegaly (690 grams), left ventricular hypertrophy (1.8 cm), myocyte hypertrophy, myocardial ischemia, coronary atherosclerosis (50%), an ## Aircraft - Registration: [N3217L](https://openairdocs.org/deregistered/N3217L-2017-07-07), registration cancelled 2017-07-07, S/N TH-1927, built 1999 (OpenAirDocs) - Reported make and model: Hawker Beechcraft Corp. 58 - Registry model: [Raytheon 58](https://openairdocs.org/model/raytheon-58) (registry code 7150003) (OpenAirDocs) - Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TH-1927 - Airframe hours: 2106.4 - Engines: Continental IO-550-C (31) 300 horsepower reciprocating; Continental IO-550-C (31) 300 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Positioning, Part 91 - Operator: Aitheras Aviation Group - Registered owner: Everair LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 20, 2007, 84.1 hours before - Departed: BKL, Cleveland, OH - Destination: IAG, NIAGARA FALLS, NY - Airport: BKL, Burke Lakefront ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: fatal; commercial, airline transport; airplane ratings: multi-engine land, single-engine sea, single-engine land; instrument ratings: helicopter, airplane; medical: class 2, with waivers/limitations; last flight review April 13, 2007; seat: left; toxicology performed; flight hours: 18,600 total, 350 in this make and model, 130 in the last 90 days, 30 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night - Wind: 120° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: 25,000 ft broken - Temperature: 32 °F, dew point 19 °F - Altimeter: 30.25 inHg - Observed at: BKL, 1 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 20080116844429A](https://openairdocs.org/incident/20080116844429A), Jan 16, 2008: Beech 58, Cleveland, OH, Destroyed, 1 fatal. (-23) On January 16, 2008, approximately 1922 local eastern standard time (0022 zulu), N3217L, a Hawker Beechcraft corporation BE-58 airplane, piloted by an… 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.