# NTSB CHI98FA028: Beech BE 58, N472TL, New Berlin, IL, October 30, 1997 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 30, 1997, 16:48 local (22:48 UTC) - Place: New Berlin, IL - Coordinates: 39.720348, -89.910209 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.7203&lon=-89.9102&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 6 fatal - Status: Completed, report June 21, 2000 - Report: Approved by Office Director - ADs cited in the narratives: [AD 77-13-22](https://openairdocs.org/ad/77-13-22) (OpenAirDocs) - NTSB case key (mKey): 10722 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI98FA028 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/10722/pdf - Page: https://openairdocs.org/ntsb/CHI98FA028 ## Probable cause A loss of engine power due to separation of the left engine's number 2 connecting rod as a result of fatigue failure. Also causal was the pilot's failure to maintain adequate airspeed which resulted in a stall/spin. Contributing to the accident was the pilot's operation of the aircraft with known deficiencies and exceeding the maximum gross weight of the airplane. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, cruise - normal - 1 engine - engine assembly,crankcase - fatigue (cause) - operation with known deficiencies in equipment - intentional, pilot in command (contributing factor) - fluid,oil - loss,partial (contributing factor) - engine assembly,connecting rod - separation (cause) - Loss of control - in flight, cruise - aircraft control - not maintained, pilot in command (cause) - stall/spin - aircraft weight and balance - exceeded, pilot in command - In flight collision with terrain/water, descent - uncontrolled ## Analysis The twin-engine airplane began its instrument flight loaded about 800 pounds beyond its certificated maximum gross take off weight. Shortly after reaching its assigned altitude of 7,000 feet above mean sea level, the pilot advised the FAA controller, '...we have an engine problem.' The problem was not identified during a subsequent radio transmission. Shortly after the pilot's last radio transmission, witnesses on the ground observed the airplane in a counterclockwise flat spin. The on-scene examination revealed the left engine had suffered a mechanical failure. Continuity of the flight, engine, fuel and propeller controls was established. An oil film was found on the left engine's nacelle, inboard half of the wing, left side of the fuselage and the horizontal stabilizer and elevator. The left engine case had fractured near the number 2 cylinder. Examination of the case fracture surfaces revealed fatigue failure at its initiation point. The fatigue extended about 7 inches from its origin. Additionally, the number 2 cylinder connecting rod had separated from the crankshaft journal. Maintenance records showed the engine had a crankcase crack that was not covered by an FAA Airworthiness Directive or engine manufacturer specifications. The maintenance personnel informed the pilot about the crack. Examination of the airplane's hangar floor revealed a pool of fresh oil beneath the area where the left engine would have been positioned. Oil-based tire imprints made by the left main landing gear tire were found on the hangar floor that lead from the oil pool to the ramp outside the hangar. The pilot's logbook records showed he had received 4 hours of multi-engine flight instruction during one flight session on one day. The next day the logbook showed the pilot had received 10-hours of multi-engine instruction during 2 flight sessions. He obtained his multi-engine rating on the third day. Before these instructional entries were made there were 6 other flight instruction entries showing, 'X Country IFR.' ## Factual narrative HISTORY OF FLIGHT On October 30, 1997, at 1648 central daylight time (cst), a Beech BE-58 Baron, N472TL, piloted by a private pilot, was destroyed during a collision with the ground following a witness reported flat spin. Visual meteorological conditions prevailed at the time of the accident. The 14 CFR Part 91 business flight was operating on an IFR flight plan. The pilot and 5 passengers were fatally injured. The flight departed Macomb, Illinois, about 1610 cdt. The pilot called the Federal Aviation Administration (FAA) Flight Service Station (FSS) at 1554 cdt on the accident date. He obtained a weather briefing for an IFR flight from Macomb, Illinois, to Sikeston, Missouri. At the end of the weather briefing the pilot filed an IFR flight plan with the FSS specialist. At 1610 cdt the pilot of N472TL called the FAA's Air Route Traffic Control Center controller (controller) advising the airplane was airborne and requesting his IFR clearance. The controller issued the IFR clearance and told the pilot to climb the airplane to 5,000-feet above mean sea level (msl). During the climb the pilot called the controller and asked if he could climb the airplane to 7,000-feet msl to get above the clouds. The pilot was given clearance to climb N472TL to and maintain 7,000-feet msl. The pilot reported N472TL was level at 7,000-feet msl at 1622 cdt and was told to contact Springfield, Illinois, Capitol Airport's FAA approach controller. N472TL's pilot acknowledged and contacted the controller shortly after receiving the directive. According to the FAA radar track data, N472TL's ground speed was 152 knots at 1634:08 cdt, the altitude was reported to be 7,000 feet msl. Twelve seconds later the ground speed was reported as 81 knots. The radar track data showed the ground speed had slowed to 70 knots by 1634:32 cdt. There were no altitude reports given for the 81 and 70 knot ground speeds. At 1634:55 cdt the pilot of N472TL said, "Tower, Baron four seven two Tango Lima, we have an engine problem." At that time the reported ground speed was 152 knots and altitude was 5,600 feet msl. The controller called N472TL's pilot 2 times before the pilot responded by saying, "Baron four seven." Subsequent calls to the pilot of N472TL were not answered. The FAA controller handling N472TL said the airplane's transponder's Mode-C readout showed a rapid descent until radar contact was lost. The last radar contact was at 1635:20 cdt. At that time the reported altitude was 2,900 feet msl. Witnesses about 1/4 to 1/2-mile from the accident site said they observed the airplane in a nose level, counterclockwise rotation, spin. One witness said he saw the airplane "Real high up, sorta nose down, spinning. Then it went flat, completely level for the last half of the descent." Some witnesses reported hearing an engine sound. One of them said the engine sound stopped when the airplane was about 150 to 200-feet above ground level. The witnesses reported seeing the airplane collide with the ground and bounce into the air and then collide with the ground a second time. According to witness statements in the Sangamon County Sheriff's Office Narrative Report (report), one witness reported hearing the airplane's engine "...surge and make a loud noise. When the engine quit the plane went into a flat spin... ." The report said one witness said "...the engines were screaming...and the landing gear was up." Another witness statement said, "...the plane was low to the ground and the engine was making a high-pitched whine sound." Other witness statements in the report said the engine was running as the airplane descended in what they called a spinning or spiraling motion. PERSONNEL INFORMATION According to FAA records, the pilot had a private pilot's certificate with a multi-engine rating. The pilot's logbook (logbook) showed he had obtained his multi-engine rating in N472TL on June 17, 1996. The logbook showed his first flight in N472TL was on May 23, 1996. The logbook entry for that flight showed "Local" dual flight instruction that lasted 2.0-hours. Six logbook entries following that flight showed "X Country IFR." On June 15, 1996, the logbook showed the pilot received 4.0-hours of instruction that included 10 instrument approaches. The logbook entry showed, "IFR Appr., Single eng. appr., single eng. Ops, Vmc demo, Avionics familiarization, autopilot ops." This entry showed 10 landings were made. There were two June 16, 1996, logbook entries. One entry showed 5.5-hours of dual and the second entry showed 4.5-hours of dual. The 5.5-hour entry showed, "Vmc, feather procedures, unfeather procedure, single eng. Ops, cross country TS, avoidance (?) Radar ops." The 4.5-hour entry showed, "X country T&L." The pilot's multi-engine flight test was given on June 17, 1996. The pilot was approved for this rating. The checkride involved 3 takeoffs and landings and .5-hour of simulated instrument flight, according to the Designated Pilot Examiner's logbook entry. The remainder of the logbook entries showed all pilot-in-command flight time and showed either "X Country" or "X Country IFR" until the date of the accident. A copy of the pilot's logbook is appended to this report. AIRCRAFT INFORMATION N472TL's airframe maintenance records (records) showed it had its annual inspection completed on April 18, 1997. The records showed it had a total airframe time of 2594.1-hours and a Hobbs time of 529.1-hours. The right engine's maintenance records showed its annual inspection was completed on April 18, 1997. On that date the records showed it had 1,111.9-hours since its last overhaul. The record showed, "Run up and operational check OK. No leaks found." The records for the left engine showed its annual inspection was also completed on April 18, 1997. On that date the records showed it had 1,111.9-hours since overhaul. The record showed, "Run up and operational check OK. No leaks found." A "Service Description" form found among the maintenance records dated July 14, 1997, stated the "Owner requests crack in engine case be checked. Dye penetrated crack in left engine case, crack has continued past previous scribe mark approximately 3/8-inch. Notified owner." The maintenance records for the left engine did not show the location or length of the crack. There was no entry showing that the crack was repaired. According to the form, the tach time was 587.3-hours. This crack was not reported in the engine's July 16, 1997, maintenance logbook entry. An airplane maintenance discrepancy list dated May 30, 1996, showed one item that said "Oil leak toward rear of left engine." An entry into the left engine's logbook, showing the oil leak had been repaired, was not found. A "Service Description" form dated May 18, 1997, showed four oil leak discrepancy line items associated with the left engine. One discrepancy involving the left engine's leaking oil sump had corrective action applied: "retorqued left engine oil sump bolts." The remaining three were deferred: "Number one cylinder left engine leaking around jug base. Number 3 cylinders lower plugs appears to have oil leaking. Number 5 cylinder oil leaks from a plug hole." A review of logbook entries after the date of these maintenance comments revealed no corrective action being taken. The engine maintenance paperwork included AeroTech Publications, Incorporated's "Continental Engine adNote" sheet that said the FAA Airworthiness Directive (AD), 77-13-22, is not applicable to the left or right engine because both serial numbers were not included in the AD. A copy of this publication is appended to this report. A review of the AD showed N472TL's engines were not covered by the FAA's Airworthiness Directive (AD), 77-13-22 that covers cracks in engine crankcases. The AD states that "This A.D. does not apply to engines [IO-520-C series] bearing the following ## Aircraft - Registration: [N472TL](https://openairdocs.org/deregistered/N472TL-1999-12-07), registration cancelled 1999-12-07, S/N TH1112 (OpenAirDocs) - Reported make and model: Beech BE 58 - Registry model: [Beech 58](https://openairdocs.org/model/beech-58) (registry code 1152740) (OpenAirDocs) - Category: Airplane - Serial number: TH1112 - Airframe hours: 2750 - Engines: Continental I0-520-CB 280 horsepower reciprocating - Damage: Destroyed - Flight: Business, Part 91 - Registered owner: Charles F. Ross - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 25, 1997, 156 hours before - Departed: MQB, MACOMB, IL - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 38; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 993 total, 401 in this make and model, 911 as pilot in command, 102 in the last 90 days, 45 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 180° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: 1,600 ft broken - Temperature: 61 °F, dew point 54 °F - Altimeter: 29.00 inHg - Observed at: SPI, 17 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 19971030031129A](https://openairdocs.org/incident/19971030031129A), Oct 30, 1997: Beech 58, New Berlin, IL, Destroyed, 6 fatal. Aircraft out of c.g. limits overgross left engine thru a rod. Pilot unskilled engine out. Stalled entered flat spin (-23) while enroute form macomb airprt,… 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.