N472TL

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 serial numbers: -C 561476 and up... ." The engine that suffered the mechanical failure was an IO-520-CB whose serial number was 571476. A copy of the AD is appended to this report.

WRECKAGE AND IMPACT INFORMATION

N472TL's wreckage was located in a plowed field about 300-feet east of Sangamon County, Illinois, County Road 10 and about 1,500-feet south of County Road 4.25S. The wreckage was confined to the immediate location of N472TL. Small pieces of side window were scattered on the west and east sides of the airplane. The airplane's heading was on a magnetic heading of about 045-degrees. N472TL's fuselage was crushed upward along its longitudinal axis. The empennage separated from the fuselage and both elevator trailing edges were buried in the dirt.

Flight control continuity was established for all 3 axis'. The flaps and landing gear were in the retracted position. Throttle, propeller and mixture control cable and rod continuity were established for both engines. The fuel selector functioned and the lines from it were not blocked. Air was blown through each position without restriction.

An oil residue was found on N472TL's left engine's nacelle, rear half of the left wing in the immediate area of the nacelle and fuselage, the left side of its fuselage cabin area and the horizontal stabilizer and elevator. One propeller blade was above ground. Oil residue covered its leading edge. The remaining 2 blades were buried in the soil. The blades appeared to be in a low pitch, high RPM, position. The linkage on the propeller governor showed the propeller to be in the high RPM setting. Examination of the left engine's cowl access door and inside the top cowling revealed they were also oil soaked. The cowl access door to the engine's oil dip stick was open and the dip stick was missing. The dip stick was not found after a search of an approximate 200 yard arc around the airplane. There were no rub or deforming marks on the inside of the access door. The oil filler neck ...