NTSB Factual Report

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: allright if you're just off of smartt field suggest you make a right turn as soon as you can make a right turn there's traffic inbound opposite direction on a v o r one eight

0953:55

N9047V: okay turn right (unintelligible)

0953:57

St. Louis TRACON: november nine zero four seven victor squawk two five five seven

0954:01

N9047V: two five five seven four seven victor

0954:03

St. Louis TRACON: twin Cessna six eight juliet traffic uh i believe just called me twelve o clock and two miles it is a uh baron just departed uh off of smartt he is making a uh right turn as we speak

0954:15

N968J: six eight juliet

0954:33

St. Louis TRACON: baron uh nine zero four seven victor remain outside of class bravo airspace i did see a target on you momentarily and i've lost it now remain outside of class bravo squawk two five five seven and you're uh you're eastbound now off of uh smartt field is that correct

0954:55

St. Louis TRACON: baron nine zero four seven victor saint louis

0955:19

St. Louis TRACON: baron nine zero four seven victor saint louis

0955:24

St. Louis TRACON: nine zero four seven victor saint louis

0955:29

St. Louis TRACON: nine six six uh nine six eight juh juliet would you see if you you can talk to a nine zero four seven victor please

0955:36

N968J: baron four seven uh victor nine uh six eight juliet

0956:17

St. Louis TRACON: november nine zero four seven victor saint louis

0956:17

St. Louis TRACON: november nine zero four seven victor are you on this frequency

A copy of the FAA ATC transcript is appended to this factual report.

WRECKAGE AND IMPACT INFORMATION

The National Transportation Safety Board's (NTSB) on-scene investigation began on August 31, 2000.

The aircraft impacted the Mississippi River near the branch of the Illinois and Mississippi Rivers. A global positioning system (GPS) receiver recorded the approximate position of the wreckage as 38-degrees 57-minutes 54.30-seconds north latitude, 90-degrees 25-minutes 3.90-seconds west longitude.

A local scuba-diving club conducted an underwater search and salvage operation with the assistance of the United States Coast Guard. Approximately 40-percent of the airplane was recovered.

The recovered portions included the outboard section of the left wing, the left and right engine nacelles, the instrument panel, the upper portion of the fuselage, occupant seats, and both engines.

All identified control cable fractures were consistent with tension overload.

Left engine crankshaft and valve train continuity was established by rotating the crankshaft through the accessory gear section. There was thumb compression on all cylinders. The fuel control unit and fuel manifold screens were clear of debris. Both magnetos produced spark on all leads when rotated in a test stand.

Right engine crankshaft and valve train continuity was established by rotating the crankshaft through the accessory gear section. There was thumb compression on all cylinders. The fuel control unit and fuel manifold screens were clear of debris. Both magnetos produced spark on all leads when rotated in a test stand.

No anomalies were found with the recovered portions of the airplane that could be associated with a pre-impact condition.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot at the Madison County Morgue, Edwardsville, Illinois, on August 31, 2000.

A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aeromedical Institute, Oklahoma City, Oklahoma.

The toxicology results for the pilot were:

* No Ethanol detected in Muscle

* No Ethanol detected in Brain

* 10 (mg/dL, mg/hg) Ethanol detected in Blood

* 10 (mg/dL, mg/hg) Acetaldehyde detected in Blood

* No drugs detected in Liver

ADDITIONAL DATA/INFORMATION

Parties to the accident were the FAA, Raytheon Aircraft Company, and Teledyne Continental Motors.

The wreckage was released to a representative of the insurance company on October 17, 2000.

NTSB 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.