NTSB Factual Report

"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%), and aortic atherosclerosis.

The FAA Civil Aerospace Medical Institute prepared a Final Forensic Toxicology Accident Report. The report listed:

0.023 (ug/mL, ug/g) CYCLOBENZAPRINE detected in Blood

CYCLOBENZAPRINE present in Urine

METOPROLOL detected in Blood

METOPROLOL present in Urine

NAPROXEN detected in Urine

FIRE

Witnesses observed a fire after the airplane impacted the lake. Post accident examination of the recovered wreckage revealed no evidence of melted or charred markings consistent with an in flight fire.

TESTS AND RESEARCH

The wreckage was examined at a hangar at BKL. The flight control cables were traced and all cable breaks were in overload. The measurement of the flaps and landing gear actuators indicated that they were retracted. Both engines' fuel manifold valves contained a liquid consistent with the color and smell of aviation gasoline. Both engines produced a thumb compression at all cylinders when their crankshafts were rotated. Disassembly of both engines' vacuum pumps revealed no anomalies. Both engines' fuel pumps pumped a liquid when they were rotated. No engine or airframe pre-impact anomalies were detected.

The Insight engine monitor was sent to the Transportation Safety Board of Canada (TSB) for examination and download of the monitor's data by its manufacturer. The monitor's main circuit board passed the manufacturer's function test and its data was downloaded and entered into a spreadsheet format. The last flight's data log spreadsheet showed data for a recorded duration of 0.23 hours. The last portion of the flight's data log showed the engines were producing indications of engines consistent with a high power setting until the data stopped.

ORGANIZATIONAL AND MANAGEMENT INFORMATION

A representative of Evertz Technologies Limited gave the following description of the organization and management of the flight operations reference the accident flight:

Everair is a wholly owned subsidiary of Evertz USA Inc. Evertz

USA Inc. is a wholly owned subsidiary of Evertz Technologies

Limited. Evertz Technologies Limited is a public company listed

on the Toronto Stock Exchange. Everair provides the airplane to

Evertz USA and Evertz USA contracts out the aircraft management

and pilot services to Aitheras.

ADDITIONAL INFORMATION

In accordance with the provisions of Annex 13 paragraph 5.18 to the Convention on International Civil Aviation, the TSB participated in the investigation as the representative of the State of Design and Manufacture and provided an accredited representative to the investigation. Insight Instrument Corp. participated in the investigation as technical advisors to the TSB.

The FAA's Aeronautical Information Manual has a section on "Illusions Leading to Spatial Disorientation." The section, in part, stated:

Various complex motions and forces and certain visual scenes

encountered in flight can create illusions of motion and position.

Spatial disorientation from these illusions can be prevented only

by visual reference to reliable, fixed points on the ground or to

flight instruments. ...

Somatogravic illusion. A rapid acceleration during takeoff can

create the illusion of being in a nose up attitude. The disoriented

pilot will push the aircraft into a nose low, or dive attitude. A

rapid deceleration by a quick reduction of the throttles can have

the opposite effect, with the disoriented pilot pulling the aircraft

into a nose up, or stall attitude.

NTSB Probable Cause

The pilot experienced spatial disorientation during the inital climb causing him to lose control of the airplane.