CEN21FA007

NTSB accident investigation · Beech S35 · Telluride, CO · October 5, 2020

Accident · FatalClass 3 · FieldFinal report
Date
October 5, 2020, 13:04 local (19:04 UTC)
Place
Telluride, CO · Mountainous Terrain
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N4444KBeech S35
Defining event
Enroute-climb to cruise: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA FSDO, Textron
FAA report
20201005016909A
Case key
102094

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot’s loss of control during the climb to cruise flight resulting in the airplane’s impact with terrain. Contributing to the accident was the pilot’s decision to not climb to a higher altitude before proceeding over high terrain.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Personnel issuesPersonnel issues › Task performance · PilotBeech S35: 1 caseAll aircraft: 137 casesProbable cause
Terrain: mountainous/hilly terrainEnvironmental issues › Physical environment · Contributed to outcomeBeech S35: 2 casesAll aircraft: 329 casesProbable cause
Planning/preparation: performance calculationsPersonnel issues › Task performance · PilotBeech S35: 1 caseAll aircraft: 114 casesProbable cause
Temp/humidity/pressure: high density altitudeEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeBeech S35: 1 caseAll aircraft: 278 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The airplane departed on a visual flight rules cross-country flight from a high-elevation (9,078 ft mean sea level) airport. Automated dependent surveillance-broadcast (ADS-B) data showed that the airplane proceeded east into a box canyon with rising terrain. The data showed that, before entering the box canyon, the airplane did not climb toward the west, where there was lower terrain. The data also showed that the airplane was in a gradual climb for about 8 miles into the canyon and that the airplane then made a right turn to the south just before impacting terrain. No known radio distress calls were received from the pilot. The airplane wreckage showed evidence of a nearly vertical impact. Postaccident examination found no preimpact anomalies with the airframe, engine, flight controls, and propeller. Flight control continuity was confirmed from the cockpit to all flight control surfaces. The elevation of the accident site was 11,823 ft mean sea level. The surrounding terrain to the north, east, and south was higher than the accident site elevation, with peaks ranging from about 12,000 to 14,000 ft. In addition, the calculated density altitude in the area of the accident site was about 13,604 ft, which would have diminished the airplane’s climb performance. There was no significant turbulence in the area. Thus, the pilot likely turned the airplane toward higher terrain and into the box canyon before the airplane could gain enough altitude to traverse the high terrain, resulting in a loss of control.

Factual narrative

Weight and balance calculations showed that the airplane, including the full fuel tanks, the two occupants, and all baggage, was about 300 pounds under maximum gross takeoff weight. On October 5, 2020, about 1304 mountain daylight time, a Beech S35 airplane, N4444K, was substantially damaged when it was involved in an accident near Telluride Regional Airport (TEX), Telluride, Colorado. The pilot and passenger sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airplane departed on a planned visual flight rules cross-country flight from runway 27 at TEX. Automated dependent surveillance-broadcast (ADS-B) data showed that the airplane had a normal takeoff and made a subsequent left turn toward the east. The airplane proceeded east into a box canyon and an area of rising terrain. The data showed that, before entering the box canyon, the airplane did not maneuver toward the west, where the terrain was lower than the surrounding terrain. The data also showed that the airplane was in a gradual climb for about 8 miles into the canyon and that the airplane then made a right turn to the south, which was immediately followed by the airplane’s impact with terrain. See figures 1 and 2. No known radio distress calls were received from the pilot after takeoff. Figure 1. ADS-B flight track from TEX to the accident location. Figure 2. ADS-B final portion of flight track. An autopsy on the pilot was performed by the Division of Forensic Pathology, Montrose Memorial Hospital, Montrose, Colorado. His cause of death was multiple traumatic injuries. Toxicology tests performed by the Federal Aviation Administration (FAA) Forensic Sciences Laboratory were negative for drugs and alcohol. An unmeasured amount of fexofenadine (Allegra) and its metabolite, azacyclonol, were detected in the pilot’s specimens. Fexofenadine (which is also known as Allegra) is a nonsedating antihistamine used to treat allergies and is acceptable for pilots to use. The calculated density altitude was about 13,747 ft at the accident site. The freezing level was just above 17,000 ft with no structural icing conditions. Light-to-moderate turbulence was generally indicated near the accident site. The pilot was a professional commercial air carrier pilot. The available evidence did not show the amount of high-altitude mountain flying experience that the pilot had accumulated in single-engine airplanes. The accident site was located in rugged mountainous terrain about 8 miles east of TEX. The elevation of the accident site was 11,823 feet msl. The surrounding terrain to the north, east, and south was higher than the accident site elevation, with peaks ranging from about 12,000 to 14,000 ft. The airplane wreckage showed evidence of a nearly vertical impact. Most of the forward section of the fuselage was crushed, and both wings showed impact damage across the leading edges of their spans. Flight control continuity was confirmedfrom the cockpit to all flight control surfaces. All structural damage to the airplane was consistent with ground impact. The airplane structures and flight controls showed no evidence of preimpact anomalies. Engine continuity was confirmed. Torsional break of the propeller flange was consistent with rotation at impact. All physical damage to the engine was consistent with ground impact; no preimpact anomalies were found. Two of the three propeller blades were recovered. All physical damage to the two recovered propeller blades was consistent rotation at ground impact. The third blade’s hub attachment showed impact damage, and the hub showed no evidence of a preimpact failure.

Aircraft

Registration
N4444K
Reported as
Beech S35
Category
Airplane
Serial number
D-7422
Built
1964
Airframe hours
5,516
Engine
Continental IO-520-BA, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 1, 2019 · 140 hours before
Destination
PWA · Oklahoma City, OK
Airport
TEX · Telluride Municipal
Equipment
Electronic multifunction display, Electronic primary flight display, Onboard weather, ADS-B, Angle of attack indicator, Auto-pilot, Electronic flight bag or handheld device

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
31
Injuries
Fatal
Certificates
Airline transport, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Left
Restraint
4-point
Toxicology
Performed
Flight hours
5,750 total · 130 in this make and model · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 10 knots, gusting 17
Visibility
10 statute miles
Lowest ceiling
None
Temperature
64 °F, dew point 9 °F
Altimeter
30.49 inHg
Turbulence
Unknown
Observed at
TEX, 8 nm away

Docket · 10

The files NTSB released with the investigation on December 1, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.8 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.