Pilot Debrief

BEECH S35 near Telluride, CO — 2020-10-05

Final reportCEN21FA007
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Date
2020-10-05
Location
Telluride, CO, USA
Airport
TEX
Aircraft
BEECH S35
Registration
N4444K
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Climb

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.

Contributing factors

Contributing to the accident was the pilot’s decision to not climb to a higher altitude before proceeding over high terrain.

NTSB narrative

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.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot did not maneuver west into lower terrain before entering the canyon.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 10 docket documents
View NTSB final reportView NTSB docket

Docket documents10

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