NTSB Factual Report

HISTORY OF FLIGHT

On February 16, 2014, at 1126 mountain standard time, a Beech 35-33, N400DJ, impacted mountainous terrain, ½ mile west of the Telluride Regional Airport (KTEX), Telluride, Colorado. The female airline transport certificated pilot, the flight instructor, and one airline transport pilot-rated passenger were fatally injured. The airplane was substantially damaged and a postimpact fire ensued. The airplane was registered to and operated by Arizona Cloudbusters Flying Club, Gilbert, Arizona, under the provisions of 14 Code of Federal Regulations Part 91 as a training flight. Instrument meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. The flight was originating at the time of the accident and was en route to Cortez Municipal Airport (KCEZ), Cortez, Colorado.

The time sources for the text messages, airport UNICOM, airport camera, and the Federal Aviation Administration (FAA) radar were different. The times provided in this report are as provided from each source and were not corrected or adjusted for any variation or discrepancy. For the purposes of this report, the FAA time stamp was used to determine the time of the accident.

According to the president of the Arizona Cloudbusters Flying Club, this was an instructional flight for the female airline transport pilot (ATP), to complete her airplane checkout as a new member of the flying club. Most likely the airplane departed Stellar Airpark (P19), Chandler, Arizona, full of fuel, and flew directly to KTEX. Their intention was to continue to KCEZ, refuel, and then return to P19.

A family member of the flight instructor received a text message from him at 1040 stating that they had landed in Telluride. At 1120, the flight instructor sent another text message indicating that they would be taking off in 5 minutes.

According to airport employees, the three pilots came in to the fixed base operator, took refreshments, and purchased t-shirts. They did not take any services. At 1108, one of the pilots called on the UNICOM frequency and reported that they were taxing from the ramp for departure. At 1118, they called and reported that they were taking the runway for departure. A camera positioned on the firehouse at the airport recorded the accident airplane departing runway 27 and passing the alpha 3 intersection at 1120:26. No other communications were heard on the UNICOM.

At 1120:38, the Denver Automated Flight Service Station (AFSS) contacted the Denver Center Sector 12 controller and requested a clearance for N400DJ. The Denver AFSS was communicating with the female ATP over Denver Radio when the clearance was requested. The Denver Center Sector 12 controller provided the clearance via the Denver AFSS. The flight was cleared from KTEX to KCEZ via the instrument flight rules (IFR) departure procedure to Cones, direct Dove Creek, and then direct KCEZ, at an altitude of 14,000 feet. The flight was instructed to contact Denver Center leaving 11,000 feet, and the clearance was void if they had not departed KTEX by 1130. The flight plan for the accident flight was not filed with the Denver AFSS, through the FAA, or through DUATS. Investigators were not able to determine what source the pilots used to file their flight plan and were unable to determine the entire contents of the flight plan.

Radar data provided by the FAA, identified and depicted the accident flight as the airplane started its takeoff roll at 1125:15. The last location of the airplane was recorded at 1126:27, just off of the departure end of runway 27, at an altitude of 9,000 feet mean sea level (msl). The pilots never established contact with air traffic control and an Alert Notification for a missing airplane was issued. Search and Rescue volunteers located the wreckage later that evening. There were no known witnesses to the accident.

PERSONNEL INFORMATION

Female ATP

The female ATP pilot, age 56, held an airline transport pilot certificate with an airplane multiengine land rating, a commercial pilot certificate with an airplane single engine land rating, and type certificates in the B-747, B-747-4, B-757, B-767, B-777, BA-3100, LR-Jet, and A-320. She also held a flight instructor certificate with airplane single and multiengine, and instrument airplane ratings issued on January 30, 2013. She was issued a first class airman medical certificate on February 1, 2014. The certificate contained the limitation "Must wear corrective lenses."

On the female ATP pilot's last application for medical certificate she reported 13,300 hours total time; 400 hours of which were recorded in the past 6 months. According to the flight club records, she had successfully completed the requirements of a flight review in January of 2014. Investigators did not establish the female ATP pilot's instrument currency or flight time and experience in the make and model of the accident airplane.

Flight Instructor

The flight instructor, age 48, held an airline transport pilot certificate with an airplane single-and multiengine land ratings, and a commercial pilot certificate with rotorcraft helicopter and instrument helicopter ratings. He also held a flight instructor certificate with airplane single and instrument airplane ratings issued on March 21, 2013. He was issued a second class airman medical certificate without limitations on January 8, 2013.

On the flight instructor's last application for medical certificate he reported 1,166 hours total time; 29 hours of which were recorded in the past 6 months. According to the flight club records, he had successfully completed the requirements of a flight review on June 4, 2013. Investigators did not establish the flight instructor's instrument currency or flight time and experience in the make and model of the accident airplane.

Male ATP

The male ATP pilot, age 64, held an airline transport pilot certificate with an airplane multiengine land rating, a commercial pilot certificate with an airplane single engine land and rotorcraft helicopter rating, and type certificates in the EMB-120, DHC-7, B-737, and A-320. He was issued a first class airman medical certificate on September 9, 2013. The certificate contained the limitation "Must wear corrective lenses."

On the male ATP pilot's last application for medical certificate he reported 28,000 hours total time; 300 hours of which were recorded in the past 6 months. According to the flight club records, he had successfully completed the requirements of a flight review on December 18, 2013. Investigators did not establish the male ATP pilot's instrument currency; he had completed his check out in the airplane the week prior to the accident flight.

AIRCRAFT INFORMATION

The accident airplane, a Beech 35-33 (serial number CD-40), was manufactured in 1960. It was registered with the FAA on a standard airworthiness certificate for normal operations. A Continental Motors IO-470-N11B engine rated at 260 horsepower at 2,625 rpm powered the airplane. The engine was equipped with a 2-blade, Hartzell propeller. The airplane was maintained and current for instrument flight.

The airplane was registered to and operated by Arizona Cloudbusters Inc., and was maintained under an annual inspection program. A review of the maintenance records indicated that an annual inspection had been completed on November 1, 2013, at an airframe total time of 4,509.6 hours. The last maintenance performed on the airframe was on January 28, 2014, at a total airframe time of 4,550.0 hours. An electronic tachometer was installed during this maintenance. January 9, 2014, the engine oil was changed at a reported engine total time of 76.4 hours.

The airplane was originally equipped with a Continental IO-470-J engine, rated at 225 horsepower at 2,600 rpm. According to the engine maintenance records, the Continental Motors IO-470-N11B engine installation was completed on November 1, 2013. This was accomplished under the supplemental type certificate (STC) SA09603SC, held by Hammock Aviation Services, Inc. The first page of the supplement stated, in part, that the information contained in the document "supplements or supersedes the Airplane Flight Manual only in those areas listed herein. For limitations, procedures, and performance not contained in this supplement, consult the Airplane Flight Manual."

METEOROLOGICAL INFORMATION

Infrared satellite imagery of Colorado displayed overcast clouds directly over the accident site. The cloud tops around at the accident site were around 23,000 feet. Doppler weather radar depicted light precipitation returns in the area at the time of the accident.

The National Weather Service (NWS) had issued AIRMET (Airman's Meteorological Information) TANGO for moderate turbulence below flight level 180. There were no SIGMETs issued for the area at the time of the accident.

The closest official weather observation station was KTEX, Telluride, Colorado, located ½ nautical mile east of the accident site. The elevation of the weather observation station was 9,070 feet msl. The automated weather observing station (AWOS) for KTEX, issued at 1135, reported, wind 080 degrees at 4 knots, visibility 1.5 miles with light snow, sky condition clouds broken at 1,000 feet, overcast at 1,400 feet, temperature 0 degrees Celsius (C), dew point temperature minus 1 degrees C, altimeter 30.17 inches.

Calculations of relevant meteorological data revealed that the density altitude was 9,230 feet, and the pressure altitude was 8,840 feet.

There was no record that any of the pilots obtained a weather briefing from the FAA Flight Service Station or Direct User Access Terminal System (DUATS) for the accident flight. One record for the accident airplane registration was located for a flight in Arizona on the day prior to the accident. It could not be determined which resources were used by any of the pilots prior to the flight.

Investigators were not able to determine what actions the pilots may have taken to remove any snow or ice which may have accumulated on the airplane prior to flight.

AIRPORT INFORMATION

Telluride Regional Airport (KTEX), Telluride, Colorado, is a public, uncontrolled airport located 5 miles west of Telluride, Colorado, at a surveyed elevation of 9,070 feet. The airport had one open runway, runway 9/27 (7,111 feet by 100 feet, asphalt). The airport had three instrument approaches. KTEX also had specific takeoff minimums and obstacle departure procedures. For runway 27, standard instrument flight rules (IFR) takeoff minimums applied which required one statute mile visibility. In addition, the departure procedure required that the airplane climb at 463 feet per nautical mile to 10,500 feet. In instrument meteorological conditions, the departure procedure required that the airplane climb to 12,000 feet via heading 273 degrees and intercept the 096 radial of the Cones (ETL) VOR.

WRECKAGE AND IMPACT INFORMATION

The accident site was located in steep mountainous terrain, 300 feet down from the top of a cliff band, ½ mile west of the departure end of runway 27. The accident site was at an elevation of 8,760 feet msl and the airplane impacted on a magnetic heading of 270 degrees. A coniferous tree located directly behind/beneath the main wreckage exhibited broken branches at the top of the tree.

The main wreckage included the fuselage, the left and right wing, the empennage, and the engine and propeller assembly. The airplane was impact and fire damaged. The propeller separated from the engine and was located uphill, a few feet west of the wreckage. Broken plexiglass and torn metal was located in the ground between the propeller and the main wreckage.

The fuselage consisted of the cabin, airplane seats, and the instrument panel. The cabin was impact damaged and was charred, melted, and partially consumed by fire. The instrument panel was impact and fire damaged. Many of the instruments were destroyed and neither the instruments nor radios conveyed reliable readings. The fire damage extended aft to the aft portion of the fuselage and the forward empennage.

An outboard section of the right wing and a section of the right aileron separated and were located downhill, just beneath the main wreckage. The leading edge of the right wing was impact damaged and the inboard portion of the right wing exhibited fire damage. The right flap was in a position consistent with flaps retracted. Control continuity to the right aileron was confirmed from the aileron inboard to the forward fuselage. Impact and fire damage precluded confirmation to the cockpit flight control yoke. The right main landing gear was located within the wheel well.

The left wing included the left aileron and left flap. The leading edge of the left wing exhibited impact damage consistent with contact with the tree directly behind (downhill from) the main wreckage. The inboard portion of the wing exhibited impact and fire damage. The left flap was in a position consistent with a flaps retracted position. Control continuity to the left aileron was confirmed to the forward fuselage. Impact and fire damage precluded confirmation to the cockpit flight control yoke. The left main landing gear was located within the wheel well.

The empennage included the horizontal and vertical stabilizer, the elevator, and the rudder. The empennage was not damaged. Control continuity to the elevator and rudder was confirmed to the forward fuselage. Impact and fire damage precluded control continuity confirmation to the cockpit flight control yoke and the rudder pedals.

MEDICAL AND PATHOLOGICAL INFORMATION

The female ATP was located in the front of the airplane wreckage. The coroner was not able to determine the seat positions of the two male passengers.

Female ATP

The autopsy was performed on the female ATP by the Montrose Memorial Hospital – Division of Forensic Pathology, on February 18, 2014, as authorized by the San Miguel County Coroner's Office. The autopsy concluded that the cause of death was multiple traumatic injuries and the report listed the specific injuries.

The FAA's Civil Aerospace Medical Institute (CAMI), Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological tests on specimens that were collected during the autopsy (CAMI Reference #20140002203). Tests for carbon monoxide and cyanide were not performed. Results were negative for ethanol and drugs.

Flight Instructor

The autopsy was performed on the flight instructor by the Montrose Memorial Hospital – Division of Forensic Pathology, on February 18, 2014, as authorized by the San Miguel County Coroner's Office. The autopsy concluded that the cause of death was multiple traumatic injuries and the report listed the specific injuries.

CAMI performed toxicological tests on specimens that were collected during the autopsy (CAMI Reference #201400022001). Tests for cyanide were not performed. Results were negative for carbon monoxide and ethanol. Cetirizine was detected in the urine and blood. Cetirizine, marketed as Zyrtec, is used to temporarily relieve allergy symptoms.

Male ATP

The autopsy was performed on the male ATP by the Montrose Memorial Hospital – Division of Forensic Pathology, on February 18, 2014, as authorized by the San Miguel County Coroner's Office. The autopsy concluded that the cause of death was multiple traumatic injuries and the report listed the specific injuries.

CAMI performed toxicological tests on specimens that were collected during the autopsy (CAMI Reference #201400022002). Tests for carbon monoxide and cyanide were not performed. Results were negative for ethanol and drugs.

TESTS AND RESEARCH

The wreckage of the airplane was recovered to a hangar in Greeley, Colorado. Investigators from the National Transportation Safety Board and Continental Motors, Inc., examined the engine and propeller assembly.

The engine was impact damaged and exhibited exposure to heat and fire. During the examination, the top spark plugs, valve covers, fuel pump, vacuum pump, fuel nozzles, oil pump, and fuel manifold were removed. The engine was rotated through at accessory housing. A blue spark was noted on all leads. Thumb compression, continuity, and

NTSB Probable Cause

The airplane’s failure to obtain a positive climb rate, which resulted in controlled flight into terrain. Contributing to the accident was the pilot’s inadequate preflight planning.