NTSB Factual Report

HISTORY OF FLIGHT

On June 21, 1996, at 1448 mountain daylight time (all times are mountain daylight time unless otherwise noted), a Beech 58, N94ZR, impacted the ground while maneuvering approximately 5 miles southeast of Castle Rock, Colorado. The private pilot and his three passengers received fatal injuries and the aircraft was destroyed. The flight was operating under Title 14 CFR Part 91 and a visual flight rules flight plan was on file. Instrument meteorological conditions prevailed in the accident area for this personal flight which originated at 1302 from Albuquerque, New Mexico.

At 1250, the pilot of 94ZR called Albuquerque Clearance Delivery and requested a VFR (visual flight rules) departure with flight following to Denver, Colorado, Centennial Airport, with a cruise altitude of 11,500 feet msl (above mean sea level). He was issued a departure radio communications frequency and VFR transponder code.

The aircraft taxied to runway 17 at Albuquerque International Airport and departed for Centennial Airport at 1302. At 1359 Albuquerque Center (ARTCC) issued the pilot of N94ZR a frequency change to Denver ARTCC who gave the pilot the Trinidad, Colorado, altimeter and issued a hazardous weather bulletin for Utah, Colorado, and New Mexico.

At 1418, Denver ARTCC passed N94ZR to Pueblo, Colorado, Approach Control for transit through their area. Approach Control issued the Pueblo altimeter to N94ZR and advised them of a weather area northeast of Pueblo moving northeast. N94ZR advised that he saw the weather on his radar. Approach Control asked N94ZR if he was going west of the weather and the pilot responded that he was going to Centennial Airport.

At 1428, N94ZR was passed to Colorado Springs Approach Control (radar south) and was issued the Colorado Springs altimeter. At 1432 the pilot was advised of a weather area north of Colorado Springs Airport. He answered that he observed the weather area and would deviate as necessary. A frequency change to Colorado Springs Approach Control (north radar) was given at 1439 and at 1442, N94ZR requested a descent to 9,500 feet msl to stay below the weather. The controller advised N94ZR to maintain VFR.

Radar service with Colorado Springs Approach Control was terminated at 1444 and the pilot was issued the appropriate Denver Approach Control frequency.

While the departure radar controller was coordinating with Denver ARTCC via land line, N94ZR attempted to contact Denver. A second call was made by the aircraft about 25 seconds later; however, the controller was again engaged in land line coordination.

At 1447, N94ZR called Colorado Springs Approach Control (north radar) and said he was turning south to avoid the weather. The actual transmissions concerning the event are as follows: "BARON NINE FOUR ZULU ROMEO I NEED TO DEVIATE AROUND THIS THING I'M GONNA HAVE TO TURN BACK TO THE SOUTH." The controller responded: "NINE FOUR ZULU ROMEO ROGER YOU'RE RADAR CONTACT AND UNDERSTAND YOU'RE GONNA BE MAKING WHAT A LEFT HAND TURN BACK TO THE SOUTH." The response from the aircraft was: "MAKING A RIGHT TURN BACK TO THE SOUTH." The controller responded "FOUR ZULU ROMEO ARE YOU ABLE TO MAINTAIN VFR CONDITIONS." The response from the aircraft to this inquiry was: "I JUST LOST (UNINTELLIGIBLE)." At 1448, the controller attempted to contact N94ZR but the pilot did not respond.

The approach controller then contacted Denver ARTCC to have them look for the transponder code of N94ZR and an air taxi transiting the area was asked to attempt contact and listen for an ELT signal. Neither were successful.

At 1452, missing aircraft procedures were initiated and the aircraft was located approximately 5 miles southeast of Castle Rock, Colorado, by the Douglas County Sheriff's Department at 1720.

PERSONNEL INFORMATION

According to Federal Aviation Administration (FAA) records, the pilot held a private pilot certificate with ratings in single engine and multiengine land and an airplane instrument certificate. His log indicated that his original certificate was issued September 10, 1994, and he added a multiengine rating on July 15, 1995. His instrument certificate was issued January 15, 1996. His log reflected that he had 11 hours of actual instrument flight time.

The pilot held a second class medical certificate with the limitation that he was required to wear corrective lenses for distant vision. His medical certificate was issued December 20, 1995.

The investigation provided no information whether or not corrective lenses were being worn at the time of the accident.

Flight experience documentation was based on extraction of information from the pilot's log and is detailed in this document on page 3. The last entry in the log was June 18, 1996. Flights which took place between that date and the date of the accident are unknown.

Between January 23,1995, and February 3, 1995, the pilot attended a Baron 55/58 pilot initial training course at Flight Safety International, Wichita, Kansas. The training was for VFR only and the record of training is attached.

AIRCRAFT INFORMATION

This aircraft, N94ZR, serial number TH-1709, was issued a Standard Airworthiness Certificate in the normal category on January 26, 1994. The aircraft was purchased from Cutter Flying Service, Albuquerque, New Mexico, who supplied the attached equipment list.

An item of equipment on board the aircraft of special interest due to the nature and circumstances of the accident, was the weather radar. The aircraft was equipped with a Bendix/King RDS 81, color display, digital weather radar. The specifications of this radar are as follows:

Peak Output 1kw nominal Antenna Size/Type 10 inch flat plate Antenna Scan Angle 90 degrees Pulse Width 7.5 to 15.4 usec, range dependent Altitude 55,000 feet unpressurized Temperature Range -55 to +70 degrees C Stabilization + or - 25 degrees combined pitch and roll Tilt 15 degrees up and 15 degrees down Display Ranges 10,20,40,80 NM

As noted in the communications transcript, the radar was being used by the pilot when he over flew Pueblo, Colorado, approximately 80 miles south of the accident site. It is not known if the unit was in use at the time of the accident.

METEOROLOGICAL INFORMATION

Albuquerque, New Mexico, weather at the time of departure was:

Clear skies with 10 miles visibility. The temperature/dew point was 92/43 and the wind was 270 degrees at 7 knots with an altimeter setting of 30.01.

Colorado Springs weather when the aircraft passed overhead was:

Measured 900 feet broken clouds, 10 miles visibility, temperature 67 degrees, dew point 47 degrees, wind from 320 degrees at 21 knots with gusts to 30 knots, and an altimeter setting of 30.19. Remarks were that the peak wind was 44 knots with a thunderstorm in progress.

Weather at Centennial Airport, which was the intended destination of the flight, located approximately 19 nautical miles northwest of the accident site was:

Broken clouds at 6,000 feet, overcast skies at 12,000 feet, wind from 260 degrees at 8 knots and an altimeter setting of 30.17. Remarks were that there were rain showers in progress and lighting was sighted to the southwest.

The weather recording facility nearest the accident site was the United States Air Force Academy located approximately 15 miles southwest. Their observation during the time when the accident occurred was:

Two hundred feet sky obscured with one mile visibility in thunderstorm activity. The temperature/dew point was 59/55 degrees, the wind was from 240 degrees at 24 knots with gusts to 27 knots and the altimeter setting was 30.21.

At 1402, Denver ARTCC issued a hazardous weather bulletin covering Utah, Colorado, and New Mexico. It is unknown if the pilot of N94ZR tuned to the appropriate frequency and listened to that information. At the time, N94ZR was in contact with Denver ARTCC in the vicinity of Trinidad, Colorado.

Two ground witnesses who did not see the aircraft, but heard an aircraft overhead, said the wind was extremely strong with heavy rain and nearly no visibility. These two witnesses, who would not provide a written statement and wished not to be identified, lived in the vicinity of the accident site and were the persons who assisted the Sheriff's Department in accessing the site.

During the investigation, information was provided by a technician at a satellite television reception station, located approximately 3 miles northwest of the accident site, that their reception equipment was damaged by the storm during the time period when the accident took place.

COMMUNICATIONS

A transcript of pertinent communications between controlling agencies and the aircraft is attached.

WRECKAGE AND IMPACT INFORMATION

The accident site was approximately 7,000 feet above mean sea level (msl), in rolling hills, with an up slope to the east. Vegetation was scrub oak and pasture land.

Wreckage scatter extended for a distance of 630 feet on a base course of 170 degrees magnetic heading. Total disintegration of the aircraft occurred during the impact sequence. (See attached photographs). All portions of the aircraft were accounted for except for two propeller blades. These two blades were found in the scrub oak on the east side of the scatter pattern by a rancher approximately 7 months after the accident.

Initial impact occurred against an up slope and consisted of a 15 foot scar followed by a 30 foot long 3 foot deep gouge. The gouge area contained a propeller spinner, propeller rings and a propeller blade. The gouge curved to the west and a path extended on a course of 170 degrees through a stand of scrub oak.

The stand of scrub oak extended for approximately 30 feet. In the stand, two portions of the left wing tip and the left aileron were found. In an open area beyond the stand of scrub oak, portions of the forward fuselage and wings were scattered over a 300 foot area. The left engine was located in a stand of trees 283 feet down the track and 23 feet left of the track centerline. Leaves and other vegetation on which the engine came to rest were scorched and burned.

The right engine with a portion of right wing attached was located against a fence post 415 feet down the track and 39 feet right of the track centerline. The vegetation around where the engine came to rest was scorched and burned.

The propeller assembly had separated from both engines due to a shaft fracture at the number one bearing.

The last 300 feet of the wreckage scatter was mostly pasture land. The items located the furthest from the initial impact point were two oxygen bottles and the body of one of the occupants. The other three occupants were found midway along the scatter pattern track.

Details of the engines and panels and controls are as follows:

Left Engine. The engine core was intact. The fuel screens were clean and the spark plug electrodes were oval and light gray in color. No evidence was found to indicate a preimpact failure or malfunction.

Right Engine. The right engine core was intact. The finger strainer was clean and the fuel distribution assembly was broken open and the screen had been contaminated by dirt and debris during breakup. The spark plug electrodes were oval and light gray in color. No evidence was found to indicate a preimpact failure or malfunction.

Propellers. Both propeller assemblies had separated from their respective engines and had shed all blades from the hubs. The blades were characterized as generally twisted toward low pitch with chordwise scratches and gouges. Both hubs were fractured.

Altimeter. The altimeter read 5,910 feet at 30.16 inches of mercury. It was an encoding altimeter with the face intact and the barrel partially crushed.

Switch Panel. Battery-on. Left alternator-off. Right alternator-on. Avionics master-off. Propeller sync-missing. Left pitot heat-on. Right pitot heat-missing. Fuel vent-on. Stall warning heat-on. Propeller de ice-on. Windshield heat-on. Left Magneto-off. Right magneto-between off and left.

Left Instrument Panel. VGI-missing. Compass-missing. Altimeter-see above, not found in panel. Airspeed-230 knots. Turn and bank-standard rate turn left wing down. HSI-160 degrees with the needle one bar to the right and two off flags in view. The heading bug was on 070 degrees. Instrument air-0. One manifold pressure gauge-35 inches, broken from panel.

All other gauges and engine accessories were damaged beyond readability and functional testing.

The throttle quadrant was broken free from all other parts of the aircraft. The propeller, throttle, and mixture controls were in the mid range. All had been damaged.

Rudder trim was half way between neutral and full left. Aileron trim was neutral. Both had incurred damage.

The right forward panel was damaged beyond readability.

The ailerons, elevators, rudder, and flaps were accounted for. Due to the disintegration of the aircraft, flight control continuity could not be established.

MEDICAL AND PATHOLOGICAL INFORMATION

An Autopsy was done on the pilot by Doctor Ben Galloway for the Douglas County, Colorado, Medical Examiner. Details of that report may be obtained from Douglas County.

A toxicological study was conducted on the pilot by the Federal Aviation Administration, Civil Aeronautical Medical Institute. The report is attached and provides information that carbon monoxide could not be tested due to a lack of a suitable specimen, there was no cyanide detected in the blood, and that varying amounts of ethanol were detected in submitted specimens. They noted that the ethanol detected could have been a result of postmortem production.

ADDITIONAL DATA/INFORMATION

The wreckage was released to Beegles Aircraft Services, Greeley, Colorado, for removal from the sight to storage on June 22, 1996. It was released to the owner's representative on July 1, 1996.

NTSB Probable Cause

failure of the pilot to maintain sufficient altitude and/or clearance from terrain, while reversing course to exit adverse weather conditions. Factors relating to the accident were: the adverse weather conditions (thunderstorm, low ceiling and reduced visibility), the pilot's inaccurate weather evaluation, and his inadvertent flight into known adverse weather conditions.