CEN14FA141

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.

The airplane departed the airport (which is at an elevation of 9,070 ft mean sea level [msl]) for a day cross-country flight in instrument meteorological conditions. The airplane wreckage was found 1/2 mile from the end of the departure runway in steep mountainous terrain 300 ft below a cliff band at an elevation of about 8,760 ft msl, which indicates that the airplane had not obtained a positive climb rate. The airplane impacted terrain in a wings-level attitude and was damaged by impact and a postimpact fire. An examination of the airplane, engine, and related systems revealed no mechanical anomalies that would have precluded normal operation. At the high end of the airplane's estimated weight, it would have just met the airport's required climb performance to clear the terrain beyond the end of the runway. Other factors that may have been present at the time of the accident, including the weather, mountainous terrain, and snow or ice accumulation before takeoff, could have adversely affected the airplane's climb performance; however, it could not be determined to what extent these factors played a role. It is likely that the airplane did not establish a positive climb rate after takeoff and, based on the wreckage orientation, that the pilot flew the airplane directly into the terrain. It could not be determined what preflight planning the pilot conducted for the flight, including whether or not she received a weather briefing.

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. 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 valve movement were noted on all cylinders. Spark plugs exhibited normal signatures when compared to the Champion Spark Plug Chart. Fuel nozzles were free of visible contamination. The fuel manifold screen was clean and no fuel was observed within the fuel manifold. The fuel pump was difficult to rotate by hand. The spline was intact and the vanes exhibited exposure to heat and fire. The spinner was crushed and torn in a rotational direction. The propeller blades were labeled "A" and "B" for identification purposes. Blade A was bent aft approx. 90 degrees and twisted along the blade length. The blade exhibited leading edge scratching and scratches on the blade face. The trailing edge outboard portion of blade was torn in several locations. Blade B was bent aft about 90 degrees and twisted along the blade length. The blade exhibited leading edge scratching and scratches on the blade face. The throttle control lever was impact damaged and the arm was loose. Further examination of the throttle control arm exhibited that the throttle shaft was bent and the machined splines were sheared which resulted in the throttle arm disengaging. The bent shaft and sheared splines were a result of impact damage. Airplane Performance According to the Beech 33 Airplane Flight Manual, Section V Performance, the climb table uses temperature, pressure altitude, and airplane weight to estimate the climb performance of the airplane. The estimated climb performance is based upon full throttle at 2,600 rpm, a leaned fuel mixture, flaps and landing gear up, and 90 knots. The following parameters were used by investigators to estimate the climb performance: - Outside Air Temperature of 0 degrees C/32 degrees Fahrenheit - Pressure Altitude of 8,840 feet - Estimated airplane weight of 2,600 to 2,700 pounds Based upon these parameters it is estimated that the climb capability of the ranged between 700 feet and 750 feet per minute. The STC for the modified engine included an FAA approved Airplane Flight Manual Supplement. In section 5, Performance, the climb speed was listed at 90 knots and the cruise climb speed was listed at 104 knots. A climb performance chart was not provided. The actual climb performance of the airplane with the modified engine is not known. 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. 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 g