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Crash of a Beechcraft BeechJet 400A in Telluride

Date & Time: Dec 23, 2015 at 1415 LT
Type of aircraft:
Operator:
Registration:
XA-MEX
Survivors:
Yes
Schedule:
Monterrey – El Paso – Telluride
MSN:
RK-396
YOM:
2004
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7113
Captain / Total hours on type:
1919.00
Copilot / Total flying hours:
8238
Copilot / Total hours on type:
1412
Aircraft flight hours:
5744
Circumstances:
The pilots were conducting an international chartered flight in the small, twin-engine jet with five passengers onboard. Since the weather at the destination was marginal, the flight crew had discussed an alternate airport in case weather conditions required a missed approach at their destination. As the airplane neared the non-towered destination airport, the flight crew received updated weather information, which indicated that conditions had improved. Upon contacting the center controller, the crew was asked if they had the weather and NOTAMS for the destination airport. The crew reported that they received the current weather information, but did not state if they had NOTAM information. The controller responded by giving the flight a heading for the descent and sequence into the airport. The controller did not provide NOTAM information to the pilots. About 2 minutes later, airport personnel entered a NOTAM via computer closing the runway, effective immediately, for snow removal. Although the NOTAM was electronically routed to the controller, the controller's system was not designed to automatically alert the controller of a new NOTAM; the controller needed to select a display screen on the equipment that contained the information. At the time of the accident, the controller's workload was considered heavy. About 8 minutes after the runway closure NOTAM was issued, the controller cleared the airplane for the approach. The flight crew then canceled their instrument flight plan with the airport in sight, but did not subsequently transmit on or monitor the airport's common traffic advisory frequency, which was reportedly being monitored by airport personnel and the snow removal equipment operator. The airplane landed on the runway and collided with a snow removal vehicle about halfway down the runway. The flight crew reported they did not see the snow removal equipment. The accident scenario is consistent with the controllers not recognizing new NOTAM information in a timely manner due to equipment limitations, and the pilots not transmitting or monitoring the common traffic advisory frequency. Additionally, the accident identifies a potential problem for flight crews when information critical to inflight decision-making changes while en route, and problems when controller workload interferes with information monitoring and dissemination.
Probable cause:
The limitations of the air traffic control equipment that prevented the controller's timely recognition of NOTAM information that was effective immediately and resulted in the issuance of an approach clearance to a closed runway. Also causal was the pilots' omission to monitor and transmit their intentions on the airport common frequency. Contributing to the accident was the controller's heavy workload and the limitations of the NOTAM system to distribute information in a timely manner.
Final Report:

Crash of a Learjet 45 in Telluride

Date & Time: Jan 3, 2009 at 1659 LT
Type of aircraft:
Operator:
Registration:
N279AJ
Flight Type:
Survivors:
Yes
Schedule:
Scottsdale - Telluride
MSN:
45-279
YOM:
2005
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3520
Captain / Total hours on type:
831.00
Copilot / Total flying hours:
3520
Copilot / Total hours on type:
831
Aircraft flight hours:
2338
Circumstances:
The airplane and two-person crew departed on a positioning flight. The pilot-in-command was not flying the airplane and sat in the right seat. The second-in-command was the pilot flying and sat in the left seat. The accident occurred on the second attempt to land at the destination airport on a snow-covered runway. While descending for the airport, the pilot not flying the airplane called the runway in sight. After assessing that they were too high the pilot not flying convinced the pilot flying to circle the airplane down to land on the runway. Circling at speeds greater than allowed by the approach categories, the crew performed a 360-degree turn to align themselves with the runway. The pilot flying did not have the runway in sight, and was verbally assisted by the pilot not flying. Both pilots stated that they were aligned with the center of the runway. During the flare to touchdown the pilot flying reported an unexpected gust of wind from the left requiring a correction. The airplane touched down about 20 feet off and to the right of the runway edge. Substantial damage was sustained to the airplane's wing and fuselage.
Probable cause:
The failure of both pilots to positively identify the runway prior to landing.
Final Report:

Crash of a Cessna 421B Golden Eagle II near Telluride: 1 killed

Date & Time: Jan 2, 2000 at 0950 LT
Operator:
Registration:
N421CF
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Montrose - Las Cruces
MSN:
421B-0513
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3700
Captain / Total hours on type:
200.00
Aircraft flight hours:
3154
Circumstances:
The non-instrument rated private pilot departed Montrose, Colorado, southbound in a Cessna 421B. According to radar data, the airplane climbed from 14,300 to 16,600 feet msl at a rate of 1,792 fpm. The data shows that 19 seconds later, the airplane lost 4,000 feet of altitude, or descended at a rate of 12,631 fpm. The airplane then climbed back to 13,300 feet msl at a rate of 1,448 fpm, and then disappeared from radar. The airplane crashed in snow covered mountainous terrain. Snowmobilers, who were in the vicinity of the impact site at the time of the accident, said that snow showers made visibility less than 1/2 sm. A pilot departing Telluride Regional Airport (located 33 nm at 045 degrees from the crash site), on a heading of 300 degrees, at approximately 1015 said that it was clear right over Telluride. He said that as he climbed out, he got into weather at 12,000 feet msl, and didn't break out until 22,000 feet msl. He also said that he experienced no icing or turbulence during his climb out.
Probable cause:
The non-instrument rated pilot's intentional flight into IMC, and his subsequent spatial disorientation that resulted in an inadvertent stall. A factor was the snow showers weather condition.
Final Report:

Crash of a Swearingen SA26AT Merlin IIB in Telluride

Date & Time: Dec 29, 1987 at 1707 LT
Type of aircraft:
Operator:
Registration:
N4468M
Flight Type:
Survivors:
Yes
Schedule:
Brenham – Telluride
MSN:
T26-119
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3344
Captain / Total hours on type:
200.00
Circumstances:
During a visual approach, the pilot said he encountered 2,000 fpm downdrafts. The pilot stated he added power and executed a normal approach at 120 knots, compensating for downdrafts/crosswinds. After touchdown, the pilot said he did not get a beta light on the right engine. He stated he brought the power levers 'behind the gate into reverse.' The aircraft drifted left. The pilot said he corrected with brakes and nosewheel steering. He applied takeoff power and the aircraft veered right, and ran off the right side of the runway. The aircraft collided with a dirt bank and then trees. Three tire skid marks were observed on the right side of the runway. A pilot-witness said winds were gusting 22-25 knots, variable from 130-220°. He said the aircraft landed fast and long. Examination of the engines and props revealed no evidence of malfunction. The engine manufacturer recommends prop reverse not be used on icy runway or when beta light on one engine does not illuminate. The aircraft manufacturer advises that nosewheel steering should not be used at speeds below 40 knots. All six occupants were injured, two seriously.
Probable cause:
Occurrence #1: loss of control - on ground/water
Phase of operation: landing - roll
Findings
1. (f) weather condition - crosswind
2. (f) weather condition - gusts
3. (f) planned approach - improper - pilot in command
4. (f) airspeed - excessive - pilot in command
5. (c) reversers - improper use of - pilot in command
6. (c) nosewheel steering - improper use of - pilot in command
7. (c) directional control - not maintained - pilot in command
8. (f) aborted landing - delayed - pilot in command
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Occurrence #2: on ground/water encounter with terrain/water
Phase of operation: landing - roll
Findings
9. Terrain condition - dirt bank/rising embankment
10. Object - tree(s)
Final Report: