Accident Review Telluride S35 Bonanza

[Music] the preliminary report for the crash of a veteo s35 bonanza is out and it's nothing short of a tragedy so stick with us at flywire as we're going to try to look for some lessons learned from this mishap [Music] hi i'm scott purdue today on flywear we're going to review the tragic mishap of an s35 that took the life of a newly wedded couple on the face of it the mishap seems to be a simple case of a flatlander flying in the mountains at high density altitudes it only took eight minutes from takeoff to tragedy but uh to a tragic end but i think it's a little more complex than that for sure this was a case of control flight inter-terrain or it seems to be one important note about the preliminary report the faa and the ntsb did travel to this mishap site they recovered the wreckage they recorded the takeoff time as 1304 mountain daylight time and the couple had just flown a sightseeing trip uh prior to this mishap flight and the adsb record shows that it landed eight minutes before the faa says the mishap takeoff occurred i don't think that's what happened but the adsb for the mishap flight has the takeoff time at 1355 and i think that's probably more likely about an hour after landing from the first flight this may seem like a small point but the previous but the previous flight in my opinion is very important to the actual mishap flight first some background on the airport and the young folks involved in the accident telluride regional airport colorado is nine thousand seventy feet above sea level and the east west runway is seven thousand one hundred and eleven feet long the airport is on a thousand foot mesa and it experiences strong virtual turbulence a vertical turbulence with any winds for this mishap the winds were out of the west at 10 gusts 17. the notes for the airport recommend that you land on runway 9 and take off on 2-7 kind of down valley there is an obstacle departure procedure which has you departing on runway two seven climbing to twelve thousand feet heading two seven six basically the runway heading to intercept a radio to the etl vor and for air aircraft southeast southeastbound they should continue climbing hold to 14 200. it's pretty high high mountains there are numerous takeoff obstacle notes and for a visual climb over the airport the departing pilot should climb in visual conditions to cross the airport westbound at or above 14 300. in short this is a challenging airport with high terrain in all quadrants i'm going to show it one to 24k topo map in a second where the terrain in the accident area was over 13 000 feet i don't know about you but nowadays for me that's sort of high the couple flew the airplane to telluride just a few days prior to the accident and got married apparently they had been there earlier in the summer and decided it was so pretty that they wanted to elope in the bonanza in telluride the young man who was piloting the airplane had just bought the s-35 in april 2020 and they lived in florida or about then they lived in florida and the pilot worked for united he had been a graduate of emba riddle university in florida and spent some time as a flight instructor ostensibly the pilot was a flatlander and he's from new england and the s35 was new to him as well okay on the best of days that i o i o 520 powered airplane would have been able to do on maybe 500 feet per minute at the density altitudes where they were on the best of days but on the day of the mishap the couple took a sightseeing flight first apparently with another couple then they refueled and topped off the tanks and then headed for home the first stop was supposed to be 600 nautic miles downrange the first flight was just after 11 am mountain time and the path the sightseeing flight followed was not exactly the same as the mishap flight i computed the density altitude for the first flight at 10 hundred and for the second the d.a was ten thousand nine hundred as i said the winds were out of the west gusting ten guests seventeen in my opinion the difference between density altitude for the two flights was not statistically significant and wasn't a factor the original thought was that it was a factor the perimeter report estimated the gross weight of the mishap flight to be about three thousand pounds probably about the same perhaps a little less than the first sight sightseeing flight with the couple that they went with again i don't think this was i don't think this was a factor either comparing the climb rate between the two flights for the first eight minutes showed the performance to be almost exactly the same very close to 350 feet per minute average the winds from the west were not very different either between the two flights most likely there was turbulence but not significant downdrafts up into ingram basin where the implant impact point is so let's take a look at that first flight the missile pilot flew over the exact same terrain on the return of the sightseeing flight and that flight path for the mishap aircraft followed uh how it followed the first pass first flight okay this is the adsd 80sb data and appears to be very good fidelity the flight path shows the s35 taken off to the west followed by an immediate left turn to the east the path wanders around the center of the valley and then bears to the right to avoid going over town a telly ride one of the notes for local operations from there the aircraft heads to the left side of the valley just before the thousand foot cliff at ingram falls and then the pilot executes a right turn keeps climbing and turns south on his return from the sightseeing trip the pilot flies very close to the outbound path of the second sortie at something like 13 000 feet over the bridge line i think that likely that the pilot was scoping out the terrain for his second flight thinking that would be a more direct way home don't know that for sure but i think that's what happened the difference can readily be seen by the flight path followed by the mishap aircraft on the second sortie let's take a look at that one this time the pilot dipped slightly to the south and then hug the left side of the valley instead of the right presumably this was to offer him an out by turning right if he needed to which he had done on that first first sorting the pilot probably believing he had a good handle on the performance of the s35 headed over ingram falls and into the basin but his average climb rate at this point was just over 200 feet per minute okay and that's pretty significant once past the falls it looks like he decided to turn around when he saw the 13 000 foot ridge line in front of him whether that was a shocker or not i don't know but i suspect that it was that it didn't look so bad when he was at altitude looking down versus close to the ground looking up let's talk for a second about that ridgeline to his east it rose over two thousand feet in about a mile the s35 was flying about a mile and a half a minute about but only climbing an average of 200 feet per minute in this part of the flight once that on top of the falls the pilot had little less than three miles of space to climb over that ridge i mean before he hit the edge of that so he didn't much room doing the math at best he would only achieve another 400 feet over that distance so turnaround was his only choice at that point if he wanted to stay flying the adsb data does not actually reveal the indicated airspeed all it works is ground speed so extrapolating the winds that's likely that he had about a 10 knot tailwind for this last flight his speed varied quite a bit as with i can show this and and the data here that it was in in general is around that vy of 85 knots most of the time once past the falls and well into the narrow ingram basin his speed began to slow down from pictures of the aircraft it appears the flaps were down and perhaps the pilot lowered them to give him an extra margin above stall we will never know the airplane turned sharply to the right and the edsb record shows a ground speed of 74 knots can i compute the stall speed at 11 4 and 30 degrees of bank to be about 68 knots so with 10 knots of ground speed subtracted as i indicated would have been about 64. you can see the 80s bit hit here the vertical speed had developed to uh minus 1472 feet per minute big decent it looks like the medium was stalled to me the next 80 sb hit shows a ground speed of 63 knots and now the flight path is perpendicular to the estimated wind and the vertical speed had increased to minus 4480 feet per minute it is definitely in a stall and headed downhill the premier league report describes the aircraft impact as crush damage on the nose and the leading edge of the wing consistent with a near vertical impact at a fairly high rate of speed the only the only way you could have done that especially with the nose is at a fairly high rate of speed there had been some there there has been some speculation that the pilot was attempting a forced landing on the terrain the flaps down but i don't think that appears to be the case the aircraft stalled and spun in it is possible that the pilot had realized that he must execute 180 degree turn to exit the valley but his speed control was erratic and much too slow to begin with he had opted to use most of his energy to climb even if it only produced a 200 foot per minute climb deciding to turn exceeded his energy budget for the situation he was in to lose a young couple just beginning their lives together um it's just simply a tragedy there's tragedy there's no other way to say it and we have to ask ourselves what we could do if ever if we were ever thrust into a similar situation pun intended maybe i'll be honest with you i'm a flatlander i've flown in a mountainous terrain quite a bit but i've always done it in jets where you know with excess thrust where da was just not a same issue don't be wrong data da still affects you but your margins are quite a bit larger to start with i do have a quite a bit of time though experiencing quite a bit experience bfm in the ground okay flying fighters i know that you need that energy i know that you need energy that's speed and altitude and turning room the other thing i know is that judging your closure rate to the rocks is a very hard thing to do even if you've been doing it for years okay it's something you have to be very cognizant of it's hard and a lot of people have not worked it out in the ga world when i've flown at similar da's to this accident i usually lean the engine on the run and execute a longer ground run and then i plan a higher liftoff speed than the book solution gives me you frankly you accelerate faster on the ground and and that's just a reality for me speed is literally life as an example several times i've left flagstaff arizona which is 7000 msl with da's above 10. i opt for a circle overhead the airport to get to an altitude that will clear the ridge to the west and even going eastbound the terrain gradually rises but it rises pretty high pretty well so a normally aspirated engine that's lost a considerable amount of power in those situations i don't take the high da's lightly density altitude was at the heart of this accident but it wasn't the proximate cro cause of the crash it was a stall spin and not a controlled flight in terrain it appears that the best option in this case probably would have been to try a forced landing and walk away the mishap pilot did not manage his energy well he mistakenly believed his airplane could outline the terrain and to put it simply he bet his life on that during the climb he during the the climb out he attempted to max climb his aircraft and sacrifice speed for altitude and frankly got neither one of those things this is the biggest effect that ida has on you this left him at slow speed close to the ground in a very narrow basin with the absolute need to execute 180 degree escape maneuver if he wanted to stay flying regardless of his flying experience doesn't matter he reverted to the ulti human tendency to pull back and climb that's what he tried to do but the physics was not going to allow that so for me the takeaway from this mishap is that uh iron before i venture forth into some serious mountain flying i intend to take a mountain flying course with an instructor with experience okay i've read books about the mountain read the books about mountain flying you know it makes sense to me but i'm reluctant to go there without someone smarter than i am showing me the right way to do it okay i think that that's the best way to mitigate the risk and always leave yourself and out when i was in the air force i was fortunate to attend many red flags in nevada a little bit of a density altitude issue especially where we're flying on the range but i remember during the mass brief before mission the red flag commander would have the final say and he would get up there on the on the stage and tell us don't do anything dumb different or dangerous the point being that you should train for it before you do it for real high altitude flying is unforgiving and if it's different in other words you don't do it or you don't do it very much train for it so i hope we can all learn something from this accident things can go horribly wrong in a very short amount of time and i think we have to think about these things these situations and talk about them on the ground and plan out a course of action and don't plan on having as much inner very much energy to execute it and maybe think about the impact of a low essay would give you situational awareness on the situation as well so a good pilot is always learning and he works hard to mitigate the risk mitigate the risk there is risk in flying so let's fly safer mitigate that risk uh if you like the video please hit the like and subscribe this is i'll put it over here this is what it looks like and you can see it down there if you hit the bell you'll get notifications in the next video if you don't like it that's fair just do me a favor and tell me what you don't like about it so i i have a chance at fixing it i want to say thanks to my patreon supporters and if you'd like to support the channel i'll put a link down below uh in the description for a patreon flywire patreon channel so thanks for watching and i'll see you next time on flywire click this link for the latest upload click this link for whatever youtube thinks you ought to watch or you can click this link to subscribe thanks for watching [Music]

Channel: FlyWire- scott perdue

Views: 263,887

Keywords: Flywire, flywire online, flywire youtube, beechcraft bonanza, general aviation, Aviation, F33C, F33 Bonanza, A36 Bonanza, V35 Bonanza, Aerobatic Bonanza, Aerobatics, Acrobatics, Flying, pilot vlog, flight training, flying vlog, cfi, pilot life, bonanza, private pilot, commercial pilot, airline pilot, ATP, pilot, atc, travel, travel by plane, flying an airplane, S35 Bonanza, Bonanza Telluride crash, accident review, accident review Telluride, crash in mountainous terrain

Id: aZedvQAyEGc

Length: 15min 56sec (956 seconds)

Published: Sun Nov 01 2020