FLAGSTAFF, AZ, USA
N4108R
PIPER PA-32-300
DURING THE PILOT'S PREFLIGHT WEATHER BRIEFING HE WAS TOLD THAT ICING CONDITIONS WERE FORECAST NEAR HIS ROUTE OF FLIGHT BELOW 16,000 FT, AND HIS ROUTE MAY INVOLVE FLYING BETWEEN TWO FRONTS. THE PILOT FILED FOR AND RECEIVED AN INSTRUMENT CLEARANCE TO FLY AT THE MEA OF 11,000 FT. THE PILOT WAS TOLD THAT SEVERAL INBOUND AIRCRAFT ENCOUNTERED ICING CONDITIONS AT 9,000 FT. THE PILOT TOOK OFF AND, 34 MINUTES LATER, REPORTED HE WAS PICKING UP ICE AND HIS PITOT/STATIC SYSTEM WAS ICED OVER. UNABLE TO CLIMB TO THE MEA, THE PILOT RECEIVED AN APPROACH CLEARANCE FOR A NEARBY AIRPORT. WHILE CRUISING BETWEEN 9,200 & 9,700 FT IN AN AREA WHERE THE MEA WAS 11,000 FT, THE PILOT SAID HE WAS STILL TRYING TO CLIMB AND WAS PICKING UP QUITE A LITTLE BIT OF ICING AND GOT AN OPAQUE WINDSHIELD. THE PILOT REPORTED THAT HE WAS 17.9 MILES OUT FROM THE AIRPORT. IN JULY 1995, THE ACFT WAS LOCATED 14.5 MILES AND 353 DEG FROM THE ARPT. THE LOCATION WAS NOT ON ANY FEDERAL AIRWAY OR ROUTE STRUCTURE ASSOCIATED WITH THE INSTRUMENT APPROACH PROCEDURE. THE PILOT WAS ISSUED AN INSTRUMENT RATING 3 WEEKS PRIOR TO THE ACCIDENT FLIGHT.
HISTORY OF FLIGHT On November 18, 1994, about 1058 mountain standard time (mst), a Piper PA-32-300, N4108R, operated by the pilot, collided with mountainous terrain after the pilot received an air traffic control clearance to perform an instrument approach to the Flagstaff Pulliam Airport, Flagstaff, Arizona. Instrument meteorological conditions prevailed at the airport. The business flight originated from the Grand Canyon Airport, Arizona, at 0958. The airplane was destroyed and the instrument-rated private pilot and passenger were fatally injured. At 0809 on the morning of November 18, the pilot telephoned the Prescott Flight Service Station (FSS) and requested a weather briefing from Grand Canyon, Arizona, to Wichita, Kansas. The pilot indicated that his route of flight would, in part, include flying over Flagstaff and Winslow, Arizona. The pilot indicated he planned to depart from the Grand Canyon in about 4 hours (about 1209 mst). FSS personnel provided the pilot with a weather briefing. In pertinent part, the FSS personnel informed the pilot that if he departed in 4 hours, the forecast indicated he would be following right behind one front and be ahead of another. The FSS personnel indicated that flight precautions were forecasting icing in clouds below 16,000 feet near the pilot's route of flight over northern Arizona, which also included the area eastward to Winslow. In addition, a deepening pressure gradient was forecast ahead of the approaching front. At 0839, the pilot filed an instrument flight plan to Albuquerque with a proposed departure time of 0939. The requested cruise altitude was 11,000 feet, and the initial route of flight was via the Bishop and Kacee Intersections, and then via Victor Airway 291 (over Flagstaff) to Winslow. Thereafter, the pilot requested a clearance to Albuquerque along the requested route. The controller then informed the pilot that several pilots in the vicinity had encountered icing conditions, and one pilot had reported the icing at 9,000 feet. The accident pilot departed from the Grand Canyon at 0958. The pilot did not report experiencing any adverse weather during the initial portion of the flight. At 1014:31, the airplane was over the Bishop Intersection at 10,000 feet. At 1020:20, the radar controller informed the pilot that radar contact was lost. The controller instructed the pilot to maintain 10,000 feet until arriving over the Kacee Intersection, and then to climb and maintain 11,000 feet. (The minimum en route altitude (MEA) between Grand Canyon and the Kacee Intersection was 10,000 feet, and the MEA between Kacee and Flagstaff was 11,000 feet.) At 1027:34, the pilot reported over the Kacee Intersection, and at 1032:09 the pilot stated he was "...picking up a little bit of ice here." About 1/2 minute later, at 1032:44, the pilot reported his altitude was 9,100 feet and "...picking up uh p uh p static is iced over right now." The controller reminded the pilot that he was supposed to climb to 11,000 feet over the Kacee Intersection. At 1033:26, the pilot responded that he was going to 11,000 feet. About 5 minutes later, at 1038:20, the pilot reported that he was at 9,700 feet and "...still trying to get up." At 1041:00, the pilot reported he was at 9,600 feet. The controller stated "Okay uh it doesn't look like you're going to make the eleven thousand then." The pilot replied "Negative we're picking up quite a little bit of icing," and at 1041:21, the pilot stated he was at 9,200 feet. The controller then asked the pilot if he needed special handling or if he desired to land at Flagstaff. The pilot replied that he desired to land at Flagstaff. At 1041:59, the pilot stated "...right now I've got a pretty uh opaque windshield." About 2 minutes later the pilot reported his altitude was 9,500 feet. At 1044:15, the controller issued the pilot an instrument approach clearance to perform the VOR approach to runway 21 at the Flagstaff Airport, and he asked if the pilot had the approach (plate) on board. The pilot indicated that he had the approach on board, and at 1048:22 the pilot stated "Well (sic) be going to (Flagstaff) tower one twenty point zero thank you." The pilot then contacted Flagstaff tower, and about 1049 the tower controller instructed the pilot to "report Sheff inbound." (Sheff Intersection, as depicted on the instrument approach procedure plate for the VOR/DME runway 21 approach, is located on the Flagstaff VOR 056 degree radial at 11 nautical miles from the Flagstaff VOR. Sheff is also an initial approach fix for the VOR/DME runway 21 instrument approach.) At 1056 the controller informed the pilot that he was not in sight, and he issued the pilot a clearance to land on runway 21. Two minutes later, in response to the pilot's statement "...what's your conditions there," the controller provided the pilot with the weather which was "...measured six hundred overcast visibility one and three quarters light snow and fog... (and the) wind is one eighty at one seven gusts two two....". The pilot acknowledged the tower's transmission, and about 1057 the pilot stated he was "...still on about seventeen point nine out..." for the "VOR DME runway 21 (approach)." The controller responded to the pilot "roger report Sheff inbound," and seconds later the pilot responded with his last recorded transmission of "zero eight romeo report Sheff." The airplane wreckage and partial remains of the occupants were found on July 21, 1995. The geographic coordinates of the accident site were 35 degrees 22.741 minutes north latitude, by 111 degrees, 38.278 minutes west longitude, at an estimated elevation of 8,500 feet mean sea level. PERSONNEL INFORMATION According to the Federal Aviation Administration (FAA), the pilot was issued a private pilot certificate on January 30, 1989, and an instrument rating on October 24, 1994. On the pilot's instrument rating application form, he reported that his total instrument flying experience was 58 hours. The pilot's flying experience in instrument weather conditions was not indicated, and was not determined. AIRCRAFT INFORMATION According to a friend of the pilot, the airplane was equipped with a 3-axis autopilot, Loran, GPS, ADF, and a DME. The airplane was equipped for flight into instrument weather conditions. It was not FAA certified for flight into icing conditions. AIDS TO NAVIGATION The FAA reported that the navigational aids associated with the Flagstaff VOR/DME Runway 21 instrument approach were functional on the day of the accident. WRECKAGE AND IMPACT INFORMATION On July 22, 1995, the airplane wreckage was examined on scene. All structural components were found in the vicinity of the main wreckage on a 24-degree upsloping terrain. A debris path consisting of a series of tree strikes and fragmented portions of the left wing tip were found along a magnetic track of 280 degrees. The fuselage was found in an upright attitude. The cockpit and right wing were destroyed by a postimpact ground fire. The fire also burned vegetation immediately adjacent to the main wreckage. Both propeller blades were found broken at midspan, and were located several feet in front of the main wreckage. The rudder and stabilator were found attached to their respective hinges on the empennage. The flight control cable system to these assemblies was found intact. The distance and bearing from the main wreckage to the Flagstaff Pulliam airport was about 14.52 nautical miles and 173.4 degrees, respectively. The wreckage location is outside all published federal airways, including route segments associated with the instrument approach clearance last issued to the accident pilot. ADDITIONAL INFORMATION The entire wreckage was verbally released on July 31, 1995, to U.S. Aviation Underwriters, the owner's assigned insurance adjuster. No parts were retained.
the pilot's intentional flight into known adverse weather conditions, his misjudged evaluation of the weather, and his inexperience in actual instrument flying.
Source: NTSB Aviation Accident Database
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