Aviation Accident Summaries

Aviation Accident Summary ANC02FA025

MANOKOTAK, AK, USA

Aircraft #1

N1220R

Piper PA-28-235

Analysis

The commercial certificated pilot telephoned an FAA Automated Flight Service Station (AFSS) and obtained a weather briefing for a flight to a remote airport, located about 58 miles from the departure airport. The briefing included marginal weather conditions at the departure airport, but improved conditions at the destination. An ARMET had been issued for mountain obscurations in the areas between the departure and destination airports. The pilot ended his weather briefing by filing a VFR flight plan. Just before departure, the AFSS specialist advised the pilot that he had received a pilot report for the area between the departure and destination airports. The pilot report included occasional visibilities 3 to 5 miles and occasional visibilities down to zero. The reporting pilot stated he followed the treeline into an intermediate airport (near the eventual crash site), and visibility and ceilings were low in the mountainous areas along the route. The accident pilot acknowledged the report and then departed. About 2 1/2 hours later, the flight was reported overdue, and an emergency locator transmitter (ELT) signal was received in an area about 18 miles west-southwest of the departure airport. The flight never reached the destination airport. Low visibility and blowing snow prevented searchers from reaching the scene until the following day. The airplane wreckage was located in an area on snow-covered hill, about 1,300 feet msl. A postaccident examination of the airplane did not reveal any preimpact mechanical malfunctions.

Factual Information

HISTORY OF FLIGHT On March 23, 2002, about 1140 Alaska standard time, a wheel-equipped Piper PA-28-235 airplane, N1220R, sustained substantial damage during a collision with snow-covered terrain, about 7.5 miles southwest of Manokotak, Alaska. The airplane was being operated as a visual flight rules (VFR) cross-country flight under Title 14, CFR Part 91, when the accident occurred. The airplane was registered to and operated by the Corporation of the Catholic Archbishop of Anchorage, Anchorage, Alaska. The commercial certificated pilot, the sole occupant, received fatal injuries. The pilot was a Catholic priest who routinely flew to remote villages as part of his ministry duties. Visual meteorological conditions prevailed at the point of departure. A VFR flight plan was filed from Dillingham, Alaska, to Togiak, Alaska, and return to Dillingham. The flight originated at the Dillingham airport at 1033. At 0937, the pilot telephoned the Federal Aviation Administration (FAA) Automated Flight Service Station (AFSS) at Dillingham, Alaska, and spoke with a flight service station specialist at the in-flight 1 position. The pilot requested weather information for Togiak, and the terminal forecast for Dillingham. The specialist commented that he did not have any pilot reports of weather conditions for the area, and then provided weather data that included reports for Togiak of overcast skies at 2,200 feet, visibility at least 10 statute miles. The specialist commented that: "...there at Togiak that's certainly better than we are here, we've got about two miles visibility...and a ceiling of 2,500 feet overcast with a few clouds or a scattered layer at about a hundred feet underneath...getting pretty good snow here right now..." The AFSS specialist continued his weather briefing to the pilot by stating: "...the terminal forecast for Dillingham from now until approximately nine o'clock this evening, calling for northeasterly wind at seven (knots)...occasional light snow and fog throughout the entire day today here...visibility could drop down to as low as four (miles), ceiling as low as 1,500 (feet) during the worst of that occasional activity...on an occasional basis, that light snow and fog is gonna drop us down to marginal VFR and of course we're below VFR on the visibility here at Dillingham." The specialist provided an area forecast for the Bristol Bay area of Alaska, and he commented that: "...there's an AIRMET for mountain obscurations in the Bristol Bay area, the mountainous areas occasionally obscured in low clouds and precipitation, that condition expected to persist throughout the day, VFR flight in the mountainous areas is not recommended based on that AIRMET." The AFSS specialist also commented that: "...you know relatively speaking, it's basically precipitation occurring in the coastal area, ah not really much ah further inland ah so hopefully it'll be confined just to the coastal area today, and maybe they'd be a little bit off the money on this forecast, but ah regardless, Dillingham is considered for weather briefing purposes, for most purposes anyway, to be part of the coastal area so ah appears that a coastal area at least could ah see this situation ah throughout the day today, according to the forecast products." The pilot then requested the terminal forecast for King Salmon, Alaska, and the winds aloft forecast. King Salmon is about 60 miles east of Dillingham. The pilot ended his weather briefing at 0946 by filing a VFR flight plan from Dillingham to Togiak and return, with an expected departure time of 1015, and an expected return time of 1500. At 1032, the pilot contacted the Dillingham AFSS by radio and advised he was taxiing for takeoff, and requested that his flight plan be activated. The pilot also requested the latest weather data for Togiak. The specialist stated: "Togiak automated, 15 past the hour, reporting wind, 060 (degrees) at 8 (knots); visibility, 10 (miles); ceiling, 1,800 overcast; temperature, 0 (degrees Celsius); dew point, -2 (degrees Celsius); altimeter, 29.78 (inHg). (A) Pilot report between Togiak and Dillingham at 1000; a Cessna 207 reported unable low summit route; occasional visibilities down to zero in the flats; said occasional visibilities through the chute, 3 to 5 miles---the picnic beach area and then he followed the treeline into Manokotak; he said the visibility and ceilings were pretty low in the summit area." At 1033, the pilot replied: "Okay, thanks allot---Dillingham traffic, Cherokee 1220R departing runway one, left turnout." FAA personnel notified the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), on March 23, at 1311, that the flight was overdue, and an emergency locator transmitter (ELT) signal was being received in the area of Manokotak. Manokotak is about 18 miles west-southwest of Dillingham, and about 40 miles east of Togiak. Low visibility and blowing snow prevented searchers from reaching the scene until March 24, at 1120. The accident area was in an area of snow-covered hills, about 1,300 feet msl. Examination of the airplane's maintenance records and pilot records, revealed that 1.3 hour elapsed on the airplane's tachometer mounted hour meter from the most recent previous flight, to the discovery of the airplane wreckage. PERSONNEL INFORMATION The pilot held a commercial pilot certificate with airplane single-engine land, multiengine land, single-engine sea, helicopter, glider, and instrument airplane ratings. In addition, he held a flight instructor certificate with airplane single-engine, multiengine, instrument airplane, and glider ratings. The most recent second-class medical certificate was issued to the pilot on February 28, 2002, and contained no limitations. According to the pilot's logbook, his total aeronautical experience consisted of about 9,403 hours. In the preceding 90 and 30 days prior to the accident, the logbook lists a total of 98 and 42 hours respectively. AIRCRAFT INFORMATION The airplane had accumulated a total time of 3308.9 hours. Examination of the maintenance records revealed that the most recent annual inspection of the airframe and engine was accomplished on November 14, 2001, 79.9 hours before the accident. The maintenance records note that a major overhaul was accomplished on October 1, 1998, 868.9 hours before the accident. METEOROLOGICAL INFORMATION The closest official weather observation station is Dillingham, which is located 25 nautical miles northeast of the accident site. On March 23, 2000, at 1051, an Aviation Routine Weather Report (METAR) was reporting in part: Wind, 030 degrees (true) at 8 knots; visibility, 3 statute miles in light snow; clouds and sky condition, 700 feet scattered, 1,500 feet overcast; temperature, 27 degrees F; dew point, 22 degrees F; altimeter, 29.81 inHg. A routine pilot report (PIREP), transmitted at 1000 in the area from Togiak to Dillingham, stated, in part: "Cessna 207; unable 'low summit' route; some zero flight visibility in the 'flats'; flight visibility 3 to 5 statute miles through the 'chute'; pilot picked his way through Picnic Beach area...followed tree line to Manokotak...pretty low in summit area." An automated weather observation system (AWOS) report from Togiak at 1055, was reporting, in part: "Wind, 050 degrees (true) at 7 knots; visibility, 2 statute miles; clouds and sky condition, 1,600 feet overcast; temperature, 32 degrees F; dew point, 28 degrees F; altimeter, 29.78 inHg. An area forecast for the Bristol Bay area, issued at 0630, and valid until 1800, stated, in part: "Synopsis, valid until 2400; a weak 1012 millibar low, 40 nautical miles south of Middleton Island, Alaska, is quasi-stationary and will dissipate by 1500. A 995 millibar low, 120 nautical miles northwest of St. Paul Island, Alaska, will move to 120 nautical miles northwest of St. Matthew Island at 2400. An associated weakening occluded front from the low to near Sand Point, Alaska, will become very weak, extending from Cape Romanzof LRRS to Chignik Bay, Alaska, by 2400. A 984 millibar low, 90 nautical miles north of Eareckson AS, Shemya, Alaska, will move to 100 nautical miles west of St. Paul Island at 2400. An associated occluded front through the Aleutians near the dateline will extend from St. Paul Island to Cold Bay, Alaska, by 2400. AIRMET for mountain obscuration; mountains occasionally obscured in clouds and in precipitation, no change. Clouds and sky condition, 2,500 feet scattered, 3,500 feet broken, 7,000 feet overcast, tops at 8,000 feet, separate layers above to 25,000 feet. Occasionally, 2,500 feet broken, 7,000 feet overcast; visibility, 4 statue miles in light snow showers and mist. Outlook, valid from 1800 to 0300 on March 24, marginal VFR with ceilings due to snow showers. Turbulence, nil significance. Icing and Freezing level, nil significance. Freezing level near the surface from the northeast, sloping to 1,500 feet toward the southwest." A terminal forecast for Dillingham, issued at 0835 on March 23, and valid from 0900 until 0900 on March 24, stated, in part: "Wind, 040 degrees at 7 knots; visibility, greater than 6 statue miles; clouds and sky condition, 3,000 feet overcast. Temporary conditions from 0900 to 2100, visibility 4 statute miles in light snow and mist; 1,500 feet overcast. From 0300 to 1500 on March 24, wind 080 degrees at 10 knots; visibility, 3 statute miles in light snow and mist; 1,500 feet overcast. Temporary conditions from 0300 to 0900, visibility 1 statute mile in snow and mist; 1,000 feet overcast." COMMUNICATIONS Review of the air ground radio communications tapes maintained by the FAA at the Dillingham AFSS facility revealed that the pilot successfully communicated with the positions of inflight 1. Following departure, no further communications were received from the airplane. A transcript of all communications between the pilot and the Dillingham AFSS is included in this report. WRECKAGE AND IMPACT INFORMATION The National Transportation Safety Board investigator-in-charge (IIC), accompanied by an air safety investigator from the Anchorage Field Office, along with the parties to the investigation, examined the airplane wreckage at the accident site on March 26, 2002. A path of wreckage debris from the first observed point of ground contact to the wreckage point of rest, was on a magnetic heading of 040 degrees. (All heading/bearings noted in this report are oriented toward magnetic north.) All of the airplane's major components were found at the main wreckage area, just below the crest of a snow-covered ridge. The snow was crusted and extensively wind-blown. The airplane was initially found by search personnel, inverted in the snow. The left wing was removed by search personnel, and the fuselage was rolled to the left to an upright position. The first observed portion of the airplane along the wreckage path was the separated nose wheel, buried in the snow, downhill from the fuselage point of rest. The nosewheel strut was separated about six inches above the nosewheel yoke. Along the left side of the wreckage path, both main landing gear assemblies were found partially buried in the snow, separated from their respective wing attach points. The right wing was torn away from the fuselage at its inboard attach point. It was observed lying inverted, leading edge facing forward, positioned on the left side of the upright fuselage. It had downward and outboard curling of the leading edge from the inboard end along a diagonal line to about the spar at the inboard edge of the main fuel tank. The right wing flap and aileron remained attached to their respective wing attach points. The right wing fiberglass wingtip fuel tank separated from its attach points on the end of the right wing. The left wing, removed by search personnel, was observed lying inverted, leading edge facing aft, to the left of the right wing, positioned on the left side of the upright fuselage. A portion of the wing from the inboard leading edge, aft to the spar and outboard to the main fuel tank, was torn away from the wing. The left wing flap and aileron remained attached to their respective attach points. The left wing main fuel tank was almost full of fuel. The left wingtip fuel tank was damaged and did not contain any fuel. Due to the impact damage, the flight controls could not be moved by their respective control mechanisms. The continuity of the flight control cables was established to the cabin/cockpit area. The stabilator antiservo trim tab jack screw was found extended "0" threads. According to the airplane manufacturer, the trim tab actuator corresponded to a full nose down setting. The fuselage had aft and downward crushing on about a 45 degree angle, from the propeller spinner to the upper windshield frame. The center windshield frame was crushed downward to the instrument panel. The interior of the fuselage was partially filled with drifted snow. The empennage had only minor damage. The horizontal stabilator, trim tab, vertical stabilizer, and rudder remained attached to the fuselage. The upper end of the vertical stabilizer had minor denting. The propeller assembly remained connected to the engine crankshaft. Both blades were loose in the hub. One propeller blade was curled aft with minor torsional twisting, gouging and tearing of the trailing edge of the blade. The second propeller blade had slight aft bending and torsional twisting. The engine was canted downward from its normal position about 45 degrees and bent to the right of the longitudinal axis of the airplane. The crankshaft could be rotated by the propeller. Gear train continuity was established when the crankshaft was rotated by hand. Visual inspection of each cylinder, utilizing a bore scope inserted into each spark plug hole, revealed no unusual observations. The magnetos produced spark at all terminals upon hand rotation. The top engine fine wire spark plugs had a gray appearance. The carburetor remained buried in the snow under the engine. Fuel was found in the line to the carburetor. MEDICAL AND PATHOLOGICAL INFORMATION A postmortem examination of the pilot was conducted under the authority of the Alaska State Medical Examiner, 4500 South Boniface Parkway, Anchorage, Alaska, on March 26, 2002. The examination revealed that the cause of death for the pilot was multiple blunt force injuries. A toxicological examination was conducted by the FAA's Civil Aeromedical Institute (CAMI) on April 30, 2002, and was negative for any alcohol or drugs. SEARCH AND RESCUE An ELT signal was received about 1228 on March 23. Search personnel from the U.S. Army Guard, U.S. Air Guard, U.S. Coast Guard, and volunteer personnel from the Village of Manokotak, attempted to reach the area of the ELT signal. Low visibility and blowing snow prevented search personnel from reaching the accident site via snow machine until March 24, about 1120. A member of the ground search team from the Village of Manokotak initially located the inverted wreckage in whiteout conditions. The search member left the accident site to gather support members, but attempts to relocate, and travel to the wreckage site were unsuccessful until March 25, about 0815. Ground visibility was near zero in the area with high wind conditions and blowing snow. ADDITIONAL INFORMATION The Safety Board did not take custody of the wreckage. No parts or components were retained by the Safety Board.

Probable Cause and Findings

The pilot's continued VFR flight into instrument meteorological conditions, and subsequent collision with terrain during cruise flight. Factors in the accident were low ceilings, snow, and mountainous snow-covered terrain.

 

Source: NTSB Aviation Accident Database

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