# NTSB ANC02FA025: Piper PA-28-235, N1220R, Manokotak, AK, March 23, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 23, 2002, 11:40 local (15:40 UTC) - Place: Manokotak, AK - Coordinates: 58.939167, -159.253051 - Nearby events: https://openairdocs.org/map.md?lat=58.9392&lon=-159.2531&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report April 8, 2003 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - Parties: FAA-AL-ANC FSDO 03, THE NEW PIPER AIRCRAFT INC., TEXTRON LYCOMING - NTSB case key (mKey): 54396 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC02FA025 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54396/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54396 - Page: https://openairdocs.org/ntsb/ANC02FA025 ## Probable cause 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. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - weather condition - low ceiling (contributing factor) - vfr flight into imc - continued, pilot in command (cause) - weather condition - snow (contributing factor) - In flight collision with terrain/water, cruise - terrain condition - snow covered (contributing factor) - terrain condition - mountainous/hilly (contributing factor) ## 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 narrative 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 wea ## Aircraft - Registration: [N1220R](https://openairdocs.org/deregistered/N1220R-2002-06-06), registration cancelled 2002-06-06, S/N 28-7310051, built 1972 (OpenAirDocs) - Reported make and model: Piper PA-28-235 - Registry model: [Piper PA-28-235](https://openairdocs.org/model/piper-pa-28-235) (registry code 7102810) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7310051 - Airframe hours: 3308.9 - Engines: Lycoming O-540-B4B5 230 horsepower reciprocating - Damage: Substantial damage - Flight: Business, Part 91 - Registered owner: Corp. of the Catholic Archbishop of Anchorage - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 14, 2001, 79.9 hours before - Departed: PADL, DILLINGHAM, AK - Destination: PATG, TOGIAK, AK - Flight plan: VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 73; injuries: fatal; commercial, flight instructor; airplane ratings: single-engine sea, single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; last flight review July 22, 2000; seat: left; toxicology performed; flight hours: 9,403 total, 8,772 as pilot in command, 98 in the last 90 days, 42 in the last 30 days ## Weather - Conditions: Instrument (IMC), Day - Wind: 11° at 8 knots - Visibility: 3 statute miles - Lowest ceiling: 1,500 ft overcast - Temperature: 27 °F, dew point 21 °F - Altimeter: 29.80 inHg - Observed at: PADL, 25 nm away ## Docket (19 files) The files NTSB released with the investigation on December 17, 2002, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54396. 2.9 MB in all. - Supplement A (item 1, .PDF, 147 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173399&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 2, .PDF, 242 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173400&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Accident Area Maps and Diagram (item 3, .PDF, 389 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173402&FileExtension=.PDF&FileName=Accident%20Area%20Maps%20and%20Diagram-Master.PDF - Weather Data (item 4, .PDF, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40401366&FileExtension=.PDF&FileName=Weather%20Data-Redacted.PDF - FAA FSS Transcripts (item 5, .PDF, 292 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40401367&FileExtension=.PDF&FileName=FAA%20FSS%20Transcripts-Redacted.PDF - FAA FSS Personnel Statements (item 6, .PDF, 146 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40401368&FileExtension=.PDF&FileName=FAA%20FSS%20Personnel%20Statements-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 7, .PDF, 311 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40401369&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Toxicological Report (item 8, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40401370&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo 1. View of separated nose wheel, located below crest of ridge. (item 9, .PDF, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173409&FileExtension=.PDF&FileName=Photo%201.%20%20View%20of%20separated%20nose%20wheel,%20located%20below%20crest%20of%20ridge.-Master.PDF - Photo 2. View of tail of airplane resting on ridge, separated main landing gear located to the left. (item 10, .PDF, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173413&FileExtension=.PDF&FileName=Photo%202.%20%20View%20of%20tail%20of%20airplane%20resting%20on%20ridge,%20separated%20main%20landing%20gear%20located%20to%20the%20left.-Master.PDF - Photo 3. Closer view of separated main landing gear below upright airplane point of rest. (item 11, .PDF, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173420&FileExtension=.PDF&FileName=Photo%203.%20%20Closer%20view%20of%20separated%20main%20landing%20gear%20below%20upright%20airplane%20point%20of%20rest.-Master.PDF - Photo 4. View of right side of airplane fuselage. (item 12, .PDF, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173422&FileExtension=.PDF&FileName=Photo%204.%20%20View%20of%20right%20side%20of%20airplane%20fuselage.-Master.PDF - Photo 5. View of separated wings, located on left side of upright fuselage. (item 13, .PDF, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173423&FileExtension=.PDF&FileName=Photo%205.%20%20View%20of%20separated%20wings,%20located%20on%20left%20side%20of%20upright%20fuselage.-Master.PDF - Photo 6. View of separated right wing lying next to left side of upright fuselage. (item 14, .PDF, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173440&FileExtension=.PDF&FileName=Photo%206.%20%20View%20of%20separated%20right%20wing%20lying%20next%20to%20left%20side%20of%20upright%20fuselage.-Master.PDF - Photo 7. Closer view inboard of leading edge of right wing, curled downward and outboard. (item 15, .PDF, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173497&FileExtension=.PDF&FileName=Photo%207.%20%20Closer%20view%20inboard%20of%20leading%20edge%20of%20right%20wing,%20curled%20downward%20and%20outboard.-Master.PDF - Photo 8. View of separated left wing, after removal by rescue personnel. (item 16, .PDF, 121 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173498&FileExtension=.PDF&FileName=Photo%208.%20%20View%20of%20separated%20left%20wing,%20after%20removal%20by%20rescue%20personnel.-Master.PDF - Photo 9. View of front of airplane and engine that is canted downward. (item 17, .PDF, 108 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173499&FileExtension=.PDF&FileName=Photo%209.%20%20View%20of%20front%20of%20airplane%20and%20engine%20that%20is%20canted%20downward.-Master.PDF - Photo 10. View of one propeller blade with aft curling. (item 18, .PDF, 128 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173500&FileExtension=.PDF&FileName=Photo%2010.%20%20View%20of%20one%20propeller%20blade%20with%20aft%20curling.-Master.PDF - Photo 11. View of second propeller blade with torsional twisting. (item 19, .PDF, 118 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40173501&FileExtension=.PDF&FileName=Photo%2011.%20%20View%20of%20second%20propeller%20blade%20with%20torsional%20twisting.-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.