NTSB Factual Report

HISTORY OF FLIGHT

On January 8, 2003, about 1220 mountain standard time, Albuquerque (ABQ) Air Route Traffic Control Center (ARTCC) lost radar and radio contact with a Piper PA-23-250, N135LA, near Flagstaff (FLG), Arizona, and the airplane subsequently collided with mountainous terrain about 10 miles north of Flagstaff. The Cowboy Church of the American West was operating the airplane under the provisions of 14 CFR Part 91. The private/instrument rated pilot, private rated pilot passenger, and two passengers all received fatal injuries. The personal cross-country flight originated at Boulder City (61B), Nevada, at 1000 Pacific standard time (PST), en route to Midland, Texas. Day visual meteorological conditions prevailed at Flagstaff (FLG), and visual flight following was requested at the time of departure. No flight plan was filed.

While en route to Flagstaff, at 11,500 feet mean sea level (msl), and receiving visual flight advisories, the pilot established radio contact with Albuquerque Center sector 45 controller and advised he was unable to maintain visual flight due to rain and ice. He requested an IFR (instrument flight rules) clearance. Review of the recorded air-ground communications tapes disclosed that his transmission was scratchy and of poor quality. The controller advised the pilot of rime ice reports at 13,000 feet on his course. The pilot reported his altitude to be 12,000 feet and said he was accumulating some ice.

The controller asked if he intended to descend into Flagstaff; the pilot stated that he had planned too. The controller issued the FLG altimeter and advised the airport location. The pilot's reply was broken. The controller asked if he has the airport in sight and the pilot responded that no he did not and that he was is in some clouds. The controller asks the pilot twice if he is ok and the pilot responded that he was and that he would like to go to the tower frequency and land at FLG. The controller issued a VFR transponder code and transferred communications to the FLG Air Traffic Control Tower (ATCT).

About 2 minutes later, the pilot reported back to the controller and advised he was unable to get a visual on the ground and would like to go IFR. The controller advised the pilot to climb to 11,000 feet. The controller advised the pilot to climb to the published holding pattern southeast of FLG. The pilot acknowledged.

The Prescott Automated Flight Service Station was relaying for FLG ATCT. The landline between sector 45 and FLG ATCT was out of service. The sector 45 controller advised the RA45 controller that FLG ATCT talked to an Aztec west of the airport and transferred communications with him to sector 45. The RA45 controller told PRC ATCT the aircraft was on their frequency. At 1216, the R45 controller asked the pilot to say altitude with no response.

On January 8, 2003, about 2050, the Federal Aviation Administration (FAA) issued an alert notice (ALNOT), for the missing airplane. On January 19, 2003, the wreckage was located by a hiker in the Coconino National Forest, about 10 miles north of FLG.

PILOT INFORMATION

The private pilot was rated for airplane single and multiengine land and instruments. The pilot's number 2 logbook was recovered at the accident site. It documented a December 6, 2002, flight in the accident airplane, noting a multiengine land and instrument flight test as passed on that date. The last logbook entry was dated January 3, 2003. The total flight time carried forward was listed as 442.8 hours, with 34.5 multi hours, and about 11.5 hours in the accident airplane. The pilot's last documented third-class flight physical occurred on September 5, 2002, with no restrictions.

PILOT RATED PASSENGER

The private rated passenger was certificated for single and multiengine land airplanes. According to records, his last third-class flight physical occurred on September 5, 2002. His flight hours at that time of the accident were not obtained.

AIRPLANE INFORMATION

A review of the airplane logbook revealed that the last annual inspection occurred on April 25, 2002, at 5,601.8 total flight hours. On March 20, 2002, compliance with F.A.R. 91.411 and 91.413 certification of the altimeter and transponder in accordance with PART 43, appendix E & F was accomplished.

METEOROLOGICAL INFORMATION

At 1210, FLG was reporting: wind calm; visibility 10; sky overcast at 1,500 feet, above ground level; temperature 39 degrees Fahrenheit; dew point 34 degrees Fahrenheit; and the altimeter was 30.23 inHg. Rain began at 1202. Moderate rime icing was reported at 13,000 feet. At 1203, the pilot reported rain and ice at 12,000 feet and requested IFR handling. Additional weather information is attached to the report.

COMMUNICATIONS

At 0845, a cut fiber optic line disrupted ATC ground-to-air communications in northern Arizona, during the time of the accident airplane's attempt to land at Flagstaff. Landlines were also affected. Air-to-ground and ground-to-air communications were broken and at times garbled.

MEDICAL AND PATHOLOGICAL INFORMATION

On January 20, 2003, the Coconino County Medical Examiner performed an autopsy on the pilot. During the procedure samples were obtained for toxicological analysis by the FAA Civil Aeromedical Institute, Oklahoma City, Oklahoma. The results of the analysis were negative for carbon monoxide, cyanide and ethanol, and positive for unquantified trace amounts of Ephedrine and Sudafed, which are over-the-counter type of weight loss and decongestant medications.

The private rated pilot/passenger was negative for the above listed tests.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located January 19, 2003, about 10 miles north of the FLG and VOR. Examination by the National Transportation Safety Board occurred on site January 20, 2003, and following recovery of the wreckage. The wreckage site was located in the Coconino National Forest about 8,900 feet msl, on forested 30-degree terrain. A post accident fire had consumed portions of the airplane center section. The fragmented wreckage path was measured about 315 degrees magnetic over about 200 feet of upslope terrain. Examination of the area revealed a topped pine tree about 12 inches in diameter. Continuing about 30 feet another tree of equal diameter had been impacted, leaving a section of the left wing leading edge imbedded at the point of contact. The radius of the impact to the leading edge was measured about 90 degrees to the leading edge span.

Limited instrument information was recovered. The 8-day clock was indicating 1352; the altimeter barometric reading was 30.25 inHg; airspeed was indicating 250 + -; radio switch panel was on Comm No. 1; the HSI bug was 100 degrees; the heading card was at 320 degrees; and the gyro rotor displayed rotational rub marks. Tachometer No. 1 indicated 2,175 rpm, with 0344.6 recorded hours. Tachometer No. 2 indicated 2,800 rpm, with 312.8 recorded hours. A King KX 175B Nav Comm radio was observed to indicate 132.4 comm frequency with only a .25 from the navigation selector function. A Bendix Autopilot selector panel was destroyed. A King Rnav was selected to the VOR function with 000 for distance and a bearing of 267 degrees. A DME indicator indicated 024 miles and a 14.5 time-to-station indication. No selected navigation frequencies were recovered.

Examination of the engines occurred after the recovery of the wreckage. Details of the examination are attached to the docket.

ADDITIONAL INFORMATION

A standard flight plan form was recovered from the accident site for the route Boulder City, Peach Springs, Flagstaff, Winslow, and Albuquerque. The time and mileage en route was listed as 431 miles and 2.5 hours with 5.5 hours of fuel. The departure time was 1000 PST. The alternate airport was Farmington, New Mexico.

On December 6, 2002, the Flagstaff visual omni range (VOR) navigational aid frequency was changed from 108.2, to 113.85. A Phoenix sectional chart dated November 1, 2001, spared from the fire, was recovered from the wreckage. No other navigational reference material was recovered.

The damaged gyro horizon instrument was taken to an FAA approved instrument repair station for examination. The examination revealed rotational signatures on the gyro rotor and rotor housing typical of rotational energy at the time of impact crushing. Neither the pitch nor roll attitudes of the instrument at the time of impact were obtained due to damage.

A King/McCoy communication and navigation radio was recovered from the wreckage with damage. The ink marking on the case was indicating radio Number 2. The radio was taken to an avionics technician for examination and attempted recovery of stored communication and nav frequencies.

The emergency crash locator beacon (ELT), a Garrett model 88, was found separated from the mounting tray with the antenna lead damaged. The battery expiration date was March 2004. The selector switch was found in the "armed" position. The unit was mildly fire damaged.

On February 23, 2003, the wreckage was released to the insurance company representative.

NTSB Probable Cause

the pilot's failure to comply with his instrument clearance route instruction and to maintain his assigned altitude. A factor in the accident was the poor quality of radio communications due to the severance of underground fiber optic voice and data lines for the ARTCC, which also affected inter and intra facility landline communications.