# NTSB LAX06FA133: Rockwell 112 TCA, N4641W, La Canada, CA, March 30, 2006 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 30, 2006, 14:53 local (22:53 UTC) - Place: La Canada, CA - Coordinates: 34.25111, -118.175834 - Nearby events: https://openairdocs.org/map.md?lat=34.2511&lon=-118.1758&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report February 28, 2008 - Report: Approved by Office Director - Parties: Commander Premier, Federal Aviation Administration, Textron Lycoming - NTSB case key (mKey): 63433 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX06FA133 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/63433/pdf - Page: https://openairdocs.org/ntsb/LAX06FA133 ## Probable cause The pilot's failure to maintain aircraft control and an adequate airspeed during climb to cruise that led to a stall/spin. Contributing to the accident were the clouds and the pilot's physiological state. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, climb - to cruise - physiological condition, pilot in command (contributing factor) - aircraft control - not maintained, pilot in command (cause) - weather condition - clouds (contributing factor) - airspeed - not maintained, pilot in command (cause) - stall/spin - inadvertent, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - mountainous/hilly ## Analysis The pilot was receiving VFR flight following services from Air Traffic Control and was climbing to his cruise altitude of 9,500 feet when he requested information regarding the tops of the clouds. The pilot stated that he was VFR, and had gone through some clouds. The controller informed the pilot that he was in an area of intermittent radar coverage, and asked him if he was able to maintain VFR. The pilot replied that he could, and that he was at 6,800 feet. A few seconds later, the controller lost radar and radio contact. No distress call was received and an over-flying airplane tried unsuccessfully to establish radio contact. Radar data indicated that a target in the vicinity of the accident site appeared to make two left 360-degree turns. A witness saw the airplane come spiraling out of the bottom of the clouds with the nose pointed straight towards the ground. No preimpact mechanical malfunctions or failures were identified in the wreckage. Two weeks prior to the accident, the pilot had extensive surgery to remove a recurrent tumor in his maxillary sinus. At the time of the accident, the pilot was returning home from a post-surgical meeting at which the surgeon informed the pilot that some tumor remained in his eye socket. The pilot's options would be radiation to the eye, additional surgery to remove the floor of the eye socket and possibly the eye as well, or watch the tumor grow prior to taking any action. The pilot had likely recovered from most of the immediate effects of that surgery. The pilot had ibuprofen in his blood, suggesting that he had some continuing pain or discomfort, which might have reduced his attention to flight related tasks. He might also have been distracted or depressed by the prospect of additional surgery and/or the possible loss of one eye. His decision to fly or respond to events during flight could have been sub optimal due to post surgical issues. ## Factual narrative HISTORY OF FLIGHT On March 30, 2006, at 1453 Pacific standard time, a Rockwell 112 TCA, N4641W, collided with terrain near La Canada, California. The pilot/owner was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. The private pilot, the sole occupant, was killed, and the airplane was substantially damaged. The cross-country personal flight departed Santa Monica, California, at 1429, with a planned destination of North Las Vegas, Nevada. Visual meteorological conditions prevailed, and no flight plan had been filed. The pilot flew into Santa Monica on the day of the accident in the morning for a doctor's appointment, and he was returning home in the afternoon. Southern California Terminal Radar Approach Control (SCT), Glendale sector reported that the pilot was receiving visual flight rules (VFR) flight following and the his cruise altitude was to be 9,500 feet mean sea level (MSL). Radar contact was established at 1451:49, and the pilot requested information regarding the tops of the clouds as he was supposed to be VFR, but he had gone through some clouds. SCT informed the pilot that he was in an area of intermittent radar coverage, and asked him if he was able to maintain VFR. The pilot replied that he could, and that he was at 6,800 feet. At 1452:52, radar and radio contact was lost with the flight, 10 miles northeast of Burbank, California. SCT reported that no distress call was received and an over-flying airplane was unsuccessful in trying to establish radio contact. A review of radar data indicated that a target in the vicinity of the accident site appeared to make two left 360-degree turns. A pilot flying a King Air in the vicinity reported that the clouds tops were estimated at 6,000 feet. A witness driving on the Angeles Crest highway, about 2 miles past the Angeles Crest Ranger Station reported that he observed an airplane spiraling out of the bottom of the clouds with the nose pointed straight towards the ground until it disappeared behind a hill. He did not observe any smoke or pieces falling from the airplane. He said that the airplane appeared to be intact; he could see both wings and the entire tail section. He did not observe any smoke coming from the airplane's location. He returned to the ranger station and reported his observations. PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records revealed that the 50-year-old pilot held a private pilot certificate with a rating for airplane single engine land. The pilot held a third-class medical certificate issued on December 17, 2004. It had the limitations that the pilot must wear corrective lenses. No personal flight records were located for the pilot. The National Transportation Safety Board investigator-in-charge (IIC) obtained the aeronautical experience listed in this report from a review of the FAA airmen medical records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. The pilot reported on his medical application that he had a total time of 216 hours, with 22 hours logged in the last 6 months. AIRCRAFT INFORMATION The airplane was a Rockwell Commander 112 TCA, serial number 13171. A review of the airplane's logbooks revealed that the airplane had a total airframe time of 1,728.35 hours at the last annual inspection. The logbooks contained an entry for annual inspection dated June 6, 2005. The tachometer read 1,829.66 hours at the accident scene. The engine was a Textron Lycoming TO-360-C1A6D, serial number L-237-69A. Time since major overhaul was 202 hours at the annual inspection. METEOROLOGICAL INFORMATION The closest official weather observation station was Burbank (KBUR) California, which was located 9 nautical miles (nm) southwest of the accident site. The elevation of the weather observation station was 778 feet msl. An aviation routine weather report (METAR) for KBUR was issued at 1453 PDT. It stated: winds variable at 6 knots; visibility 10 miles; skies 5,000 feet broken; temperature 17/62 degrees Celsius/Fahrenheit; dew point 4/39 degrees Celsius/Fahrenheit; altimeter 29.99 inches of Mercury. There were no communications between the pilot and any Automated Flight Service Station (AFSS) facility for the flight from Santa Monica to North Las Vegas. Nor was there any contact between the pilot, and the direct user access terminal service (DUATS). WRECKAGE AND IMPACT INFORMATION The airplane came to rest at the base of trees in rugged mountainous terrain. Only trees within a wingspan sustained damage. MEDICAL AND PATHOLOGICAL INFORMATION The Los Angeles County Coroner completed an autopsy. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, performed toxicological testing of specimens of the pilot. Analysis of the specimens contained no findings for carbon monoxide, cyanide, or ethanol detected in blood. The report contained the following findings for tested drugs: ibuprofen detected in blood. The Safety Board's Medical Officer examined a certified copy of the airman's medical records and the pilot's personal medical records, and prepared a factual report, which is part of the public docket for this accident. An application for a third-class medical certificate in August 2000, noted that the pilot had a cyst removed from behind his right eye in 1996, and reconstructive eye surgery in 1998. His most recent application for a medical certificate in December 2004, regarding admission to hospitals or other illnesses or surgeries contained the comment, "previously noted." Two weeks prior to the accident, the pilot had extensive surgery to remove a tumor that had returned in his right maxillary sinus. The procedure included removal of his entire right maxillary sinus (including several teeth), much of the roof of his mouth, and portions of the floor of his eye socket. The surgeon replaced the removed tissue with a temporary prosthetic device, which he screwed into place with several screws inside the mouth. The pilot lost a substantial amount of blood during the procedure, and was hospitalized for 3 days. At the post-surgical meeting on the morning of the accident, the surgeon informed the pilot that some tumor remained in the eye socket. The pilot's options would be radiation to the eye, additional surgery to remove the floor of the eye socket and possibly the eye as well, or watch the tumor grow prior to taking any action. TESTS AND RESEARCH Investigators examined the wreckage at Aircraft Recovery Service, Littlerock, California, on April 24, 2006. The two-bladed propeller remained attached at the crankshaft flange. One blade exhibited leading edge gouges, twist, and cambered striations across the cambered surface. The other blade had leading edge damage. The engine was removed from the airframe. The top spark plugs were removed and it was noted that all were clean with no mechanical deformation. The spark plug electrodes were circular and gray, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart. A borescope inspection revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder head. Investigators manually rotated the crankshaft with the propeller. The crankshaft rotated freely, and the valves moved approximately the same amount of lift in firing order. The gears in the accessory case turned freely. Compression was developed in all of the cylinders. The magnetos were rotated by hand and a spark was produced from all towers. The vacuum pump drive gear remained unbroken, and the vacuum pump turned freely. All vacuum pump vanes were whole, in position, and moved freely. The oil sump screen was clean and open. The oil filter was crushed, but clean. The fuel pump separated from the engine. A portion of the mounting flange remain ## Aircraft - Registration: [N4641W](https://openairdocs.org/deregistered/N4641W-2006-09-19), registration cancelled 2006-09-19, S/N 13171, built 1977 (OpenAirDocs) - Reported make and model: Rockwell 112 TCA - Registry model: [Rockwell International 112TCA](https://openairdocs.org/model/rockwell-international-112tca) (registry code 7630307) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 13171 - Airframe hours: 1829 - Engines: Lycoming TO-360-C1A6D 210 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: John G. Rice - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 1, 2005 - Departed: SMO, Santa Monica, CA - Destination: VGT, North Las Vegas, NV ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3; seat: left; toxicology performed; flight hours: 216 total ## Weather - Conditions: Visual (VMC), Day - Wind: 6 knots - Visibility: 10 statute miles - Lowest ceiling: 5,000 ft broken - Temperature: 63 °F, dew point 39 °F - Altimeter: 29.98 inHg - Observed at: BUR, 9 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20060330010019A](https://openairdocs.org/incident/20060330010019A), Mar 30, 2006: Gulstm 112TCA, La Canada, CA, Destroyed, 1 fatal. (-23) Visual meteorological conditions prevailed (VFR) private pilot- VFR rated. Several witnesses stated the aircraft came spiraling out of the bottom of… 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.