MIA89MA023

NTSB accident investigation · Rockwell 1121A · Oak Grove, PA · November 2, 1988

Accident · FatalMajor investigationFinal report
Date
November 2, 1988, 10:13 local (15:13 UTC)
Place
Oak Grove, PA
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N44Rockwell 1121A
Weather
Instrument (IMC) · Day
Status
Completed · report January 16, 1990
Report
Approved by Office Director
Case key
32511

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

Failure of the pilot in command to observe the rapid accretion of ice on the airplane due to his attention being diverted.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight encounter with weatherManeuvering - holding(ifr)
Weather condition - icing conditionsFactor
Ice/frost removal from aircraft - delayedPilot in commandCause
InattentivePilot in commandFactor
Psychological conditionPilot in commandFactor
Psychological conditionCopilot/second pilotFactor
Inadequate initial trainingCopilot/second pilotFactor
Inadequate surveillance,insufficient staffFaa(organization)
Loss of engine power(total) - nonmechanicalManeuvering - holding(ifr)
Fuselage - iceFactor
Ice/frost removal from aircraft - performed
Compressor assembly,blade - foreign object damageCause
In flight collision with terrain/waterDescent - emergency
Object - tree(s)

Analysis

Acft entered an area of fcst mod icing. Ice detection sys had been intrmtly inop. The acft entered holding in icing condwhile ckg flt insp equip. Evidence indicated crew noted ice accretion, activated surface de-ice sys, ice broke loose andentered eng intakes. Both engs flamed out. Drg emerg descent crew init re-starts, but neither eng would sustain pwr. Crew rqstd vectors to more distant airport. Both plts were seen drinking prev night. C/p had recently lost drivers license for dui. Capt had decided to retire that day. C/p had worked in flt ops 3 days in 8 wks and had lmtd trng in fltinspection. Both plts had personal stresses which may have influenced performance. Capt's contaminated thoracic blood revealed 0.057% alcohol. Putrification would acct for part of alcohol level. C/p had trace alcohol in urine only. Both engs showed compressor FOD consistent with ice ingestion. No other acft sys or eng malfunction found.

Aircraft

Registration
N44
Reported as
Rockwell 1121A
Category
Airplane
Serial number
130
Airframe hours
10,519
Engine
GE CJ-610-5, 2,950 horsepower, turbo jet
Damage
Destroyed
Fire
On-Ground
Flight
Part 91
Registered owner
Federal Aviation Admin.
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · September 26, 1988 · 121 hours before
Departed
AGC · Pittsburgh, PA
Destination
LBE · Latrobe, PA
Flight plan
IFR
Airport
LBE · Westmoreland Co., runway 23, 5,501 × 100 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
64
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
16,957 total · 4,428 in this make and model · 13,000 as pilot in command · 94 in the last 90 days · 24 in the last 30 days · 10 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
250° at 10 knots
Visibility
6 statute miles
Lowest ceiling
800 ft broken
Temperature
39 °F, dew point 36 °F
Altimeter
29.00 inHg
Observed at
LBE, 7 nm away