# NTSB MIA89MA023: Rockwell 1121A, N44, Oak Grove, PA, November 2, 1988

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Major investigation · Final report
- Date: November 2, 1988, 10:13 local (15:13 UTC)
- Place: Oak Grove, PA
- Coordinates: 40.390342, -79.149116 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=40.3903&lon=-79.1491&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 3 fatal
- Status: Completed, report January 16, 1990
- Report: Approved by Office Director
- NTSB case key (mKey): 32511
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA89MA023
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/32511/pdf
- Page: https://openairdocs.org/ntsb/MIA89MA023

## 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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- In flight encounter with weather, maneuvering - holding(ifr)
  - weather condition - icing conditions (contributing factor)
  - ice/frost removal from aircraft - delayed, pilot in command (cause)
  - inattentive, pilot in command (contributing factor)
  - psychological condition, pilot in command (contributing factor)
  - psychological condition, copilot/second pilot (contributing factor)
  - inadequate initial training, copilot/second pilot (contributing factor)
  - inadequate surveillance,insufficient staff, faa(organization)
- Loss of engine power(total) - nonmechanical, maneuvering - holding(ifr)
  - fuselage - ice (contributing factor)
  - ice/frost removal from aircraft - performed
  - compressor assembly,blade - foreign object damage (cause)
- In flight collision with terrain/water, descent - 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](https://openairdocs.org/deregistered/N44-1989-01-19), registration cancelled 1989-01-19, S/N 130 (OpenAirDocs)
- Reported make and model: ROCKWELL 1121A
- Registry model: [Aero Commander 1121A](https://openairdocs.org/model/aero-commander-1121a) (registry code 0142006) (OpenAirDocs)
- Category: Airplane
- Serial number: 130
- Airframe hours: 10519
- Engines: GE CJ-610-5 2950 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 64; 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

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.