WPR15FA163

NTSB accident investigation · Rockwell Commander 114 · Laughlin, NV · May 18, 2015

Accident · FatalField investigationFinal report
Date
May 17, 2015, 18:00 local (May 18, 2015, 01:00 UTC)
Place
Laughlin, NV
Injuries
3 fatal, 1 serious
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N4775WRockwell Commander 114
Defining event
Initial climb: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report June 7, 2017
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration, Lycoming Engines
FAA report
20150517007349A
Case key
91181

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

A partial loss of engine power due to the turbocharger's seizure as a result of a severely worn turbowheel. Contributing to the accident was the failure of the pilot/owner to have the turbo normalization system inspected every 100 hours as required, which allowed erosion on the exhaust side of the turbowheel to go undetected.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelRockwell International 114: 1 caseAll aircraft: 167 casesProbable cause
Turbocharging (recip only): turbochargerAircraft › Aircraft power plant · Fatigue/wear/corrosionRockwell International 114: 1 caseAll aircraft: 29 casesProbable cause
Terrain: rough terrainEnvironmental issues › Physical environment · Contributed to outcomeRockwell International 114: 2 casesAll aircraft: 442 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The private pilot/owner reported that, during the climb to between about 300 and 400 ft above the ground, the engine started running roughly, and the airplane was not accelerating or climbing. The terrain ahead was rising, so the pilot turned right. Due to the low altitude and reduced engine power, the pilot chose to conduct an off-airport landing, during which he attempted to troubleshoot the engine issue without success. As the airplane continued to descend, the pilot saw houses and bushes ahead; he aimed the airplane away from the houses, and the airplane eventually hit trees and terrain about 4.6 nautical miles from the airport. A postimpact engine fire ensued. Postaccident examination of the engine revealed that the turbocharger was seized and that the exhaust side of the turbowheel was severely eroded, which led to the engine running rough. A review of the airplane's maintenance records revealed that a turbocharger normalization system had been installed on the airplane under a supplemental type certificate (STC) 13 years before the accident. The STC's instructions for continued airworthiness required that the turbocharger normalization system be inspected every 100 hours. However, a review of the airplane's maintenance records revealed that the system had only been inspected once since its installation and that the inspection was completed 6 years before the accident. No other abnormalities were noted with the airframe or engine that would have precluded normal operation. It is likely that the eroded turbowheel would have been detected if the turbocharger normalization system had been inspected as required.

Factual narrative

The four-seat airplane, serial number 14105, was equipped with a Lycoming IO-540-T4A5D engine, serial number L-15117-48A. A review of the airplane's logbooks revealed that its last annual inspection was completed on October 28, 2014, at a total airframe time of 3,436.5 hours. A review of the airplane's maintenance records revealed a total time since engine overhaul of 1,148.8 hours. The maintenance records showed that, on May 11, 1995, A McCauley 3-bladed propeller and a Woodward Governor were installed in accordance with STC No. SA4444NM. The original propeller installed on the Rockwell 114 was a 2-bladed Hartzell propeller model HC-C2YR-1BF. The maintenance records also showed that, on April 18, 2002, an aftermarket turbo normalization system was installed on the engine under Supplemental Type Certificate (STC) Number SE00357DE. At that time, the total airframe time was 2,758.0 hours, and the time since engine overhaul was 480.3 hours. The STC's instructions for continued airworthiness required that the turbo normalization system be inspected every 100 hours. On December 9, 2009, the turbo normalization system was removed, inspected, and reinstalled. The logbook entry noted that casting voids were found on the exhaust side of the turbocharger. The entry also noted that photographs had been provided to the turbocharger manufacturer for evaluation and that the manufacturer had deemed it airworthy. The engine logbooks contained no other entries indicating that the turbo normalization system was inspected in the 6 years before the accident. IFP fueling records indicated that the airplane was last fueled on May 17, 2015, with 20.0 gallons of 100LL aviation fuel. On May 17, 2015, about 1800 Pacific daylight time, a Rockwell Commander 114B airplane, N4775W, crashed shortly after takeoff near Laughlin, Nevada. The private pilot/owner sustained serious injuries, and the three passengers sustained fatal injuries. The airplane was destroyed by impact forces and postcrash fire. The pilot was operating the airplane as a 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions existed at the accident site about the time of the accident, and no flight plan had been filed. The flight departed Laughlin/Bullhead International Airport (IFP), Bullhead City, Arizona, at 1756, destined for Goodyear, Arizona. According to the pilot, he conducted an engine test run with no anomalies noted. At 1756, the tower controller cleared the flight for a straight-out departure to the south. During the climb to between about 300 and 400 ft above the ground, the engine started running roughly, and the airplane was not accelerating or climbing. The terrain ahead was rising, so the pilot turned right. Due to the low altitude and power, the pilot chose to conduct an off-airport landing, during which he attempted to troubleshoot the engine issue without success. As the airplane continued to descend, the pilot saw houses and bushes ahead; he aimed theairplane away from the houses, and the airplane eventually hit trees and terrain. A postimpact engine fire ensued. Several witnesses near the accident site reported seeing the airplane flying at a very low altitude. One witness reported seeing it descend into trees followed by a fireball. Another witness reported seeing the airplane flying on a southbound track with its wings level and then descending out of his sight; he then saw an explosion followed by a fireball. The pilot held a private pilot certificate with an airplane single-engine land rating. The pilot was issued a Federal Aviation Administration third-class medical certificate on December 18, 2014, with the limitations that he must wear corrective lenses/glasses for distant vision and possess glasses for near vision. The wreckage was transported to Air Transport, Phoenix, Arizona, for further examination. No abnormalities were noted with the airframe that would have precluded normal operation. The engine was removed and disassembled. The propeller hub remained attached to the engine. The three propeller blades were present and exhibited thermal damage. The turbocharger, magnetos, and oil filter remained attached to the engine. All the other engine components were attached at their respective positions and exhibited thermal damage. The turbocharger was found to be seized, it was disassembled, and examination of the turbowheel revealed that the blades were eroded. The overall diameter of the turbowheel was 2.451 inches. According to the manufacturer, a new turbowheel diameter is about 2.5 inches. It was also noted that the turbine impeller was significantly eroded and the heat shield was eroded which would allow hot gases to enter the bearing area and coke up the shaft. The airplane crashed in Big Bend State Park. The main wreckage was located 4.6 nautical miles southwest of IFP. The airplane initially hit a mesquite tree, then impacted sand, and finally came to rest 120 ft south of the first impact point on a magnetic heading of 273°. The postimpact fire consumed most of the airplane. Flight control continuity was established with all the flight control surfaces. The structure of all of the flight control surfaces and their corresponding counterweights were found in their correct positions. The landing gear were found in the retracted position. All of the cockpit components and instrumentation were consumed by fire. The main wing assembly sustained thermal damage consistent with a fuel-fed fire. All of the wing components were found in their respective locations. Both flap assemblies were consumed by fire and found near the attachment point to the wing structure. The right wing was found up against the right side of the fuselage and was consumed by fire.

Aircraft

Registration
N4775W
Reported as
Rockwell Commander 114 (B)
Category
Airplane
Serial number
14105
Built
1976
Airframe hours
3,436.5
Engine
Lycoming IO-540-T4A5D, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · October 28, 2014 · 20 hours before
Departed
IFP · Bullhead City, AZ
Destination
GYR · Goodyear, AZ
Airport
IFP · Laughlin/Bullhead Intl

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
59
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
July 12, 2013
Seat
Left
Flight hours
2,069 total · 1,920 as pilot in command · 9 in the last 90 days · 2.2 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 13 knots, gusting 21
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 28 °F
Altimeter
29.85 inHg
Observed at
KIFP, 5 nm away

Docket · 12

The files NTSB released with the investigation on June 1, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 15.4 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.