# NTSB WPR15FA163: Rockwell Commander 114, N4775W, Laughlin, NV, May 18, 2015 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: May 17, 2015, 18:00 local (May 18, 2015, 01:00 UTC) - Place: Laughlin, NV - Coordinates: 35.116664, -114.639167 - Nearby events: https://openairdocs.org/map.md?lat=35.1167&lon=-114.6392&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Fatal - Injuries: 3 fatal, 1 serious - Status: Completed, report June 7, 2017 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration, Lycoming Engines - NTSB case key (mKey): 91181 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR15FA163 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91181/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91181 - Page: https://openairdocs.org/ntsb/WPR15FA163 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Inspection: scheduled/routine inspection](https://openairdocs.org/ntsb-findings/02061520): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Rockwell International 114, 1 case](https://openairdocs.org/ntsb-findings/02061520/cases.md?model=7630314), [All aircraft, 167 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md) - [Turbocharging (recip only): turbocharger](https://openairdocs.org/ntsb-findings/01058120): Aircraft › Aircraft power plant · Fatigue/wear/corrosion (probable cause); cases with it: [Rockwell International 114, 1 case](https://openairdocs.org/ntsb-findings/01058120/cases.md?model=7630314), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/01058120/cases.md) - [Terrain: rough terrain](https://openairdocs.org/ntsb-findings/03021015): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Rockwell International 114, 2 cases](https://openairdocs.org/ntsb-findings/03021015/cases.md?model=7630314), [All aircraft, 442 cases](https://openairdocs.org/ntsb-findings/03021015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Rockwell International 114, 1 case](https://openairdocs.org/ntsb-events/342/sequence.md?model=7630314), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Rockwell International 114, 4 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7630314), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N4775W-2017-06-23), registration cancelled 2017-06-23, S/N 14105, built 1976 (OpenAirDocs) - Reported make and model: ROCKWELL COMMANDER 114 (B) - Registry model: [Rockwell International 114](https://openairdocs.org/model/rockwell-international-114) (registry code 7630314) (OpenAirDocs) - Category: Airplane - Serial number: 14105 - Year built: 1976 - Airframe hours: 3436.5 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 59; injuries: serious; 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 ## 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 20150517007349A](https://openairdocs.org/incident/20150517007349A), May 17, 2015: Rockwell International 114, Laughlin, NV, Destroyed, 3 fatal. On 5/17/2015, at approximately 1745 local time, N4775W, a Rockwell International GA-114 piloted by [privacy data omitted] , joined by three passengers,… ## Docket (12 files) The files NTSB released with the investigation on June 1, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91181. 15.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 614 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452728&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Accident Map with Witness Locations (item 2, .PDF, 230 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452729&FileExtension=.PDF&FileName=Accident%20Map%20with%20Witness%20Locations-Master.PDF - Record of Interview - Torres (item 3, .PDF, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452730&FileExtension=.PDF&FileName=Record%20of%20Interview%20-%20Torres-Master.PDF - NTSB Field Investigation Report (item 4, .PDF, 5.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452731&FileExtension=.PDF&FileName=NTSB%20Field%20Investigation%20Report-Master.PDF - NTSB Engine Examination Report (item 5, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452732&FileExtension=.PDF&FileName=NTSB%20Engine%20Examination%20Report-Master.PDF - N4775W- Aircraft Logbook Annual Entry (item 6, .PDF, 291 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452733&FileExtension=.PDF&FileName=N4775W-%20Aircraft%20Logbook%20Annual%20Entry-Master.PDF - N4775W Engine Logbook Excerpt Pages (item 7, .PDF, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452734&FileExtension=.PDF&FileName=N4775W%20Engine%20Logbook%20Excerpt%20Pages-Master.PDF - STC SE00357DE- Maintainance Istructions (item 8, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452735&FileExtension=.PDF&FileName=STC%20SE00357DE-%20Maintainance%20Istructions-Master.PDF - Fueling Invoice (item 9, .PDF, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452736&FileExtension=.PDF&FileName=Fueling%20Invoice-Master.PDF - STC SE00357DE- Original and Current (item 10, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452737&FileExtension=.PDF&FileName=STC%20SE00357DE-%20Original%20and%20Current-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 11, .PDF, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452738&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 12, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452739&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF 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.