NTSB Factual Report

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 CONDITIONS

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 remained secured to its mounting pad. Internal examination revealed no internal malfunctions or any obstructions to flow. A blue fluid remained within internal cavities of the pump. Investigators disassembled the carburetor, which sustained mechanical damage. The throttle valve was bent; the screen separated, and was not located. There were no visible contaminants in the fuel bowl.

The turbocharger components were secure at their mounting points. The compressor and turbine impellers appeared undamaged. The turbine rotated freely by hand; each exhaust clamp was secure. The exhaust bypass valve (wastegate) remained secure, and the butterfly valve appeared undamaged.

Examination of the airframe noted that the landing gear was in the up position. The elevator trim was at an intermediate position between neutral and down. Both rudder cables separated in a broomstraw pattern. The elevator control cables were intact from the cockpit to the control surfaces; they were cut during recovery. One cable to each aileron separated in a broomstraw pattern. The other cable was cut during recovery. The elevator trim cables were intact from the cockpit to the trim tab; they were cut during recovery. The fuel selector valve was in the right main position.

The pitot system was connected to the instruments, but separated at the left wing root. Investigators cut the line aft of the airspeed indicator. Air was blown into the line, and the airspeed indicator moved through its full range. Air came out of the fractured line at the wing root and no leaks were noted.

NTSB 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.