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Inflight break-up fatal for two

By NTSB · March 8, 2016 ·

The pilots of the twin-engine Piper PA-44-180 were conducting a cross-country instrument flight rules (IFR) flight. Although both pilots were instrument-rated and IFR-current, the right seat pilot had only 8.8 hours of actual instrument experience, and the left seat pilot had only 1.8 hours of actual instrument experience.

While en route and likely operating in IFR conditions, radio and radar contact were lost after the airplane entered a descending, 180° right turn. Both pilots were killed in the crash.

Examination of the wreckage at the accident site near Brunswick, Ga., revealed signatures consistent with an in-flight breakup of the airframe.

The horizontal situation indicator (the only vacuum-system-driven flight instrument that was recovered) exhibited signatures showing that it was likely not operational when the airplane hit the ground. Both of the engine-driven vacuum pumps exhibited fractured rotors.

Although physical examination of the vacuum pumps could not determine whether the rotors fractured before or during impact, the inoperative horizontal situation indicator suggests that both pumps had failed before the impact.

The operator reported that the vacuum pump mounted to the airplane’s right engine was not operational before the airplane was dispatched on the accident flight and that the pilots had been advised of this deficiency.

The operator used the Part 91 minimum equipment limitations for flights, which permitted dispatching the airplane with only one of the two engine-driven vacuum pumps operational.

However, the FAA’s master minimum equipment list for the airplane for Part 91 operators advises them to limit the airplane to daytime visual flight rules flights when only one of the two vacuum pumps is operational.

The decision to dispatch the airplane with a known mechanical deficiency and no operational limitations reduced the safety margin for the flight and directly contributed to the accident.

It is likely that the left vacuum pump failed en route, rendering the vacuum-driven flight instruments inoperative.

Given the pilots’ minimal flight experience operating in IFR conditions, combined with the difficulty of detecting and responding to the loss of attitude information provided by the vacuum-driven flight instruments, it is likely that the pilots became spatially disoriented and lost control of the airplane, resulting in the subsequent inflight breakup.

The NTSB determined the probable cause as an inflight failure of the airplane’s only operating vacuum pump, which resulted in the loss of attitude information provided by vacuum-driven flight instruments.

Also causal was the pilots’ failure to maintain control of the airplane while operating in instrument flight rules (IFR) conditions, likely due to spatial disorientation, following the failure of the vacuum pump.

Contributing to the accident was the operator’s decision to dispatch the airplane with a known inoperative vacuum pump into IFR conditions.

NTSB Identification: ERA14FA168

This March 2014 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.

About NTSB

The National Transportation Safety Board is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in the other modes of transportation, including railroad, transit, highway, marine, pipeline, and commercial space. It determines the probable causes of accidents and issues safety recommendations aimed at preventing future occurrences.

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Comments

  1. C J says

    March 9, 2016 at 9:20 am

    When operating any aircraft with a vacuum pump system. One should know the age and hours on those components. I recommended that with a twin you replace one dry pump with 500 hr. and leave the remaining pump on the aircraft. That way you have a better chance of operational success. I have seen dry pumps fail within 5 hr. of each other due to age. Wet pumps will generally last until engine overhaul. Then overhaul them! Dry systems fail the rubber couplings which can be seen upon examination on the engine. Ask the mechanics, Ask the owner, ask your self do you trust it enough for bad weather. I lost one on a Mooney in November with a starless night coming out of Meig’s field Chicago decades ago. The owner pilot didn’t recognize the problem until I pointed out the turn coordinator angle. The gyros had died and he didn’t believe it as we had just landed an hour before to pick up is two sons.

  2. John says

    March 9, 2016 at 8:23 am

    Stupid pilot tricks again. The aircraft should have been limited to day VFR local flying until the vacuum pump was replaced. This fatal accident could have and should have been prevented. It would be interesting to see more context to the story to find out why these two pilots felt they had to fly that aircraft on that day and why the aircraft was even dispatched with the known deficiency.

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