# NTSB ATL91FA067: Piper PA-28-201T, N2871H, Hamilton, NC, March 18, 1991

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: March 18, 1991, 09:10 local (14:10 UTC)
- Place: Hamilton, NC
- Coordinates: 35.939025, -77.200431 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=35.9390&lon=-77.2004&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 2 fatal
- Status: Completed, report December 15, 1992
- Report: Approved by Office Director
- NTSB case key (mKey): 8315
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL91FA067
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/8315/pdf
- Page: https://openairdocs.org/ntsb/ATL91FA067

## Probable cause

THE PILOT'S IMPROPER USE OF EQUIPMENT WHICH AFFECTED THE OPERATION OF THE STANDBY VACUUM PUMP, THE PILOT'S LOSS OF AIRCRAFT CONTROL AFTER EXPERIENCING SPATIAL DISORIENTATION, AND HIS EXCEEDING THE DESIGN STRESS LIMITS OF THE AIRCRAFT.  FACTORS RELATED TO THE ACCIDENT WERE: THE MECHANIC'S IMPROPER USE OF THREAD COATING MATERIAL, THE PILOT'S OPERATION OF THE AIRCRAFT WITH A KNOWN MALFUNCTION OF THE PRIMARY VACUUM PUMP, AND THE ADVERSE WEATHER CONDITIONS.

## Sequence of events

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

- Airframe/component/system failure/malfunction, cruise - normal
  - maintenance,installation - improper, other maintenance personnel (contributing factor)
  - vacuum system - foreign object damage (contributing factor)
  - operation with known deficiencies in equipment - continued, pilot in command (contributing factor)
  - vacuum system - failure,partial
  - vacuum system - improper use of, pilot in command (cause)
  - weather condition - clouds (contributing factor)
  - weather condition - icing conditions (contributing factor)
  - pitot/static system - undetermined
- Loss of control - in flight, cruise - normal
  - aircraft control - not maintained, pilot in command (cause)
  - spatial disorientation, pilot in command (cause)
- Airframe/component/system failure/malfunction, descent - uncontrolled
  - design stress limits of aircraft - exceeded, pilot in command (cause)
  - flight control,stabilator - overload
  - wing - overload
  - flight control,rudder - overload
- In flight collision with terrain/water, descent - uncontrolled

## Analysis

THE PILOT REPORTED A VACUUM SYSTEM FAILURE AND A PITOT STATIC SYSTEM MALFUNCTION DURING AN INSTRUMENT FLIGHT UNDER INSTRUMENT WEATHER CONDITIONS, BUT HE ELECTED TO CONTINUE THE FLIGHT. THE FLIGHT TRACK AND ALTITUDE WERE ERRATIC. AFTER 28 MINUTES OF FLIGHT, THE PILOT REPORTED THAT HE WAS IN A DIVE. SUBSEQUENTLY, THE RIGHT OUTBOARD WING PANEL, RUDDER AND HORIZONTAL STABILATOR(S) SEPARATED IN FLIGHT. EXAMINATION OF THE AIRPLANE REVEALED THAT THE VACUUM PUMP DRIVE COUPLING SHEARED BECAUSE OF IMPROPER THREAD TREATMENT (SEALANT TAPE) USED DURING INSTALLATION. THE AIRPLANE WAS EQUIPPED WITH A STANDBY VACUUM SYSTEM, WHICH AT HIGHER ALTITUDES, REQUIRED THAT THE PILOT SPOOL THE SYSTEM (REDUCE POWER THEN ADVANCE THE THROTTLE) TO MAINTAIN VACUUM PRESSURE.

## Aircraft

- Registration: [N2871H](https://openairdocs.org/deregistered/N2871H-2014-09-25), registration cancelled 2014-09-25, S/N 28-7921081 (OpenAirDocs)
- Reported make and model: PIPER PA-28-201T
- Registry model: [Piper PA-28-201T](https://openairdocs.org/model/piper-pa-28-201t) (registry code 7102819) (OpenAirDocs)
- Category: Airplane
- Serial number: 28-7921081
- Engines: CONTINENTAL TSIO-360 200 horsepower reciprocating
- Damage: Destroyed
- Flight: Business, Part 91
- Operator: Sansoucie, Barry R.
- Registered owner: Sansoucie, Barry R.
- Departed: CRE, MYRTLE BEACH, SC
- Destination: PAH, NEWPORT NEWS, VA
- Flight plan: IFR

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 45; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; toxicology performed; flight hours: 813 total

## Weather

- Conditions: Instrument (IMC), Day
- Wind: 300° at 10 knots
- Lowest ceiling: 300 ft overcast
- Temperature: 57 °F, dew point 57 °F
- Altimeter: 29.00 inHg
- Observed at: RWI, 35 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 19910318005709A](https://openairdocs.org/incident/19910318005709A), Mar 18, 1991: Piper PA28201T, Hamilton, NC, Destroyed, 2 fatal. Vacuum pump shaft sheared,unable control. Reported dive,lost empannage. Vacuum fouled by improper installation.

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.