ATL94FA029

NTSB accident investigation · Piper PA-32R-301T · Covington, GA · December 10, 1993

Accident · FatalField investigationFinal report
Date
December 10, 1993, 18:40 local (23:40 UTC)
Place
Covington, GA
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N8340YPiper PA-32R-301T
Weather
Instrument (IMC) · Night/dark
Status
Completed · report October 20, 1994
Report
Approved by Office Director
FAA report
19931210046699A
Case key
3280

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

Spatial disorientation experienced by the pilot, resulting in his failure to maintain aircraft control. Factors were the total failure of the engine driven vacuum pump, and the night, cloud conditions prevailing at the time of the accident.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionCruise
Engine accessories,vacuum pump - failure,totalFactor
Loss of control - in flightCruise - normal
Weather condition - cloudsFactor
Light condition - dark nightFactor
Aircraft control - not maintainedPilot in commandCause
Spatial disorientationPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The private pilot was returning to his home base on an IFR flight plan. Night, IMC prevailed. Several minutes prior to the accident, he informed ATC that his instrument gyro had failed. He later reported that his instruments were working; however, there was a 'light on'. He then reported that he was 'in trouble'. ATC observed the aircraft in a rapid descent prior to a loss of radar contact. The aircraft impacted wooded terrain in a steep, nose low attitude. An examination of the vacuum system revealed that the engine driven vacuum pump had failed due to oil ingestion. Further investigation revealed that an engine oil leak was repaired in June 1993, and the origin of the leak was the engine accessory drive seal, where the vacuum pump attaches to the engine. The failed pump was installed as new about a week prior to the oil leak repair. The pump that was removed in June 1993, also failed due to oil ingestion.

Factual narrative

History of flight

On December 10, 1993, at 1840 eastern standard time, a Piper PA-32-R-301T, N8340Y, collided with terrain following an in flight loss of aircraft control near Covington, Georgia. The private pilot was fatally injured. The aircraft was destroyed by impact forces and fire. The aircraft was operated under 14 CFR Part 91 by the pilot. Instrument meteorological conditions prevailed at the time, and an instrument flight rules (IFR) flight plan was in effect for the personal flight to the Dekalb-Peachtree Airport in Atlanta, Georgia. The flight originated in Vero Beach, Florida, about 1553.

According to recorded air traffic control communications, the pilot of N8340Y reported at 1829:12 that he had lost his "instrument gyro" and was inquiring into areas of visual flight rules (VFR) weather. When queried if he was in VFR weather conditions, the pilot replied "Ah no sir I'm in the soup." At 1832:24, N8340Y stated that "Ah yeah they seem to be working now ah still got the warning light but the instruments are working properly." At 1839:31, N8340Y reported "I'm still in trouble here I need to go somewhere clear." Prior to a loss of radar contact by Air Traffic Control, the pilot reported "Yeah I'm in trouble here."

An Air Traffic Control Specialist who was working the flight reported that prior to losing radio contact with N8340Y, the aircraft was observed to be in a "rapid descent." A witness who lives adjacent to the accident site reported that he first saw the aircraft about 250 feet above the ground, in a steep, left bank, and descending rapidly. Prior to this, he had heard the airplane circling for about four minutes. When he saw the aircraft in the descent, he reported that the engine was "running wide open."

Personnel information

Information on the pilot is included in this report at the section titled "First Pilot Information." A pilot logbook was not located following the accident. Pilot flight time information was obtained from the pilot's insurance company and from the Federal Aviation Administration. The pilot's flight instructor reported that, according to his records, the accident pilot had flown about 60 hours in N8340Y, therefore 50 hours were added to the hours shown on the insurance company pilot record to obtain the total time shown in the flight time matrix on page 3.

Mr. Dan Horton, Chief Pilot at Flight Level Aviation, Atlanta, Georgia, reported the following: He flew dual instruction with Mr. Edwards prior to Mr. Edwards obtaining his instrument rating in January of 1993. Mr. Edwards' performance allowed him to complete his training in minimum time. During the dual instruction prior to the instrument check ride, all areas of instrument flight were performed, including emergency procedures and partial panel procedures. He reported that Mr. Edwards' partial panel procedures were "flawless," and various scenarios were covered, including the loss of attitude and heading indicators. He recalled that Mr. Edwards was proficient in the use of the standby vacuum system, which is connected to the engine intake manifold. He commented that Mr. Edwards was not the type to panic in an emergency situation.

Aircraft information

Information on the aircraft is contained in this report at the section titled "Aircraft Information."

The maintenance logbooks were found in the burned area of the wreckage, and recent logbook entries were destroyed. The following maintenance records were provided by the pilot's family and by maintenance personnel known to have serviced the aircraft.

As per work order dated June 22, 1993 (aircraft total time 1486 hours), the engine driven vacuum pump, Airborne Model 211CC, serial number 2AH1910, was removed from N8340Y as inoperative, and a new vacuum pump, serial number 8AH5332, was installed. This work was performed by Flight Level Aviation, Atlanta, Georgia. The inoperative pump was subsequently sent to Airborne for warranty consideration. After an inspection by Airborne, a letter was sent to Flight Level Aviation, dated July 28, 1993, stating that the pump failed due to oil ingestion. The letter explained the consequences of oil contamination to the pump, along with their recommendations for extended life of future applications.

As per work order dated June 30, 1993 (aircraft total time 1494 hours), the aircraft was repaired for an oil leak at Miracle Strip Aviation, Inc., in Destin, Florida. According to the maintenance personnel at Miracle Strip Aviation, the origin of the oil leak was determined to be from the engine pad drive seal, where the vacuum pump attaches to the engine. The oil seal was replaced, the vacuum pump was remounted, and the underside and cowling of the aircraft was washed.

The last maintenance record that contained aircraft time information was a work order dated October 1, 1993, from Flight Level Aviation (aircraft total time 1529 hours). This work order pertained to an engine oil and filter change.

The aircraft hour meter was not recovered from the wreckage, therefore the time of aircraft operation since October 1, 1993 is not known.

Meteorological information

Instrument meteorological conditions existed at the time of the accident. Meteorological information is included in this report at the section titled "Weather Information."

Wreckage and impact information

The aircraft impacted trees and terrain in a rural, wooded area. The engine and propeller assembly was found in hard, red clay, about six feet below the surface of the ground, with the cockpit area located about two feet below the surface of the ground. The wings, fuselage, and empennage were found adjacent to the engine crater. The wing surfaces were compressed chordwise, from the leading edges aft, and the entire wing area was burned. The vertical stabilizer and rudder were found with the inboard sections of the stabilator. The outer tips of the stabilator were found adjacent to the main wreckage. Flight control continuity was confirmed from the stabilator and rudder to the cockpit area.

The propeller hub assembly was crushed aft, and one of the three blades remained attached to the hub. The other two blades were found at the lowest point inside the crater where the engine was found. All three blades were twisted toward low pitch, showed "s" bending, and chordwise scratching signatures. Several spark plugs were removed from the engine; all plugs were normal in color and wear when compared to a manufacturer's inspection chart. Fuel was found inside the fuel injector servo.

The engine driven vacuum pump was removed from the engine. The plastic drive shaft was fractured at the shear point, and the pump would not rotate. The seal on the engine accessory section for the vacuum pump drive showed no evidence of oil leakage, however the vacuum pump had oily residue on the drive section.

The vacuum-operated artificial horizon was disassembled and inspected. There was extensive crushing damage to the case and internal components. The rotor was removed from its' housing; there were several static marks on the inside surface of the rotor housing which matched the vanes on the rotor.

Medical and pathological information

A post mortem examination of the pilot was performed by the Georgia Bureau of Investigation, Division of Forensic Sciences. Toxicological testing was negative for drugs and carbon monoxide. There was 58 mg/dL of ethanol found in the kidneys, however, the report states that the ethanol found in this case is most likely from postmortem ethanol production.

Additional information

The engine driven vacuum pump was removed from the engine and shipped to the FAA Manufacturing Inspection District Office (MIDO) in Cleveland, Ohio, so that an inspection of the pump could be performed at the manufacturer's facility. According to Airborne/Parker Aerospace engineers, the pump failed due to oil ingestion over an extended period of time. A co

Aircraft

Registration
N8340Y
Reported as
Piper PA-32R-301T (PA-32R-301)
Category
Airplane
Serial number
32R-8129042
Engine
Lycoming TIO-540-S1AD, 300 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Edwards, Thomas E., doing business as Vector Corporation
Registered owner
Edwards, Thomas E.
Airworthiness certificate
Standard, Normal
Departed
VRB · Vero Beach, FL
Destination
PDK · Atlanta, GA
Flight plan
IFR

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
45
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--no waivers/lim.
Toxicology
Performed
Flight hours
530 total · 60 in this make and model

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
250° at 7 knots
Visibility
5 statute miles
Lowest ceiling
200 ft overcast
Temperature
55 °F, dew point 55 °F
Altimeter
29.00 inHg
Observed at
ATL, 32 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.