# NTSB ATL94FA029: Piper PA-32R-301T, N8340Y, Covington, GA, December 10, 1993 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 10, 1993, 18:40 local (23:40 UTC) - Place: Covington, GA - Location: 33.6054° N, 83.8466° W: Placed by OpenAirDocs: center of Covington, GA, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=33.6054&lon=-83.8466&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report October 20, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 3280 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL94FA029 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/3280/pdf - Page: https://openairdocs.org/ntsb/ATL94FA029 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, cruise - engine accessories,vacuum pump - failure,total (contributing factor) - Loss of control - in flight, cruise - normal - weather condition - clouds (contributing factor) - light condition - dark night (contributing factor) - aircraft control - not maintained, pilot in command (cause) - spatial disorientation, pilot in command (cause) - In flight collision with terrain/water, descent - 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](https://openairdocs.org/deregistered/N8340Y-2013-05-30), registration cancelled 2013-05-30, S/N 32R-8129042, built 1981 (OpenAirDocs) - Reported make and model: PIPER PA-32R-301T (PA-32R-301) - Registry model: [Piper PA-32R-301T](https://openairdocs.org/model/piper-pa-32r-301t) (registry code 7103220) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 32R-8129042 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; 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 (OpenAirDocs). - [Accident 19931210046699A](https://openairdocs.org/incident/19931210046699A), Dec 10, 1993: Piper PA32R301T, Covington, GA, Destroyed, 1 fatal. Reported gyro failed on approach. Lost control. Hit trees. Vacuum pump failed due oil seal leak. Unable part panel. 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.