DEN93FA099

NTSB accident investigation · Piper PA-32-300 · Delight, AR · August 6, 1993

Accident · FatalField investigationFinal report
Date
August 6, 1993, 11:40 local (16:40 UTC)
Place
Delight, AR
Injuries
6 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N479KCPiper PA-32-300
Weather
Visual (VMC) · Day
Status
Completed · report June 22, 1994
Report
Approved by Office Director
FAA report
19930806028069A
Case key
11084

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

The failure of the vacuum pump, and an inoperative turn coordinator. Factors which contributed to the accident were: the pilot's loss of control of the airplane as a result of spatial disorientation, the pilot exceeding the design stress limits of the airplane, and the weather conditions (clouds).

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 - normal
Engine accessories,vacuum pump - failure,totalCause
Flight/nav instruments,turn and bank indicator - inoperativeCause
Loss of control - in flightManeuvering
Weather condition - cloudsFactor
Aircraft control - uncontrolledPilot in commandFactor
Spatial disorientationPilot in commandFactor
Design stress limits of aircraft - exceededPilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled

Analysis

After being cleared for the localizer approach to the texarkana airport, the pilot cancelled his IFR flight plan, and said he would proceed VFR to nashville, AR. Shortly thereafter, the pilot reported he was in the clouds and that he had lost his vacuum, the turn coordinator did not work, and he was on the verge of vertigo. The controller attempted to vector the pilot back to texarkana, but noted he was having difficulty holding a heading. The airplane broke up in flight. The left wing spar was found twisted up and aft, the right wing spar was bent slightly down and aft, and the vertical stabilizer spar was bent aft. Laboratory examination of the vacuum pump revealed the drive shaft had sheared in torsion, the rotor had broken in overstress, and the vanes were worn. It could not be determined if the inoperative turn coordinator, which had an electrical impedance of 10,000 ohms, had failed prior to or on the accident flight.

Factual narrative

History of flight

On August 6, 1993, at approximately 1140 central daylight time, a Piper PA-32-300, N479KC, was destroyed when it broke up in flight and impacted terrain about seven miles southeast of Delight, Arkansas. The pilot and five passengers were fatally injured. Visual meteorological conditions prevailed at the site: however, the airplane was in instrument meteorological conditions when contact was lost. An IFR flight plan had been filed.

The pilot contacted the McAlester (OK) Flight Service Station via radio at 0924 while in flight and, after receiving a briefing on weather conditions in the Texarkana, Arkansas area, filed an IFR flight plan. At 1035, he requested clearance from the Fort Worth Air Route Traffic Control Center (ARTCC) to descend from 5,000 feet to 4,000 feet "to see if we can make a visual approach into Nashville, Arkansas." The controller said this was not possible due to the minimum vectoring altitudes (MVA) in the area, but cleared him to "cruise" to the Nashville Airport at 5,000 feet.

At 1047, after reporting he was still in the clouds and could not see the airport, the pilot was given radar vectors to intercept the localizer course at Texarkana Airport, and was cleared to descend to 2,100 feet. At 1059 the pilot asked, "Can we go ahead and go on our own and get back to Nashville now and go through the clouds. I see a shot where we can make it." He then cancelled his IFR flight plan and radar services were terminated.

At 1110, the pilot reported back on the Fort Worth ARTCC frequency and said, "We've lost our vacuum. We're in the clouds. We're in a helluva bind...Nothing's working...My directional gyro I don't believe is working either. It went to spinning awhile ago." The controller attempted to vector him back to the Texarkana Airport, but noted the pilot was having difficulty holding a heading. At 1114, the pilot confirmed he was declaring an emergency. A 1127, another pilot who had been listening to the radio conversation suggested that he use the turn and bank indicator for attitude information. The pilot replied that it "does not work." Shortly thereafter, the pilot said, "I need to get above these clouds. I'm fixin' to get vertigo." He was cleared to 9,000 feet, and acknowledged the clearance at 1138. This was the last known radio communication with the pilot.

Personnel information

Flight times found in this report are based on a photostatic copy of a portion of the pilot's most recent log book. This document contained entries from December 28, 1989, to December 3, 1992, and indicated the pilot had obtained instrument competency checks on March 22, 1992, and March 11, 1993. According to the instructor who administered these checks, partial panel procedures were reviewed and the pilot's performance had been satisfactory.

Wreckage and impact information

Wreckage was strewn through a heavily wooded area for about 1/4 mile on a magnetic heading of 005 degrees. The left wing outboard panel, with the aileron missing, was found on top of a shed in the rear of a residence. Across the street, in the back yard of another residence, was the left wing tip. The left wing inboard panel, with the landing gear still attached, was located in the woods behind this house. The inverted fuselage, with the right wing attached by aileron cables, was found about 1/4 mile away. The separated stabilator, vertical stabilizer, and rudder were in close proximity to the fuselage. The tops of several trees lay on the ground nearby. The left wing spar was twisted up and aft; the right wing spar was bent slightly down and aft. The front spar of the vertical stabilizer was bent aft.

Tests and research

The vacuum pump, low vacuum annunciator light, vacuum gauge, and the filter from the gyroscopic artificial horizon vacuum were examined at NTSB's metallurgical laboratory. According to the metallurgist's factual report, the vacuum pump rotor was broken in three pieces "consistent with overstress breaks is castings." The vanes were intact but worn, measuring between 0.58 and 0.62 inch. The vacuum pump drive shaft coupling was fractured. On the engine (drive) side, the fracture was on helical planes "indicative of a brittle torsional separation...There was no evidence of ductility." On the pump (driven) side, there was "post fracture rotational damage...and the resulting shape was conical."

The low vacuum annunciator light filament was stretched, "indicative of the filament being hot" on impact. The filter in the gyroscopic artificial horizon filter had two small tears and contained amounts of carbon, oxygen, silicon, sulfur, aluminum, potassium, calcium, and iron deposits. The vacuum gauge bore no evidence of needle indicator marks on its face.

The turn coordinator was examined at AMR Combs, Denver, Colorado. Despite impact damage to the instrument, the turn needle and gyroscope were free to turn, but the slip tube glass was broken and the ball was missing. An electrical impedance test disclosed a 10,000 ohm resistance. It could not be determined if this resistance was a preexisting condition or the result of impact.

Additional information

The wreckage was released on August 7, 1993, and the turn coordinator, filter from the gyroscopic artificial horizon, and the vacuum pump, gauge, and annunciator light were released on January 26, 1994, to the John Ashford Company, Sherman, Texas.

Aircraft

Registration
N479KC
Reported as
Piper PA-32-300
Category
Airplane
Serial number
32-7840019
Airframe hours
2,497
Engine
Lycoming IO-540-K1G5D, 300 horsepower, reciprocating
Damage
Destroyed
Flight
Business · Part 91
Registered owner
Mcglaughlin, Earl W.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 12, 1993 · 67 hours before
Departed
LNK · Lincoln, NE
Destination
M77 · Nashville, AR
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
40
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
628 total · 29 in this make and model · 415 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 8 knots
Visibility
5 statute miles
Lowest ceiling
1,300 ft broken
Temperature
81 °F, dew point 73 °F
Altimeter
29.00 inHg
Observed at
TXK, 40 nm away

Docket · 38

The files NTSB released with the investigation on June 3, 1995, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.3 MB in all.

Supplement AItem 1 · .PDF · 237 KBSupplement BItem 2 · .PDF · 375 KBSupplement KItem 3 · .PDF · 420 KBSupplement SItem 4 · .PDF · 58 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2Item 5 · .PDF · 648 KBFactual Report from NTSB Metalurgy LabItem 6 · .PDF · 82 KBPhoto 1. Overall view of components as received.Item 7 · .PDF · 25 KBPhoto 2. view of vacuum pump internal rotor and vanes after removal of pump back arrowed "p" in figure 1, X2Item 8 · .PDF · 36 KBPhoto 3. Closeup of bulb from low vacuum warning annunciator light, arrowed "b" in figure 1. X10Item 9 · .PDF · 27 KBPhoto 4A. View left X4 and right X10, of Gyroscopic artificial horizon vaccum filter arrowed "f" in figure 1.Item 10 · .PDF · 21 KBPhoto 4B. Two views, left X4 and right X10, of Gyroscopic artificial horizon vacuum filter arrowed "f" in figure 1.Item 11 · .PDF · 54 KBPhoto 5A. Views of separated drive shaft coupling on the pump side. Left view looking directly toward pump and right view is inclined to show coning.Item 12 · .PDF · 41 KBPhoto 5B. View of separated drive shaft coupling on the pump side. Left view looking toward pump and right view is inclined to show coning.Item 13 · .PDF · 34 KBPhoto 6A. View of separated drive shaft coupling on the engine side. Left side looking directly toward engine and right view is inclined to show helical fracture planes.Item 14 · .PDF · 33 KBPhoto 6B. View of separated drive shaft coupling on the engine side. Left view looking directly toward engine and right view is inclined to show helical fracture planes.Item 15 · .PDF · 29 KBPhoto 7. Higher magnification inclined view of separated drive shaft on the engine side with the coupling rotated somewhat form the position shown in right view in figure 6.Item 16 · .PDF · 34 KBPhoto 8. SEM view of the origin area indicated by bracket "01" in figure 7. x 18.6Item 17 · .PDF · 41 KBPhoto 9A. SEM photograph of main origin area, arrowed "0" on drive shaft coupling.Item 18 · .PDF · 46 KBPhoto 9B. SEM photograph of main origin area, arrowed "0" on drive shaft coupling.Item 19 · .PDF · 52 KBPhoto 9C. SEM photograph of main origin area, arrowed "0", on drive shaft coupling..Item 20 · .PDF · 50 KBPhoto 9D. Photograph is higher magnification view of area outline by dashed line.Item 21 · .PDF · 54 KBPhoto 10. Light microscope view of origin area on drive shaft coupling. X20Item 22 · .PDF · 62 KBPhoto 11. Underside of the engine side portion of the coupling after removing from the drive spline. X4Item 23 · .PDF · 35 KBPhoto 12A. New coupling obtained from Airborne and subjected to torsional overstress to near breakage. X4.Item 24 · .PDF · 34 KBPhoto 12B. New coupling obtained from Airborne and subjected to torsional overstress to near breakage. X10Item 25 · .PDF · 35 KBPhoto 13. Fracture surface of another new coupling overstress fractured in torsion. X4Item 26 · .PDF · 35 KBWitness Statement, Jerry MohlerItem 27 · .PDF · 55 KBWitness Statement, Kyle AndrewsItem 28 · .PDF · 12 KBMaps or Charts of Accident Area, VFR SectionalItem 29 · .PDF · 441 KBWeather Reports and RecordsItem 30 · .PDF · 184 KBReports from Federal Agencies - ATC TranscriptItem 31 · .PDF · 656 KBPhoto 1. The left outboard wing panel on roof of shed.Item 32 · .PDF · 37 KBPhoto 2. The left wing tip, found in the backyard of residence. Left outboard wing panel was found behind first residence across street (arrow)Item 33 · .PDF · 46 KBPhoto 3: The left wing and landing gearItem 34 · .PDF · 48 KBPhoto 4: Trees struck by falling aircraft fuselageItem 35 · .PDF · 60 KBPhoto 5. Airplane wreckageItem 36 · .PDF · 52 KBPhoto 6. Airplane wreckageItem 37 · .PDF · 32 KBPhoto 7. Airplane wreckageItem 38 · .PDF · 46 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.