History of Flight
On March 24, 2014, about 1738 Eastern Daylight Time, a Piper PA-44-180, N923RS, was destroyed during an inflight breakup and subsequent impact with terrain near Brunswick, Georgia. The flight departed from Concord Regional Airport (JQF), Concord, North Carolina, about 1551 and was destined for Jacksonville Executive Airport at Craig (CRG), Jacksonville, Florida. Day visual meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed. The two private pilots were fatally injured. The personal flight was conducted under Part 91.
Personnel Information
The right seat pilot held a private pilot certificate with ratings for airplane single- and multi-engine land, and instrument airplane. He held a first-class medical certificate issued February 4, 2014, with no limitations, reporting 73 total hours. His logbook last entry on March 24 indicated a flight from JQF to CRG in a different PA-44-180; total recorded time was 155.3 hours and 8.8 hours of actual instrument.
The left seat pilot also held a private pilot certificate with single, multi, and instrument ratings, and a first-class medical/student pilot certificate issued May 20, 2013, with no limitations. He reported no previous flight experience at that medical. His logbook last entry dated March 23 indicated a flight from Daytona Beach International to JQF; total recorded time was 163.7 hours and 1.8 hours of actual instrument.
Aircraft Information
The airplane was issued an airworthiness certificate on August 19, 1976, and registered to ATP Aircraft 2, LLC since January 29, 2008. It was powered by Lycoming O-360-E1A6D and LO-360-E1A6D engines. No autopilot was installed. The last recorded Hobbs meter entry was 2,290.6 hours, corresponding to an airframe total time of 6,664.3 hours.
The left engine vacuum pump was installed May 13, 2011 (Hobbs 1,082.8). The right engine vacuum pump was installed August 31, 2013 (Hobbs 2,118.1), but the serial number in maintenance records did not match the installed unit. The operator stated the actual right pump was installed January 24, 2014; it had been overhauled June 18, 2013. According to maintenance records, the right pump had accumulated about 65 hours since overhaul, but was noted as inoperative and placarded per FAR 91.213(d) prior to the accident flight. The pilots were advised of this discrepancy and could refuse the airplane. No flight limitations existed for an inoperative vacuum pump beyond applicable FARs and the Pilot's Operating Handbook.
Meteorological Information
The 1755 weather observation at Brunswick Golden Isle Airport (BQK), about 3.5 miles west-southwest of the accident, included wind from 050 degrees at 10 knots gusting to 16 knots, visibility 10 miles, overcast clouds at 3,800 feet agl, temperature 12°C, dew point 7°C, and altimeter 30.08 inHg. The 2000 upper air sounding from Jacksonville, Florida, 50 miles south, indicated the freezing level at 10,000 feet, no icing, LCL at 1,580 feet agl, relative humidity >80% from LCL to 6,300 feet, a low-level frontal inversion from 2,500 to 3,800 feet with high probability of moderate turbulence at 3,800 feet, and a stable atmosphere. GOES-13 infrared satellite at 1745 showed low to mid-level stratocumulus to nimbostratus clouds with cloud tops near 20,000 feet; no cumulonimbus were identified.
The pilot obtained a preflight weather briefing via DUATS at 1516 and filed an IFR flight plan through ForeFlight. En route at 1647, he contacted Flight Watch and issued a pilot report indicating 10 miles visibility, no turbulence, no visible weather, and light haze.
Communications
Recorded air traffic control communications showed the flight contacted Jacksonville ARTCC at 1727:23 and reported altitude 8,000 feet. The controller provided the local altimeter setting, which the flight confirmed at 1727:32. No further communications were received. Several attempts to contact the flight between 1739:27 and 1740:36 were unanswered. The controller solicited assistance from another aircraft, stating the accident flight was seen descending and lost on radar. That aircraft was unable to locate the accident airplane, and no ELT was heard.
Radar Data
Review of radar data indicated the flight was cruising at 8,000 feet msl. The last four radar targets over 38 seconds showed descent from 7,900 to 7,200 feet msl. The last return at 1738:10 indicated 0 feet msl near the accident location. The final four targets above 7,000 feet were consistent with a descending right 180-degree turn.
Wreckage and Impact
The wreckage was in a marsh area in about 15 feet of water, inverted at N 31:16.793, W 081:24.687, elevation 4 feet msl. The debris path was about 2 miles long on a linear path. Engines remained attached to the airplane and were co-located with the main wreckage. Debris orientation was on a 225-degree magnetic heading from the main wreckage, which was about half a mile from the last radar return on a 130-degree heading. Outboard wing sections were found about 0.9 mile from the main wreckage; the vertical stabilizer was about 2 miles away. Examination of the recovered airframe and flight control systems showed no evidence of preimpact mechanical malfunctions. The only recovered air-driven gyro instrument (HSI) had minimal housing damage and no evidence of crush damage; disassembly found no scoring or rotational damage.
Medical and Pathological Information
Autopsies of both pilots, performed March 27, 2014, by the Georgia Bureau of Investigation, listed the cause of death as "Multiple Injuries due [to] Aircraft Accident" with specific injuries documented. Forensic toxicology for the right seat pilot found no carbon monoxide in cavity blood, no ethanol in vitreous, and no drugs in urine. For the left seat pilot, no carbon monoxide in cavity blood, and no ethanol or drugs in urine.
Tests and Research
Both vacuum pumps were found attached to their respective engines with sheared drive shafts and salt deposits. The left pump had accumulated 1,207.8 hours since overhaul. Disassembly revealed the rotor fractured in multiple locations, cracks on 4 of 6 slots, and a transverse crack across a rotor flange hole. Rotor faces showed dents and wear consistent with non-rotational contact, but housing interior had circumferential wear marks from rotation. The fracture surfaces were consistent with brittle overstress and multiple crack initiations. Horizontal and vertical sliding marks on vanes indicated rotational operation. The left pump's vanes were narrower and inconsistent compared to the right pump's vanes.
A report from Replacement Aircraft Parts Co. (RAPCO) on shear coupling force failure after simulated in-flight vacuum pump failure described melting of base material at various post-failure run times. The left pump exhibited melting similar to 30-second and 1-minute post-failure components, but the investigation could not determine how long it operated after the coupling sheared.
Organizational and Management Information
The airplane was operated by Airline Transport Professionals, Inc. (ATP), which conducted flight training at 38 centers in 18 states and operated 266 aircraft, including 104 Piper PA-44s. The accident pilots were based in Jacksonville, Florida. ATP had six maintenance centers and used contract maintenance providers, including one in Jacksonville.
Additional Information
RAPCO Service Letter RASL-005 (revised October 6, 2010) recommended replacing vacuum pumps at 500 flight hours or 6 years from installation. The FAA Pilot's Handbook of Aeronautical Knowledge noted the unreliability of the vestibular system when visual horizon is lost. The FAA Instrument Flying Handbook described spatial disorientation scenarios, including the graveyard spiral. The Piper PA-44 Maintenance Manual required vacuum pump inspections every 100 hours. The Pilot's Operating Handbook specified vacuum system procedures and emergency actions for gyro suction failures. The FAA Piper PA-44 Master Minimum Equipment List for Part 91 operations allowed one vacuum pump to be inoperative for day VFR flights. 14 CFR Part 91.205 required gyroscopic instruments for IFR flight.