ERA14FA168

An inflight failure of the airplane's only operating vacuum pump, which resulted in the loss of attitude information provided by vacuum-driven flight instruments. Also causal was the pilots' failure to maintain control of the airplane while operating in instrument flight rules (IFR) conditions, likely due to spatial disorientation, following the failure of the vacuum pump. Contributing to the accident was the operator's decision to dispatch the airplane with a known inoperative vacuum pump into IFR conditions.

The pilots of the twin-engine airplane were conducting a cross-country instrument flight rules (IFR) flight. Although both pilots were instrument-rated and IFR-current, the right seat pilot had only 8.8 hours of actual instrument experience, and the left seat pilot had only 1.8 hours of actual instrument experience. While en route and likely operating in IFR conditions, radio and radar contact were lost after the airplane entered a descending, 180-degree right turn. Examination of the wreckage at the accident site revealed signatures consistent with an in-flight breakup of the airframe. The horizontal situation indicator (the only vacuum-system-driven flight instrument that was recovered) exhibited signatures showing that it was likely not operational when the airplane impacted the ground. Both of the engine-driven vacuum pumps exhibited fractured rotors. Although physical examination of the vacuum pumps could not determine whether the rotors fractured before or during impact, the inoperative horizontal situation indicator suggests that both pumps had failed before the impact. The operator reported that the vacuum pump mounted to the airplane's right engine was not operational before the airplane was dispatched on the accident flight and that the pilots had been advised of this deficiency. The operator used the Part 91 minimum equipment limitations for flights, which permitted dispatching the airplane with only one of the two engine-driven vacuum pumps operational. However, the Federal Aviation Administration's master minimum equipment list for the airplane for Part 91 operators, advises operators to limit the airplane to daytime visual flight rules flights when only one of the two vacuum pumps is operational. The operator's decision to dispatch the airplane with a known mechanical deficiency and no operational limitations reduced the safety margin for the flight and directly contributed to the accident. It is likely that the left vacuum pump failed en route rendering the vacuum-driven flight instruments inoperative. Given the pilots' minimal flight experience operating in IFR conditions combined with the difficulty of detecting and responding to the loss of attitude information provided by the vacuum-driven flight instruments, it is likely that the pilots became spatially disoriented and lost control of the airplane, resulting in the subsequent inflight breakup. No definitive determination could be made as to which of the two pilots was acting as pilot-in-command of the airplane at the time of the loss of control.

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 the 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 the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. According to Federal Aviation Administration (FAA) records and Lockheed Martin Flight Service records, the pilot seated in the right seat filed and IFR flight plan with an intended departure time of 1530, and had requested an enroute cruise altitude of 8,000 feet above mean sea level (msl). PERSONNEL INFORMATION According to FAA and operator records, the right seat pilot, held a private pilot certificate with ratings for airplane single and multi-engine land, and instrument airplane. He held an FAA first-class medical certificate, issued February 4, 2014, with no limitations. At the time of the medical examination, the pilot reported 73 total hours of flight experience and no flight experience within the 6 months prior to the medical application. The pilot's logbook was located within the wreckage and the last recorded entry was dated March 24, 2014, and indicated a flight from JQF to CRG, in a different PA-44-180. Including that entry, the total recorded flight time was 155.3 flight hours and 8.8 hours of actual instrument flight experience. According to FAA and operator records, the pilot seated in the left front seat held a private pilot certificate with ratings for airplane single and multi-engine land , and instrument airplane He held a FAA first-class medical/student pilot certificate issued May 20, 2013, with no limitations. At the time of the medical examination the pilot reported no previous flight experience. The pilot's logbook was located within the wreckage and the last recorded entry was dated March 23, 2014, and indicated a flight from Daytona Beach International Airport (DAB), Daytona Beach, Florida, to JQF. Including that entry, the total recorded flight time was 163.7 flight hours and 1.8 hours of actual instrument flight experience. AIRCRAFT INFORMATION According to FAA and airplane maintenance records, the airplane was issued an airworthiness certificate on August 19, 1976, and was originally registered to ATP Aircraft 2, LLC on January 29, 2008. It was powered by a Lycoming O-360-E1A6D and LO-360-E1A6D engines. The airplane was not equipped with an autopilot, nor was it required to be. According to the operator, the last recorded Hobbs meter entry was 2,290.6 flight hours, which correlated to an airframe total time of 6,664.3 hours. According to maintenance records, the left engine vacuum pump was installed on May 13, 2011, with a recorded Hobbs time of 1,082.8 hours. The right engine vacuum pump was installed on August 31, 2013, with a recorded Hobbs time of 2,118.1 hours; however, the unit's serial number in the maintenance logbook did not coincide with the serial number on the vacuum pump in the accident airplane. According to the operator, the right vacuum pump that was actually installed on the airplane had been installed on January 24, 2014; however, the information submitted to the NTSB did not contain a serial number nor was the information located within the airplane's maintenance logbooks provided by the operator. The Airworthiness Approval Tag, associated with the right vacuum pump, that was at the accident scene, indicated that it had been overhauled on June 18, 2013. According to maintenance records for the accident airplane, the right engine vacuum pump had accumulated about 65 total hours since overhaul. However, information provided by the operator also revealed that this vacuum pump was noted as inoperative and placarded in accordance with Federal Aviation Regulation (FAR) 91.213(d) and their maintenance procedures prior to the accident flight. The operator further determined to have the airplane flown to the maintenance facility at CRG to repair the inoperative vacuum pump. Additionally, the pilots had been verbally advised of this discrepancy and were provided the opportunity to refuse the airplane, prior to departing on the accident flight. According to a representative of the operator, no flight limitations existed, for their airplane, for an inoperative vacuum pump beyond those prescribed by applicable FARs and the airplane Pilot's Operating Handbook. METEOROLOGICAL INFORMATION The 1755 recorded weather observation at Brunswick Golden Isle Airport (BQK), Brunswick, Georgia, located approximately 3.5 miles to the west southwest of the accident location, included wind from 050 degrees at 10 knots with gusts up to 16 knots, visibility 10 miles, overcast clouds at 3,800 feet above ground level (agl), temperature 12 degrees C, dew point 7 degrees C; and barometric altimeter setting of 30.08 inches of mercury. The regional radar mosaic from the University Center for Atmospheric Research for 1745 indicated an area of very light intensity echoes in the vicinity of Brunswick, Georgia, in the range of 5 to 15 dBZ. Sounding The Jacksonville (KJAX), Florida 2000 upper air sounding, located approximately 50 miles south of the accident site indicated the freezing level was at 10,000 feet, and implied no in-flight icing in the vicinity. The lifted condensation level (LCL) or approximate base of the clouds was at 1,580 feet agl, with the relative humidity greater than 80% from the LCL to approximately 6,300 feet which supported low stratiform clouds. The sounding indicated a defined low-level frontal inversion from 2,500 to 3,800 feet with a marked change in wind direction and a high probability of moderate turbulence at 3,800 feet. The Lifted Index (LI) was 12, and indicated a stable atmosphere. The wind profile indicated light northeasterly winds at the surface with a low-level wind maximum at 2,000 feet from 060 degrees at 26 knots, with wind veering rapidly to the south above the inversion, and then veering to the southwest and west by 10,000 feet. The mean wind was from 270 degrees at 27 knots. A defined jetstream was over the regions with the maximum wind located above the tropopause at 38,000 feet with wind from 270 degrees at 140 knots. Satellite imagery The GOES-13 infrared image at 1745 indicated a layer of low to mid-level stratocumulus to nimbostratus type clouds with a radiative cloud top temperature of 256 Kelvin or -17 C, which indicated cloud tops near 20,000 feet. No defined cumulonimbus clouds were identified in the vicinity of the accident site. Weather Briefing The pilot obtained a preflight weather briefing prior to departure from a qualified Direct User Access Terminal System (DUATS) provider at 1516, and filed an IFR flight plan through ForeFlight.com with Lockheed Martin Flight Service. While enroute, he also contacted Flight Watch at 1647:32, obtained the latest weather for the destination, obtained the updated AIRMET (Airman's Meteorological Information) Sierra for IFR conditions over Florida, and issued a pilot report (PIREP). The report indicated that the flight was 11.8 miles southeast of Barnwell Regional Airport (BNL), Barnwell, South Carolina; the PIREP indicated 10 miles visibility, no turbulence, no visible weather, and light haze. The recording ended at 1652:28. COMMUNICATION According to recorded air traffic control communications provided by the FAA, the flight contacted Jacksonville Air Route Traffic Control Center (ARTCC) at 1727:23 and reported their altitude as 8,000 feet. The controller then provided the flight with the local altimeter setting. At 1727:32 the flight confirmed the alt