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NTSB Report
March 18, 1991 · Piper PA-28-201T · N2871H
Hamilton, NC
Overview
Report Status
Probable Cause
Event Type
Accident
Date
March 18, 1991
Injury Outcomes
2 injuries (2 fatalities)
Location
Hamilton, NC
Aircraft
Piper PA-28-201T
Tail Number
N2871H
Operator
Sansoucie Barry R
Injuries
Fatal
Aircraft Damage
Destroyed
NTSB Number
ATL91FA067
THE PILOT REPORTED A VACUUM SYSTEM FAILURE AND A PITOT STATIC SYSTEM MALFUNCTION DURING AN INSTRUMENT FLIGHT UNDER INSTRUMENT WEATHER CONDITIONS, BUT HE ELECTED TO CONTINUE THE FLIGHT. THE FLIGHT TRACK AND ALTITUDE WERE ERRATIC. AFTER 28 MINUTES OF FLIGHT, THE PILOT REPORTED THAT HE WAS IN A DIVE. SUBSEQUENTLY, THE RIGHT OUTBOARD WING PANEL, RUDDER AND HORIZONTAL STABILATOR(S) SEPARATED IN FLIGHT. EXAMINATION OF THE AIRPLANE REVEALED THAT THE VACUUM PUMP DRIVE COUPLING SHEARED BECAUSE OF IMPROPER THREAD TREATMENT (SEALANT TAPE) USED DURING INSTALLATION. THE AIRPLANE WAS EQUIPPED WITH A STANDBY VACUUM SYSTEM, WHICH AT HIGHER ALTITUDES, REQUIRED THAT THE PILOT SPOOL THE SYSTEM (REDUCE POWER THEN ADVANCE THE THROTTLE) TO MAINTAIN VACUUM PRESSURE.
NTSB Probable Cause
THE PILOT'S IMPROPER USE OF EQUIPMENT WHICH AFFECTED THE OPERATION OF THE STANDBY VACUUM PUMP, THE PILOT'S LOSS OF AIRCRAFT CONTROL AFTER EXPERIENCING SPATIAL DISORIENTATION, AND HIS EXCEEDING THE DESIGN STRESS LIMITS OF THE AIRCRAFT. FACTORS RELATED TO THE ACCIDENT WERE: THE MECHANIC'S IMPROPER USE OF THREAD COATING MATERIAL, THE PILOT'S OPERATION OF THE AIRCRAFT WITH A KNOWN MALFUNCTION OF THE PRIMARY VACUUM PUMP, AND THE ADVERSE WEATHER CONDITIONS.
Full Narrative
THE PILOT REPORTED A VACUUM SYSTEM FAILURE AND A PITOT STATIC SYSTEM MALFUNCTION DURING AN INSTRUMENT FLIGHT UNDER INSTRUMENT WEATHER CONDITIONS, BUT HE ELECTED TO CONTINUE THE FLIGHT. THE FLIGHT TRACK AND ALTITUDE WERE ERRATIC. AFTER 28 MINUTES OF FLIGHT, THE PILOT REPORTED THAT HE WAS IN A DIVE. SUBSEQUENTLY, THE RIGHT OUTBOARD WING PANEL, RUDDER AND HORIZONTAL STABILATOR(S) SEPARATED IN FLIGHT. EXAMINATION OF THE AIRPLANE REVEALED THAT THE VACUUM PUMP DRIVE COUPLING SHEARED BECAUSE OF IMPROPER THREAD TREATMENT (SEALANT TAPE) USED DURING INSTALLATION. THE AIRPLANE WAS EQUIPPED WITH A STANDBY VACUUM SYSTEM, WHICH AT HIGHER ALTITUDES, REQUIRED THAT THE PILOT SPOOL THE SYSTEM (REDUCE POWER THEN ADVANCE THE THROTTLE) TO MAINTAIN VACUUM PRESSURE.
Flight
Event TypeAccident
Event Time09:10 EST
Nearest Airport0nm N
Runway0
Flight Plan FiledIFR
Aircraft FireNo
Aircraft ExplosionNo
Aircraft
AircraftPiper PA-28-201T
Tail NumberN2871H
Aircraft CategoryAir
DamageDestroyed
OperatorSansoucie Barry R
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsContinental · TSIO-360 · Reciprocating · 200
Seats4
People & Injuries
Injury Summary2 injuries (2 fatalities)
Fatal2
Serious0
Minor0
Uninjured0
Total2
Crew 1Age 45 · Second Class
Conditions
ConditionsIMC
LightDaylight
Wind300° @ 10 kt
CeilingOvercast 300 ft
Temperature / Dew Point57 / 57
Altimeter29.00 inHg
Observation Time14:01
Weather SourceWFAC