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Accidents · NTSB ERA14FA168 · Final report

Piper PA-44-180 accident near Brunswick, Georgia, March 24, 2014

On March 24, 2014 at about 9:38 pm local time, a 1979 Piper PA-44-180, registered N923RS, was destroyed in an accident during enroute near Brunswick, Georgia. It was an instructional flight under general aviation rules (Part 91). 2 people were killed. The weather was visual conditions (good weather).

The NTSB's probable cause their words, unchanged

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.

Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.

What the record shows

Date
March 24, 2014 · about 9:38 pm local time
Place
Brunswick, Georgia · map
Type
Accident
Injuries
2 people were killed.
Weather
visual conditions (good weather)
Aircraft
Piper PA-44-180, built 1979 · all PA-44-180s on the register
Registration
N923RS · no longer on the register · serial 44-7995196
Damage
Destroyed
Flight
Instructional flight · general aviation rules (Part 91)

The NTSB's narrative final · quoted from the NTSB record

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.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.

The factual record from the NTSB's investigation tables, in plain English

What happened, in order

  1. Aircraft maintenance event during prior to flight
  2. Flight instrument malf/fail during enroute
  3. Loss of control in flight during enroute defining event
  4. Aircraft structural failure during uncontrolled descent
  5. Part(s) separation from AC during uncontrolled descent
  6. Collision with terrain or object (not controlled flight into terrain) during uncontrolled descent

The NTSB's findings

  • cause Personnel issues › Psychological › Perception/orientation/illusion › Spatial disorientation › Pilot
  • cause Personnel issues › Task performance › Use of equip/info › Aircraft control › Pilot
  • cause Aircraft › Aircraft systems › Vacuum system › (general) › Failure
  • factor Organizational issues › Management › Policy/procedure › Adequacy of policy/proc › Operator
  • factor Aircraft › Aircraft systems › Vacuum system › (general) › Damaged/degraded

Pilot

  • Certificate: private
  • Ratings: multi-engine land; single-engine land; instrument: airplane
  • Flight time: 155.3 hours in all; 55.2 in this make and model; 95.9 as pilot in command
  • Medical certificate: Class 1 (without waivers/limitations)
  • Seat: rgt
  • Injury: fatal

Pilot-Rated Passenger

  • Certificate: private
  • Ratings: multi-engine land; single-engine land; instrument: airplane
  • Flight time: 163.6 hours in all; 38.9 in this make and model; 97.4 as pilot in command
  • Medical certificate: Class 1 (without waivers/limitations)
  • Seat: left
  • Injury: fatal

The aircraft

  • Airframe total time: 6,645.6 hours
  • Last inspection: 100-hour inspection, March 13, 2014; 19 hours since
  • Maximum gross weight: 4,400 lb
  • Seats: 4
  • Landing gear: retractable
  • Engine 1: Lycoming O-360-E1A6D (piston); 9,164 hours total
  • Engine 2: Lycoming LO-360-E1A6D (piston); 3,499 hours total
  • Operator: Atp USA, Inc.

The flight

  • Departed from: JQF Concord NC at 7:51 pm
  • Destination: CRG Jacksonville FL
  • Flight plan: IFR
  • A second pilot was aboard

Weather at the time

  • Light: daylight
  • Wind: from 050° at 10 knots, gusting 6
  • Visibility: 10 statute miles
  • Sky: overcast at 3,800 ft; clear
  • Temperature: 54°F (12°C), dew point 45°F (7°C)
  • Altimeter: 30.07 inHg
  • Observation at 9:55 pm from BQK, 4 miles away

Injuries

FatalSeriousMinorNone
Flight crew2

Documents from the investigation the NTSB's docket: the evidence folder behind the report

25 documents, released by the NTSB on October 13, 2015. View them here, or download them; the NTSB redacts some personal details before release, and this site shows the NTSB's own titles rather than its file names.

#DocumentWhat it is
1 Pilot/operator Aircraft Accident Report, NTSB Form 6120.1 PDF, 9 pages View Download
2 Electronic Devices - Specialist's Factual Report PDF, 3 pages View Download
3 Weather Specialist's Factual Report PDF, 9 pages View Download
4 Materials Laboratory Factual Report PDF, 19 pages View Download
5 Rapco Shear Coupling Force Failure Report PDF, 13 pages View Download
6 Right Seat Pilot’s Logbook [excerpts] PDF, 2 pages View Download
7 Left Seat Pilot's Logbook [excerpt] PDF, 2 pages View Download
8 Maintenance Records [excerpts] PDF, 9 pages View Download
9 Vacuum Pump Information Provided by Operator PDF, 4 pages View Download
10 Right Vacuum Pump Information Provided by Operator PDF, 4 pages View Download
11 On-scene Documentation of Airplane PDF, 14 pages View Download
12 Maintenance Manual Excerpts - PA-44 PDF, 4 pages View Download
13 Rapco Service Letter RASL-005 PDF, 2 pages View Download
14 Flight Plan PDF, 2 pages View Download
15 Flight Service Station Contact Transcript PDF, 3 pages View Download
16 Air Traffic Control Transcripts - Jacksonville Center [partial] PDF, 23 pages View Download
17 Witness PDF, 2 pages View Download
18 Savannah Approach radar Data - Overlay in Google Earth PDF, 2 pages View Download
19 radar Ntap Data map file Download
20 Toxicological Report – Right Seat Pilot PDF, 1 page View Download
21 Toxicological Report - Pilot in the Left Seat PDF, 1 page View Download
22 Statement of Party Representatives to NTSB Investigation PDF, 17 pages View Download
23 Party Submission - Operator PDF, 3 pages View Download
24 Release of Aircraft Wreckage, NTSB Form 6120.15 and Evidience Contol Forms PDF, 3 pages View Download
25 Photo Array - 4 PDF, 4 pages View Download

The same docket at the NTSB · documents without a copy here are fetched from the NTSB when you open them.

Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.