Pilot Debrief

PIPER PA 28R-201T near Everglades City, FL — 2013-10-27

Final reportERA14LA024
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Date
2013-10-27
Location
Everglades City, FL, USA
Airport
X01
Aircraft
PIPER PA 28R-201T
Registration
N2702M
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Go-around

Probable cause

The pilot’s failure to maintain airplane control and airspeed during a go-around, which resulted in a stall and impact with terrain. Contributing to the accident were the pilot’s inadvertent use of an outdated GPS navigation database, which provided an incorrect common traffic advisory frequency, and the inaccessibility of the visual flight rules sectional chart.

Contributing factors

Contributing to the accident were the pilot's inadvertent use of an outdated GPS navigation database, which provided an incorrect common traffic advisory frequency, and the inaccessibility of the visual flight rules sectional chart.

NTSB narrative

While en route, the pilot established two-way communications with several Federal Aviation Administration air traffic control facilities; no communication difficulties were reported. While inbound to the destination airport, the pilot made three separate radio calls on 122.8 MHz. The pilot announced the airplane's position, but he received no reply. As the airplane neared the airport, the pilot observed an airplane on a taxiway near the approach end of runway 15. The pilot entered the traffic pattern for runway 33 and, while on the downwind leg, he broadcast his intention to land on 122.8 MHz but again received no reply. While on final approach with the flaps and landing gear fully extended, he again broadcast his intention to land and received no reply. He reported seeing a "white shimmer" from an airplane near the approach end of runway 15, which he attributed to movement. The accident pilot chose to perform a go-around because he had not communicated with the other pilot and was concerned about a collision. The accident pilot added full power during the go-around. He reported that, although the engine responded, the airplane had poor climb performance. When the airplane was clear of trees, he banked it hard left, and the airplane subsequently stalled and then impacted water. Following recovery of the airplane, the engine was started and operated normally. Examination of the engine revealed no evidence of a preimpact failure or malfunction that would have precluded normal operation. The investigation revealed that 122.8 MHz was the incorrect common traffic advisory frequency (CTAF) for the destination airport; the correct CTAF was 123.075 MHz. Although the pilot reported that he transmitted on 122.8 MHz, it is likely that he actually transmitted on 122.9 MHz because this was the frequency depicted in his GPS navigation database, which had expired nearly 5 years earlier. The pilot did not have a subscription to update any of the GPS databases, and he and his wife erroneously believed that, when they downloaded information to the unit less than 1 month earlier, the databases were also updated. Although an outdated visual flight rules sectional chart, which depicted the correct CTAF for the destination airport, was onboard the airplane, it was out of the pilot's reach during the flight. If the pilot had updated his GPS navigation database or used the outdated sectional chart, he likely would have selected the correct CTAF and been able to communicate with the other pilot, and he might not have chosen to conduct a go-around.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot did not verify CTAF frequency before landing approach.

NTSB coding

Evidence available

  • ATC audio
  • Photos
  • 22 docket documents
View NTSB final reportView NTSB docket

Docket documents22

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