Pilot Debrief

PIPER PA-32R-301T near North Captiva Island, FL — 2014-07-16

Final reportERA14FA343
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Date
2014-07-16
Location
North Captiva Island, FL, USA
Airport
FL90
Aircraft
PIPER PA-32R-301T
Registration
N297AS
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Initial climb

Probable cause

The pilot’s failure to secure the cargo in the cargo compartment, which resulted in a weight shift that led to the center of gravity exceeding its aft limit during a go-around attempt and a subsequent aerodynamic stall. Also causal to the accident were the pilot’s inadequate preflight inspection and his loading the airplane beyond the cargo compartment weight limit.

NTSB narrative

A witness familiar with the pilot reported that the accident flight was the pilot's second flight to the airport that day to transport ceramic tiles to that location. One witness reported that the airplane appeared to be "taking off attempting to recover [from] an aborted landing and did not have the airspeed to recover." Several witnesses observed the airplane having difficulty climbing before it impacted water in a left-wing-low attitude. Based on the witness statements, the pilot was likely performing a go-around maneuver before the accident, and the airplane entered an aerodynamic stall. The airplane came to rest on its left side in about 8 ft of water and 200 yards from the departure end of the intended runway. Several witnesses reported hearing the engine operating with no hesitations noted, and postrecovery examination revealed no mechanical malfunctions or abnormalities of the airframe or engine that would have precluded normal operation. During the examination, 666 lbs of ceramic tiles were found unsecured in the cargo compartment; this exceeded the cargo compartment weight limit by 57 lbs and would have degraded the airplane's climb performance and increased its stall speed. The investigation could not determine the actual distribution of the unsecured tiles in the cargo compartment before the accident, so postaccident weight and balance calculations were performed for several tile distribution scenarios. The calculations revealed that, with a relatively even distribution or with the tiles in the forward position of the cargo compartment, the center of gravity (CG) would have been within the CG envelope limits; with the tiles in the forward position, the CG would have been near its forward limit. However, with the tiles in the aft position, the CG could have exceeded the aft CG limit by as much as about 4 inches. Based on the evidence, it is likely that, during the approach to land, the unsecured tiles began to slide forward, which would have made the airplane's nose feel heavy and might have led to the pilot's decision to go around. However, when the pilot applied power and began to pitch the airplane's nose up during the go-around, it is likely that the unsecured tiles slid aft, which resulted in the CG exceeding its aft limit, the airplane's nose pitching up further, and the pilot's pitch control authority decreasing. These conditions resulted in the airplane exceeding its critical angle-of-attack, experiencing an aerodynamic stall, and colliding with water. Although pilots operating under 14 Code of Federal Regulations (CFR) Part 91 are not required to conduct preflight weight and balance calculations, 14 CFR 91.9 does require the pilot-in-command to comply with the operating limits, including weight and balance, in the approved airplane flight manual, which provides pilots weight and balance computations, charts, and graphs. Although toxicology testing of the pilot revealed ethanol in both the liver and muscle specimens, the variation in the amount of ethanol in the tissue specimens suggests that most, and perhaps all, of the ethanol came from sources other than ingestion. Therefore, it is very unlikely that the pilot was impaired by ethanol at the time of the accident. Further, no evidence for medical impairment or incapacitation was found.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have aborted the takeoff due to insufficient climb performance.

NTSB coding

Evidence available

  • Photos
  • 15 docket documents
View NTSB final reportView NTSB docket

Docket documents15

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