ERA14FA343

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.

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.

The airport was privately owned and at the time of the accident did not have a control tower. There was one runway designated runway E/W. The turf runway was 1,800 feet long and 100 feet wide. The airport was about 6 feet above mean sea level and had a sandy beach area located at both ends of the runway. CFR Part 91.9(a) states, "Except as provided in paragraph (d) of this section, no person may operate a civil aircraft without complying with the operating limitations specified in the approved Airplane or Rotorcraft Flight Manual, markings, and placards, or as otherwise prescribed by the certificating authority of the country of registry." Pilots Handbook of Aeronautical Knowledge (FAA-H-8083-25A) Section 4 "Aerodynamics of Flight" states "The CG [center of gravity] range is very important when it comes to stall recovery characteristics. If an aircraft is allowed to be operated outside of the CG, the pilot may have difficulty recovering from a stall. The most critical CG violation would occur when operating with a CG which exceeds the rear limit. In this situation, a pilot may not be able to generate sufficient force with the elevator to counteract the excess weight aft of the CG. Without the ability to decrease the AOA [angle of attack], the aircraft continues in a stalled condition until it contacts the ground." The "Glossary" defines CG as "the point at which an airplane would balance if it were possible to suspend it at that point. It is the mass center of the airplane, or the theoretical point at which the entire weight of the airplane is assume to be concentrated. It may be expressed in inches from the reference datum, or in percentage of mean aerodynamic chord (MAC). The location depends on the distribution of weight in the airplane." Advisory Circular (AC) 61-67C "Stall and Spin Awareness Training" Chapter 1 "Ground Training: Stall and Spin Awareness" states in part "The CG location has a direct effect on the effective lift and AOA of the wing, the amount and direction of force on the tail, and the degree of stabilizer deflection needed to supply the proper tail force for equilibrium. The CG position, therefore, has a significant effect on stability and stall/spin recovery. As the CG is moved aft, the amount of elevator deflection needed to stall the airplane at a given load factor will be reduced…this could make the entry into inadvertent stalls easier…IN an airplane with an extremely aft CG, very light back elevator control forces may lead to inadvertent stall entries…" Saratoga II TC PA-32R-301T Pilot Operating Handbook (POH) Section 6 "Weight and Balance" states in part "Misloading carries consequences for any aircraft. An Overloaded airplane will not take off, climb or cruise as well as a properly loaded one. The heavier the airplane is loaded, the less climb performance it will have. Center of gravity [C.G.] is a determining factor in flight characteristics. If the C.G. is too far forward in any airplane, it may be difficult to rotate for takeoff or landing. If the C.G. is too far aft, the airplane may rotate prematurely on takeoff or tend to pitch up during climb. Longitudinal stability will be reduced. This can lead to inadvertent stall and even spins…" Weight and Balance According to the POH the airplane's maximum gross weight limit was 3600 pounds and the CG envelope was between 78 and 95 inches, depending on the aircraft weight. The airplane's weight and balance was calculated utilizing the available information for the fuel, pilot's weight at autopsy, cargo distribution, and airplane configuration. Although it could not be conclusively determined the amount of fuel on board at the time of departure, 15 gallons of fuel was removed from the right fuel tank. Assuming that the left fuel tank was devoid of fuel, the airplane would have weighed approximately 3,547 pounds. The CG Moment Envelope indicated that the accident airplane's CG may have been near the aft CG limit, but within the envelope. However, it could not be accurately determined how the tiles were distributed in the cabin. If the tiles were loaded in, or shifted to, the forward section of the cargo compartment the CG could have been as far forward as 91.56 inches. If the tiles were loaded in, or shifted to, the aft section of the cargo compartment then the CG could have been as much as 98.93 inches or 3.93 inches aft of the most rearward approved CG. An autopsy was performed on the pilot on July 19, 2014 by District 21, State of Florida, Office of the District Medical Examiner. The cause of death was listed as "Drowning." Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronuatical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report revealed the following: 96 (mg/dl, mg/hg) Ethanol detected in Liver 46 (mg/dl, mg/hg) Ethanol detected in Muscle N-Propanol detected in Liver N-Propanol detected in Muscle Additionally, putrefaction (which consists of the post-mortem creation of ethanol) was noted as yes. The report further stated that no drugs were detected in the liver. The airplane was located in 8 to 10 feet of water, approximately 200 yards west-southwest of the extended centerline of the runway designated "W." The main wreckage was located at coordinates 26:36'215N 082:13.640W. The airplane was resting its left side on the sea floor. The left wing separated during the impact sequence and was originally found at coordinates 26:35'250N 082:13.670W. The engine remained attached to the airplane and was collocated with the main wreckage. The airplane came to rest on a magnetic heading of approximately 340 degrees. The airplane was recovered utilizing three lifting air bags. During recovery the tie straps damaged the right wing in the vicinity of the aileron. The stabilator and left wing could not be located utilizing sonar or visual sighting. Post recovery examination of the wreckage and witness statements indicated that the airplane impacted the water in a left wing low attitude. The fuselage was placed on a hangar floor for the examination. The right wing was removed to facilitate transportation and the left wing was not located at the accident location. The nose gear as viewed was in the nose wheel well; however, the hydraulic extension ram was extended and bent aft during the accident sequence. The right main landing gear was impact-separated at the attach point; however, the hydraulic ram was extended 8 inches, correlating to the right main landing gear being extended and locked at the time of impact. The flap jackscrew was measured at 3 exposed threads, which correlated to a flaps 40 position or fully extended position. Porcelain tiles and two wooden pallets were located, unsecured in the cabin section of the airplane. The tiles and pallets were removed and weighed, on a scale; the contents weighed a total of 666 pounds. A placard located on the aft wall of the cargo compartment indicated that 609 pounds was the maximum allowed cargo weight. Fuselage The fuselage remained intact; the left cargo/passenger door remained attached, had an approximate 8 inch gouge just aft of the forward hinge point, and the cabin had a gouge on the roof approximately 6 inches above the pilot, or left side, window. The windows remained in position; except for the pilot side windscreen and pilot side window, which were not located. The forward cabin door remained attached and during recovery the locking mechanism operated normally; however, during post recovery examination the door was slightly ajar and would not lock into position. The airplane was equipped with two front seats; the four aft passenger seats were removed sometime prior to the accident flight. The pilot seat exhibited torsional twist to the left, similar to the torsional twist of a mass in place at the time of impact. Both seats remained on their respective seat tracks and locked in place. Seat restraints were loca