# NTSB ERA14LA024: Piper PA 28R-201T, N2702M, Everglades City, FL, October 27, 2013

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: October 27, 2013, 13:57 local (17:57 UTC)
- Place: Everglades City, FL
- Coordinates: 25.858333, -81.394721 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=25.8583&lon=-81.3947&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Defining event: [Approach-VFR go-around: Loss of control in flight](https://openairdocs.org/ntsb-events/240)
- Highest injury: Serious injuries
- Injuries: 2 serious, 2 minor
- Status: Completed, report November 13, 2014
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: Piper Aircraft, FAA/FSDO, Continental Motors, Inc.
- NTSB case key (mKey): 88318
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14LA024
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88318/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88318
- Page: https://openairdocs.org/ntsb/ERA14LA024

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 Contributing to the accident were the pilot’s inadvertent use of an outdated GPS navigation database, which provided an incorrect common traffic advisory frequency, and the inaccessibility of the visual flight rules sectional chart.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28R-201T, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=7102813), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28R-201T, 5 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102813), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Navigation system: flight environment data](https://openairdocs.org/ntsb-findings/01023410): Aircraft › Aircraft systems · Not serviced/maintained (probable cause); cases with it: [Piper PA-28R-201T, 1 case](https://openairdocs.org/ntsb-findings/01023410/cases.md?model=7102813), [All aircraft, 1 case](https://openairdocs.org/ntsb-findings/01023410/cases.md)
- [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28R-201T, 3 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102813), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Approach-VFR go-around: Course deviation](https://openairdocs.org/ntsb-events/281); cases with it: [Piper PA-28R-201T, 1 case](https://openairdocs.org/ntsb-events/281/sequence.md?model=7102813), [All aircraft, 52 cases](https://openairdocs.org/ntsb-events/281/sequence.md)
- [Approach-VFR go-around: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-28R-201T, 3 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102813), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28R-201T, 11 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102813), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

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.

## Factual narrative

On October 27, 2013, about 1357 eastern daylight time, a Piper PA-28R-201T, N2702M, registered to Burlingame Financial Advisors LLC, crashed into water during a go-around after touchdown at Everglades Airpark (X01), Everglades City, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal flight from Grass Roots Airpark (06FD), Groveland, Florida. The airplane sustained substantial damage, and the private pilot and one passenger sustained serious injuries, while 2 passengers sustained minor injuries. The flight originated about 1242 from 06FD.The pilot stated that before departure he utilized his I-Pad for weather information which also contains VFR sectional charts, but he inadvertently left it behind. He also indicated that he did have sectional charts in his flight bag which was on-board the airplane. He was however using an on-board portable GPS receiver, which provided navigation information and also contained in part an airport database containing frequencies. He reported updating the software for the GPS less than 1 month earlier, while his wife reported by e-mail they, "…didn't have a subscription with Garmin. We didn't think we had to have a 'subscription' because we could update and download information at anytime on our own. Absolutely we believed that when we did an update it would do just that, update any and all new information for navigation and airports." The pilot further stated that after takeoff while proceeding towards the destination airport he established two-way communications with several air traffic control facilities which included Tampa, Orlando, and Fort Myers Approach Control. No communications difficulties were reported although there was no record that the pilot established contact with Fort Myers Approach Control. The pilot reported that he obtained the common traffic advisory frequency (CTAF) for X01 from his GPS receiver, which was 122.8 MHz. Using that frequency and his GPS receiver for exact position information, he announced when the flight was 20, 10, and 5 miles away from X01 but there was no reply. The flight continued towards X01, and when closer he observed an airplane on a taxiway near the approach end of runway 15. He stated that he did not understand why the pilot of that airplane did not acknowledge his radio calls, and with the wind from the northeast, entered the downwind leg for landing on runway 33. When the flight was abeam the numbers he again announced his intention on the same frequency but there was no reply. He turned onto base, and then final, and with the flaps fully extended and landing gear extended, he again announced his intention but there was no reply. He landed left of runway centerline near the numbers and as he touched down, he observed what he reported was a "white shimmer" he attributed to be movement from the airplane that was located in the run-up area near the approach end ofrunway 15. Because he had not communicated with that pilot and he was not sure what that pilot intended on doing, he added full power to perform a go-around. He later indicated that the engine did respond but the airplane had poor climb performance because the flaps were full down, and he, "…pulled up too hard" during the aborted landing. When clear of trees, he banked hard to the left, although he was not sure of the bank angle. He did not hear a warning horn, and reported the airplane stalled, which he informed the passengers they were going to crash. He tried to push over, but the airplane went into a flat spin and impacted the water backwards on the left wing. They opened the door, and all exited the airplane. While in the water out of the airplane his wife called 911 using her cell phone; the call occurred at 1358. The pilot later stated that his mistake was that he overreacted to the airplane, but in his mind he did not want a head-on collision. He further stated there was no preimpact failure of malfunction of the airplane or engine that precluded normal operation. The pilot in the airplane in the run-up area east of the approach end of runway 15 reported that he landed at X01 about 1140, had lunch, and before boarding the airplane for his intended flight, went to the fixed base operator (FBO). He was informed that the wind was from 080 degrees at 7 to 8 knots, and after starting the engine, he taxied to the approach end of runway 15, and was facing westbound with the parking brake applied doing checklist items. He was monitoring 123.075 MHz, and did not hear any radio calls on that frequency from the pilot of the accident airplane. He noticed the accident airplane flying on a close-in downwind leg for runway 33 about 1,000 feet above ground level (agl), and thought the airplane was crossing over the airport going somewhere else. The observed the airplane bank steep to the left going from a downwind to base and final for runway 33 in one turn; the bank angle was between 50 to 60 degrees. He did not perceive the airplane touch down, and when the airplane was about ¼ to ½ way down the runway at less than 100 feet agl with the landing gear extended, he observed the accident airplane bank 50 to 60 degrees left wing low, then it went behind trees. When he did not see the airplane, or about 1 minute later, her turned about 90 degrees to the left and taxied to the ramp where he secured the airplane. While walking towards the FBO an individual from there came out and he advised that individual about the crash. The GPS receiver from his airplane was sent to the NTSB for read-out to the NTSB Vehicle Recorder Laboratory, located in Washington, D.C. Following recovery of the accident airplane, inspection of the cockpit and cabin was performed by the Federal Aviation Administration (FAA) inspector-in-charge (IIC). During that inspection, bags behind the passenger seats were inspected which revealed an outdated Miami VFR Sectional Chart. Inspection ofthat chart revealed the X01 CTAF to be 123.075 MHz. The GPS receiver was removed and sent for read-out to the NTSB Vehicle Recorder Laboratory, located in Washington, D.C. Also following recovery of the airplane, the point opening of either magneto could not be determined because of internal debris; both magnetos were tight on the accessory case with no evidence of movement/slippage. With NTSB permission, the magnetos were removed, cleaned, and installed on the engine and timed to specification. The engine core and cylinders were flushed of debris, and because the wings were not attached, an alternate fuel supply was plumbed into the fuel system. With FAA oversight, the engine was started and found to operate normally achieving 2,562 rpm maximum; maximum specified red line rpm is 2,575. Each magneto drop was reported to be 50 rpm each. No discrepancies were noted. Examination of the GPS receiver from the accident airplane revealed that the Americas Aviation Data Cycle history was 0811 effective 20 October 2008 to 20 November 2008. The common traffic advisory frequency for X01 based on the installed Americas Aviation Data Cycle 0811 navigation database was 122.9 MHz. Additionally, the accident flight from takeoff to accident was recorded which included 384 recorded points starting at 1234:03, and ending at 1358:17. A review of a plot of the recorded points associated with the approach and landing reflect the airplane was west of the runway flying in a southeasterly direction parallel to the runway about 1356:02, consistent with a downwind leg for runway 33, and continued in the same direction followed by left turns onto base and final. The recorded data also indicates the airplane was left of centerline at the approach end of the runway, continued to the left edge of the runway where the minimum GPS altitude of negative 9 feet occurred at 1357:37. The recorded data indicates the airplane bank to the left achieving the maximum GPS altitude of positive 43 feet at 1357:44, followed by decreasing altitude and groundspeed. The last data point associated a groundspeed value consistent with flight was at 1357:44; the groundspeed at that time was recorded to be 71 knots. The next recorded data point 3 seconds later indicates the groundspeed was 15 knots. Examination of the GPS receiver from the airplane in the run-up area east of the approach end of runway 15 revealed it recorded the taxi beginning about 1352:34, and stopping at 1355:58. No movement was detected until 1358:32, which was 14 seconds after the last data point from the accident airplane, at which time the airplane was taxied down the taxiway to the ramp. The published CTAF on the date and time of the accident for X01 was 123.075MHz. It was previously 122.9 MHz, but changed in 2009 to 123.075 MHz. The airport manager at X01 reported there was no reported issue with the current CTAF either by pilot's or airport users. Additionally, on the day of the accident between 1350 and 1400 hours, anoperations specialist at X01 was temporarily off airport, arriving back at the airport at the same time the first responders arrived on-scene. Based on the comment from the pilot that he communicated on 122.8 MHz, NTSB contacted Florida Keys Marathon Airport (MTH) and Marco Island (MKY), both of which utilize 122.8 MHz as their published CTAF. There were no reports from either airport of personnel hearing a radio call from the accident pilot on that frequency. The Pilot's Operating Handbook did not specify balked landing procedures.

## Aircraft

- Registration: [N2702M](https://openairdocs.org/deregistered/N2702M-2018-02-12), registration cancelled 2018-02-12, S/N 28R-7803140, built 1977 (OpenAirDocs)
- Reported make and model: PIPER PA 28R-201T
- Registry model: [Piper PA-28R-201T](https://openairdocs.org/model/piper-pa-28r-201t) (registry code 7102813) (OpenAirDocs)
- Registry engine: [Continental TSIO-360 series](https://openairdocs.org/engine/continental-tsio-360-series) (registry code 17019, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 28R-7803140
- Year built: 1977
- Airframe hours: 1761
- Engines: CONT MOTOR TSIO-360-F 200 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, December 19, 2012, 52 hours before
- Departed: 06FD, Groveland, FL
- Destination: X01, Everglades City, FL
- Airport: X01, Everglades Airpark, runway 33, 2,400 × 60 ft, asphalt
- Equipment: Handheld GPS

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 52; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: left; restraint: lap only; flight hours: 350 total, 265 in this make and model

## Weather

- Conditions: Visual (VMC), Day
- Wind: 60° at 4 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 82 °F, dew point 55 °F
- Altimeter: 30.04 inHg
- Observed at: APF, 28 nm away

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 20131027020189A](https://openairdocs.org/incident/20131027020189A), Oct 27, 2013: Piper PA-28R-201T, Everglades City, FL, Destroyed. On October 27, 2013, aircraft departed from grass roots airpark, FL (06FD) at approximately 11:15L with three (3) passengers and one (1) pilot, enroute X01 for…

## Other investigations on N2702M (1)

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

- [NTSB LAX78DUJ80](https://openairdocs.org/ntsb/LAX78DUJ80), Jun 1, 1978: Piper PA-28R (N2702M), Dolan Springs, AZ, substantial damage

## Docket (22 files)

The files NTSB released with the investigation on October 2, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88318. 12.2 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417268&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- GPS Factual Report (item 2, .PDF, 717 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417269&FileExtension=.PDF&FileName=GPS%20Factual%20Report-Master.PDF
- GPS Factual Report Tabular Data for N2702M (item 3, .CSV, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417270&FileExtension=.csv&FileName=GPS%20Factual%20Report%20Tabular%20Data%20for%20N2702M-Master.csv
- GPS Factual Report Tabular Data for N846JM (item 4, .CSV, 1 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417271&FileExtension=.csv&FileName=GPS%20Factual%20Report%20Tabular%20Data%20for%20N846JM-Master.csv
- Weather Reports and Records (item 5, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40403334&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF
- Reports from Local Agencies-Collier County Sheriff's Office (item 6, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40403335&FileExtension=.PDF&FileName=Reports%20from%20Local%20Agencies-Collier%20County%20Sheriff%27s%20Office-Redacted.PDF
- Report from Party to the Investigation – Continental Motors, Inc. (item 7, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417272&FileExtension=.PDF&FileName=Report%20from%20Party%20to%20the%20Investigation%20%E2%80%93%20Continental%20Motors,%20Inc.-Redacted.PDF
- Record of NTSB Conversations (item 8, .PDF, 202 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417273&FileExtension=.PDF&FileName=Record%20of%20NTSB%20Conversations-Redacted.PDF
- FAA Record of Interview with Mrs. Jodi Boyatt (item 9, .PDF, 262 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40403337&FileExtension=.PDF&FileName=FAA%20Record%20of%20Interview%20with%20Mrs.%20Jodi%20Boyatt-Redacted.PDF
- FAA Inspector Statement (item 10, .PDF, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417274&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Master.PDF
- Excerpt from Airport Facility Directory (item 11, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40403338&FileExtension=.PDF&FileName=Excerpt%20from%20Airport%20Facility%20Directory-Master.PDF
- Statements Concerning Everglades Airpark (item 12, .PDF, 256 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40403408&FileExtension=.PDF&FileName=Statements%20Concerning%20Everglades%20Airpark-Redacted.PDF
- Statement Concerning Marco Island Airport (item 13, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40403413&FileExtension=.PDF&FileName=Statement%20Concerning%20Marco%20Island%20Airport-Redacted.PDF
- Statement from Donald DeGraw, Assistant Director of Airports, County of Monroe, Florida (item 14, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40403336&FileExtension=.PDF&FileName=Statement%20from%20Donald%20DeGraw,%20Assistant%20Director%20of%20Airports,%20County%20of%20Monroe,%20Florida-Redacted.PDF
- E-mail from Pilot’s Wife Regarding GPS Subscription Information (item 15, .PDF, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417275&FileExtension=.PDF&FileName=E-mail%20from%20Pilot%E2%80%99s%20Wife%20Regarding%20GPS%20Subscription%20Information-Redacted.PDF
- Transcription of Communications (item 16, .PDF, 286 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417276&FileExtension=.PDF&FileName=Transcription%20of%20Communications-Redacted.PDF
- Excerpts of Pilot’s Operating Handbook (item 17, .PDF, 400 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417277&FileExtension=.PDF&FileName=Excerpts%20of%20Pilot%E2%80%99s%20Operating%20Handbook-Redacted.PDF
- Certification of Party Representatives to NTSB Investigation (item 18, .PDF, 503 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417278&FileExtension=.PDF&FileName=Certification%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF
- NTSB Retention/Release of Wreckage Form 6120.15, and NTSB Evidence Control Forms (item 19, .PDF, 270 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417279&FileExtension=.PDF&FileName=NTSB%20Retention%2FRelease%20of%20Wreckage%20Form%206120.15,%20and%20NTSB%20Evidence%20Control%20Forms-Redacted.PDF
- Photo 1: Digital Photograph Provided by FAA. View Depicting the Separated Left Wing (item 20, .PDF, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40403447&FileExtension=.PDF&FileName=Photo%201%3A%20Digital%20Photograph%20Provided%20by%20FAA.%20View%20Depicting%20the%20Separated%20Left%20Wing-Master.PDF
- Photo 2: Digital Photograph Provided by FAA. View Depicting the Airplane in the Water. Note the Separated Upper Engine Cowling. (item 21, .PDF, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40403444&FileExtension=.PDF&FileName=Photo%202%3A%20Digital%20Photograph%20Provided%20by%20FAA.%20View%20Depicting%20the%20Airplane%20in%20the%20Water.%20Note%20the%20Separated%20Upper%20Engine%20Cowling.-Master.PDF
- Photo 3: Digital Photograph Provided by Insurance Adjuster. View Depicting the Instrument Panel Following Recovery of the Airplane. (item 22, .PDF, 742 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40403445&FileExtension=.PDF&FileName=Photo%203%3A%20Digital%20Photograph%20Provided%20by%20Insurance%20Adjuster.%20View%20Depicting%20the%20Instrument%20Panel%20Following%20Recovery%20of%20the%20Airplane.-Master.PDF

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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