# NTSB ERA24FA300: Piper PA-28-161, N81250, Palm Beach Gardens, FL, July 10, 2024 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: July 10, 2024, 14:08 local (18:08 UTC) - Place: Palm Beach Gardens, FL · Marsh/pond off end of runway - Coordinates: 26.843908, -80.208463 - Nearby events: https://openairdocs.org/map.md?lat=26.8439&lon=-80.2085&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Unknown or undetermined](https://openairdocs.org/ntsb-events/000) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Piper, FAA/FSDO, Lycoming - NTSB case key (mKey): 194668 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA24FA300 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/194668/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=194668 - Page: https://openairdocs.org/ntsb/ERA24FA300 ## Probable cause A loss of engine power for reasons that could not be determined. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Piper PA-28-161, 14 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=7102803), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Unknown or undetermined](https://openairdocs.org/ntsb-events/000) (defining event); cases with it: [Piper PA-28-161, 4 cases](https://openairdocs.org/ntsb-events/000/sequence.md?model=7102803), [All aircraft, 1,703 cases](https://openairdocs.org/ntsb-events/000/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-161, 58 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102803), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis About three hours into a cross-country instructional flight, the private pilot and flight instructor were performing a touch-and-go landing when during takeoff, the airplane reached an altitude of 75 ft above ground level (agl), made a right 180° turn, and impacted a pond just beyond the departure end of the runway. The airplane had undergone significant maintenance in the days before the accident and its maintenance logbooks had not been properly endorsed for flight. The maintenance performed included an engine replacement and modification of the engine’s magnetos, air box, and oil filter. Additionally, the airplane was modified with a backup battery as required by the installation of the electronic magnetos. Despite the lack of documentation regarding the work performed, postaccident examination of the airplane and engine did not reveal evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. About 12 to 14 gallons of fuel remained in the left wing fuel tank. The right wing had separated in the pond and the right wing fuel tank was breached. Only pond water was recovered from the right main fuel tank. The fuel selector was found positioned to the right fuel tank. Although a fuel receipt indicated that 18 gallons of fuel was added to the airplane before the flight, the fuel quantity in the right fuel tank at the time of the accident could not be determined due to impact damage. Based on the available information, it is likely that the engine lost power during takeoff and the pilots attempted to return to the runway with insufficient altitude to complete the turn. The reason for the power loss could not be determined based on the available information. ## Factual narrative HISTORY OF FLIGHT On July 10, 2024, about 1408 eastern daylight time, a Piper PA-28-161, N81250, was substantially damaged when it was involved in an accident near West Palm Beach, Florida. The flight instructor and private pilot were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to air traffic control information obtained from the Federal Aviation Administration, the airplane departed Sarasota Bradenton International Airport (SRQ), Sarasota, Florida, at 1121. The airplane flew east over Satellite Beach and performed maneuvers over the ocean before flying to Melbourne Orlando International Airport (MLB), Melbourne, Florida, where it performed a touch-and-go landing at 1247. The airplane then flew south to North Palm Beach County General Aviation Airport (F45), West Palm Beach, Florida, where it performed a touch-and-go landing. During the subsequent takeoff, the airplane reached an altitude of 75 ft above ground level (agl), made a right turn, and was about 25 ft agl above a pond at the last recorded data point. A witness at the airport stated that he observed an airplane perform a touch-and-go landing on runway 27L. The airplane took off, performed a 180° descending right turn, and disappeared behind trees. He then heard the airplane splash into water. He and another person drove to the pond to render assistance. An airport security video captured the airplane perform a touch-and-go landing, and during the takeoff, at an altitude about 75 ft agl, the airplane made a right 180° turn and disappeared from view behind trees. AIRCRAFT INFORMATION According to a mechanic, on or about July 2, 2024, he removed the airplane’s previously installed Lycoming O-320-D3G engine and installed a Lycoming O-320-D2B. He further modified the engine to a O-320-D2A by replacing the Bendix magnetos with Slick magnetos. The owner of the airplane then supplied the mechanic with two SureFly electronic ignition modules, installed under a supplemental type certificate (STC) that also required the installation of a backup battery system. There were no logbook entries associated with the work performed. The mechanic stated that he did not complete the logbook endorsements because he became sick and was home for several days. The airplane manager stated that four different pilots flew the airplane about 14 hours after the maintenance was performed. The last annual inspection was completed on December 8, 2023, at a tachometer time of 6,133.5 hours. The tachometer was digital and destroyed by water; therefore, the time since the annual inspection could not be determined. The airplane’s Pilot’s Operating Handbook stated that the airplane’s useable fuel capacity was 48 gallons. Although a fuel receipt indicated that 18 gallons of fuel was added to the airplane before departing on the flight, the total amount of fuel onboard at the time of departure could not be determined. The POH also stated that theairplane’s fuel consumption rate in cruise flight at best economy was approximately 8.5 gallons per hour. WRECKAGE AND IMPACT INFORMATION The airplane came to rest in a pond about 600 ft to the right of the departure end of runway 27L. The airplane was submerged in about 15 ft of water. The right wing was impact separated and located on the north side of the pond. Flight control cable continuity was confirmed throughout the airframe. The stabilator trim actuator was found with 0.6 inches of extension on the top side of the drum, which corresponded to a partial nose-down trim position. The fuel selector valve was found on the right tank and was in a tactile detent for that position. The valve was functionally tested in both the left and right tank positions. Low-pressure air was applied and air successfully flowed in both fuel selector positions from the wing roots through the selector valve and to the fuel strainer. Additionally, both fuel tank vent lines were unobstructed. The electric fuel pump was removed and functioned when powered with a 12-volt power source. Approximately 12 to 14 gallons of fuel consistent with 100LL aviation gasoline was found in the left main fuel tank. The main fuel tank in the separated right wing contained only water. The engine remained attached to the fuselage at its mount. The mount was impact damaged and the engine was tilted nose-down about 20°. The engine cowling was not present. The induction air box was crushed, and the induction air filter was not observed. The exhaust system was impact damaged but not obstructed. The engine was partially disassembled to facilitate additional examination. Water drained from the engine cylinders when the lower spark plugs were removed. Water and oil drained from the oil sump drain when it was opened. The crankshaft was rotated by turning the propeller and continuity of the crankshaft to the rear accessory gears and to the valve train was confirmed. Compression and suction were confirmed in all four cylinders. The interiors of the cylinders were examined using a lighted borescope and no damage was noted. The propeller remained attached to the engine crankshaft flange. The propeller spinner was impact damaged. No damage was noted to one of the two propeller blades. The other propeller blade was bent aft about 5° about 6 inches from the blade tip. The carburetor remained attached to the engine. The carburetor air box and carburetor heat valve were partially crushed. The throttle cable remained attached to the carburetor throttle control arm. The arm was observed against the full throttle stop. Both electronic magnetos remained attached to the engine. Power was applied to both electronic magnetos. One tower of the left magneto produced spark when the magneto drive was rotated by hand. The right magneto produced no spark when rotated by hand. Water drained from both magnetos when the distributor covers were removed. Both magnetos were set aside to dry overnight. Both magnetos werepowered the following morning and rotated using an electric drill. Neither magneto produced spark from any electrode tower. The electronic magnetos were sent to the manufacturer for further examination and testing. The circuit board and coil pack on both magnetos exhibited corrosion/damage consistent with being submerged under water with power applied. For testing purposes, a new circuit board and coil pack was installed in both magnetos and put on a test bench. Both units passed the test and produced spark on all leads. The right wing center wing box and section of the main spar were sent to the NTSB Materials Laboratory for examination. The examination revealed that the fracture was due to bending overload, and no signs of preexisting damage were noted. ## Aircraft - Registration: [N81250](https://openairdocs.org/aircraft/N81250), registered now, S/N 28-8016147, built 1979 (OpenAirDocs) - Reported make and model: PIPER PA-28-161 - Registry model: [Piper PA-28-161](https://openairdocs.org/model/piper-pa-28-161) (registry code 7102803) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-8016147 - Year built: 1979 - Airframe hours: 8074 - Engines: LYCOMING O-320 SERIES 160 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 8, 2023 - Departed: SRQ, Sarasota, FL - Destination: Same as departure - Flight plan: IFR - Airport: F45, North Palm Beach County General Aviation, runway 27L, 4,300 × 100 ft, asphalt - Equipment: Stall warning system, Onboard weather, ADS-B, Electronic multifunction display, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 59; injuries: fatal; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: right; flight hours: 9,000 total, 9,999 in this make and model - Pilot; age 58; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; seat: left; toxicology performed; flight hours: 164 total, 99 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 230° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: 14,000 ft overcast - Temperature: 88 °F, dew point 79 °F - Altimeter: 30.00 inHg - Observed at: PBI, 11 nm away - METAR: KPBI 101853Z 23005KT 10SM FEW050 OVC140 31/26 A3000 RMK AO2 SLP160 T03110261 ## 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 20240710012759A](https://openairdocs.org/incident/20240710012759A), Jul 10, 2024: Piper PA-28-161, West Palm Beach, FL, Substantial damage, 2 fatal. Aircraft was substantially damaged when it crashed into a lake adjacent to the departure end of runway 27L at F45 for unknown reasons after performing a touch… ## Docket (17 files) The files NTSB released with the investigation on April 1, 2025, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=194668. 44.2 MB in all. - Witness statements (item 1, PDF, 8 pages, 387 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18340760&FileExtension=pdf&FileName=witness%20statements_Redacted-Rel.pdf - Fuel receipt (item 2, PNG, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18358747&FileExtension=png&FileName=Fuel%20Sarasota-Rel.png - Excerpts from POH - fuel capacity and consumption rate (item 3, PDF, 2 pages, 519 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18358855&FileExtension=pdf&FileName=excerpt%20from%20POH%20fuel%20capacity-burn-Rel.pdf - Excerpt from FAA airplane flying handbook emergency procedures (item 4, PDF, 1 page, 203 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18360395&FileExtension=pdf&FileName=FAA%20Flying%20Handbook%20FAA-H-8083-3C%20Emergency%20Procedures-Rel.pdf - Excerpts from aircraft maintenance logbooks (item 5, PDF, 4 pages, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18344524&FileExtension=pdf&FileName=Maintenance%20logs_Redacted-Rel.pdf - ADS-B track (google earth file) (item 6, KMZ, 353 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18340348&FileExtension=kmz&FileName=20240710_AB13EA_556160102_ADSB-Rel.kmz - ADS-B raw data (item 7, CSV, 17.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18340797&FileExtension=csv&FileName=20240710_AB13EA_556160102_ADSB-Rel.csv - Video of touch and go, followed by turn back to the airport (MP4, 31 seconds, 15MB) (item 8, MP4, 15.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18340807&FileExtension=mp4&FileName=vlc-record-2025-02-18-15h02m41s-7-10-24%201408%20video.mp4--Rel.mp4 - Wreckage examination summary (item 9, PDF, 8 pages, 208 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18340904&FileExtension=pdf&FileName=Wreckage%20Examination%20Summary-Rel.pdf - Reports from parties to the investigation (magneto inspection) (item 10, PDF, 10 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18340338&FileExtension=pdf&FileName=Surefly%20Electronic%20Ignition%20examination%20report_Redacted-Rel.pdf - Investigative photos (item 11, PDF, 4 pages, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18340640&FileExtension=pdf&FileName=Investigative%20Photos-Rel.pdf - Toxicological report-cfi (item 12, PDF, 1 page, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18339888&FileExtension=pdf&FileName=TOX-CFI_Redacted-Rel.pdf - Toxicological report-pilot (item 13, PDF, 1 page, 160 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18340436&FileExtension=pdf&FileName=TOX-pilot_Redacted-Rel.pdf - Materials laboratory factual report 24-048 (item 14, PDF, 8 pages, 6 photos, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17499916&FileExtension=pdf&FileName=24-048-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 15, PDF, 1 page, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18340894&FileExtension=pdf&FileName=Release-of-Wreckage%20(1)_Redacted-Rel.pdf - Evidence control forms (item 16, PDF, 2 pages, 130 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17629281&FileExtension=pdf&FileName=Evidence-Control-Form-spar-mags-Rel.pdf - Statement of party representatives to NTSB investigation (item 17, PDF, 2 pages, 468 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18358943&FileExtension=pdf&FileName=NTSB%20Party-Representative%20Form_Redacted-Rel.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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.