Accident Overview
During the takeoff roll, as the airplane reached approximately 90 knots, the pilot applied back pressure to the control yoke to initiate the climb. A brief positive rate of climb was followed by a sinking sensation. The airspeed rapidly decayed, and the stall warning horn activated. The pilot lowered the nose, then pulled back on the yoke and leveled the wings just before impacting the ocean.
Pilot and Aircraft Information
The pilot reported no preaccident mechanical malfunctions or anomalies that would have precluded normal operation. The airplane's estimated gross weight at the time of the accident was about 769.6 pounds over its approved maximum gross weight, and the estimated center of gravity was about 8.24 inches beyond the approved aft limit at maximum gross weight.
Wind Conditions and Preflight Briefing
Wind about the time of the accident was recorded as 110 degrees downwind of the airplane at 15 knots, gusting to 28 knots. Passengers recalled that the pilot's preflight briefing mentioned the downwind takeoff but included no discussion of the potential effect of the wind conditions on the takeoff. Downwind takeoffs result in higher groundspeeds and increase takeoff distance.
Operator's Safety Management System
Several instances of noncompliance with the operator's operational procedures and risk mitigations were discovered during the investigation. These included two overweight flights, inaccurate and missing information on aircraft flight logs, and the accident pilot's failure to complete a flight risk assessment for the accident flight. The operator had a safety management system (SMS) in place that required active monitoring of its systems and processes to ensure compliance. However, the discrepancies noted with several flights, including the accident flight, indicate that the operator's SMS program was inadequate to actively monitor, identify, and mitigate hazards and deficiencies.