What happened
On March 22, 2001, a Piper PA-31-350 Chieftain, registration PH-ABD, operated by Tulip Air, was attempting a takeoff from runway 23 at Orléans Saint Denis de l'Hôtel. The flight was a scheduled passenger service bound for Paris Le Bourget. During the takeoff roll, the pilot in command, positioned in the right seat, was unable to achieve rotation.
Upon realizing the aircraft would not lift off, the crew attempted to abort the takeoff. However, due to the wet runway surface, the aircraft could not stop before the end of the pavement. The aircraft veered slightly to the left and exited the runway, traveling approximately 180 meters into a muddy field. The impact caused the nose gear to collapse and resulted in damage to the propellers and the forward fuselage. There were no fatalities or injuries among the two crew members and eight passengers on board.
The investigation
The investigation focused on why the aircraft failed to rotate and why the crew failed to stop the aircraft within the runway limits. Investigators discovered that the crew had failed to remove the flight control locking device, which was designed to prevent control surface movement while the aircraft was parked. This device held the control wheel in a horizontal position, effectively pinning the elevator in a nose-down position.
Further examination of the aircraft's weight and balance revealed that the crew had used estimated weights for passengers and omitted a significant amount of baggage weight (approximately 262 lbs). This resulted in a takeoff mass very close to the maximum structural limit. Additionally, the investigation found that the company's checklist was incomplete compared to the aircraft's official flight manual and did not include all necessary pre-flight verification steps.
Findings
- The primary cause of the accident was the failure of the crew to perform pre-flight checks to ensure the flight controls were free and the control lock was removed.
- The crew lacked structured Crew Resource Management (CRM) training, which contributed to the oversight; the pilots did not function as a coordinated team, and the pilot not flying failed to detect the lock.
- The aircraft was operating near its maximum takeoff weight, and the omission of baggage weight in the calculations meant the actual mass was higher than recorded.
- The crew did not utilize the 15-degree flap setting recommended in the flight manual for short-field takeoffs, which would have provided a larger safety margin.
- The operator's internal checklists were inconsistent with the approved flight manual.