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Failure to follow procedure fatal

By NTSB · June 27, 2011 ·

This June 2009 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.

Aircraft: Piper Cherokee Lance. Injuries: 3 Fatal, 1 Serious, 1 Minor. Location: Lakeview, Ark. Aircraft damage: Destroyed.

What reportedly happened: The private pilot had logged more than 670 hours, including 165 in the Piper. An employee who helped load the airplane told investigators that he thought it was overloaded, noting that the passengers were holding luggage on their laps. He added that the passengers seemed tense and in a hurry to leave.

According to the surviving passenger, prior to takeoff the pilot remarked that they were going to need all of the 3,200-foot grass runway for takeoff. The pilot attempted to takeoff with the flaps up, which was contrary to the procedures outline in the airplane’s Pilots Operating Handbook.

The passenger said the airplane lifted off at the end of the runway, dropped down into a shallow valley, touched the ground, and lifted off again. Witnesses said the airplane lifted off in a nose high attitude, and appeared to be porpoising. It touched down a second time, smashed into a barbed wire fence and tree, and rolled several times.

After the accident, it was calculated that at takeoff, the airplane was 188 pounds over maximum certificated gross weight, and the aft c.g. limit was exceeded by 0.15 inches. It was calculated that the flaps up takeoff ground roll would be approximately 1,970 feet, and the flaps up takeoff distance over a 50-foot barrier would be approximately 3,190 feet. GPS data indicates the airplane lifted off between 74 and 78 mph and climbed no more than 29 feet AGL. A videotape of the takeoff corroborated witness’ observations. Post-accident examination of the airplane and engine did not reveal any evidence of a mechanical malfunction.

Probable cause: The pilot’s poor judgment and decision making in attempting the no-flap takeoff, his failure to comply with weight and balance limitations, and his failure to calculate the airplane’s performance under existing conditions.

For more information: NTSB.gov. NTSB identification: CEN09FA393.

About NTSB

The National Transportation Safety Board is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in the other modes of transportation, including railroad, transit, highway, marine, pipeline, and commercial space. It determines the probable causes of accidents and issues safety recommendations aimed at preventing future occurrences.

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