Alitalia A320 at Milan on Aug 17th 2017, rejected takeoff after tail strike
Last Update: April 15, 2021 / 20:17:42 GMT/Zulu time
Incident Facts
Date of incident
Aug 17, 2017
Classification
Incident
Airline
Alitalia
Flight number
AZ-9041
Departure
Milan Malpensa, Italy
Destination
Rome Fiumicino, Italy
Aircraft Registration
EI-DTB
Aircraft Type
Airbus A320
ICAO Type Designator
A320
Airport ICAO Code
LIMC
A replacement Airbus A320-200 registration EI-DSV reached Rome with a delay of about 4 hours.
On Aug 24th 2017 Italy's ANSV reported EI-DTB rejected takeoff from runway 35R following a tail strike. The aircraft returned to the apron. Following collection of evidence the ANSV rated the occurrence a serious incident and opened an investigation.
On Aug 31st 2017 The Aviation Herald received additional information from the ANSV stating the aircraft "sustained a tail strike after setting takeoff thrust". Following an immediate reduction of takeoff thrust and application of brakes the aircraft's attitude returned to normal. The aircraft taxied off the runway, passengers disembarked normally.
The occurrence aircraft remained on the ground in Milan until Aug 23rd, then positioned to Rome, but has not yet resumed service 169 hours after rejected takeoff in Milan and 28 hours after landing in Rome.
On Apr 15th 2021 the ANSV released their final report in Italian only (editorial note: to serve the purpose of global prevention of the repeat of causes leading to an occurrence an additional timely release of all occurrence reports in the only world spanning aviation language English would be necessary, an Italian only release does not achieve this purpose as set by ICAO annex 13 and just forces many aviators to waste much more time and effort each in trying to understand the circumstances leading to the occurrence. Aviators operating internationally are required to read/speak English besides their local language, investigators need to be able to read/write/speak English to communicate with their counterparts all around the globe.)
The report concludes the probable causes of the serious incident were:
human/organizational factors, an inappropriate distribution of passengers caused a serious imbalance of the aircraft at the start of the takeoff run.
Contributing factors were:
- the sporadicity of the multi leg flights performed by the operator
- lack of procedures for locd control and monitoring of load distribution due to insufficient information exchange between handlers and dispatch office, also due to the inadequacy of the module used to communicate the load for multi leg flights
- the lack of visual checks of the passenger distribution on board prior to takeoff compared to the load sheet
- the lack of perceiption by the cabin crew of the criticality of the passenger distribution for the safety of the flight
The ANSV reported the aircraft did not receive any structural damage, an abraded surface of about 1.80 meters by 30cm was noted at the bottom of the fuselage and an abrasion at the drain mast though.
The ANSV analysed weather did not play any role in the occurrence. The data downloaded from the black boxes did not show any anomaly or mistake by the operating flight crew nor did they provide any evidence of a malfunction of the aircraft.
The aircraft had operated a multi-leg daily rotation from Rome Fiumicino to Milan Malpensa to Hamburg (Germany) to Milan Malpensa to Rome Fiumicino.
The ANSV analysed 171 passengers had departed Hamburg, 68 of which were destined for Milan and 103 for Rome. The handler in Hamburg assigned seat rows 1-12 to the passengers to Malpensa and seat rows 13 and aft to the passengers to Rome. In addition three ULDs of luggage destined for Milan were put into the forward cargo hold. This distribution was intended to facilitate unloading and refitting at Malpensa, however, the handler in Hamburg was not using the software system used by the operator requiring to send the loading data in e-mail using the A320 LDS paper form to dispatch/load control.
The software module was not designed to accept the seat conditions on multi-leg flights distinct for two or more destinations. The load controller thus did not have the information to finalize the load sheet and assumed a reasonable but unverified seat distribution. This did not cause any problem on the sector HAM-MXP, however, the controller did not anticipate that the MXP handler would consider the seat distribution as valid. The load sheet thus assumed 33 passengers in the forward section of the aircraft, 39 in the middle section and 31 in the aft section of the cabin. However, the actual distribution was 4 passengers in the forward, 47 passengers in the middle and 52 passengers in the aft section of the cabin. In addition the forward cargo hold became emptied in MXP.
In this weight distribution, when the crew applied thrust for takeoff, the aircraft became sufficiently unbalanced so that the tail contacted the runway surface. The crew immediately rejected takeoff, the maximum speed over ground reached was 42 knots.
The ANSV had concluded in a similiar way about a similiar occurrence in 2009, see Accident: BH Air A320 at Verona on Sep 1st 2009, tail strike on takeoff. Germany's BFU had also released similiar conclusions in 2014, see Report: Sky Airlines B738 at Stuttgart on Apr 23rd 2005, tail strike at low speed, rejected takeoff.
Metars:
LIMC 171720Z 24008KT CAVOK 31/15 Q1017 NOSIG=
LIMC 171650Z 23006KT 200V270 9999 FEW060 31/16 Q1017 NOSIG=
LIMC 171620Z 22008KT 200V270 9999 FEW050 32/16 Q1017 NOSIG=
LIMC 171550Z 27007KT 190V320 9999 FEW060 32/16 Q1018 NOSIG=
LIMC 171520Z 26006KT 190V320 9999 FEW060 32/16 Q1018 NOSIG=
LIMC 171450Z VRB04KT 9999 SCT050 33/16 Q1018 NOSIG=
LIMC 171420Z 29007KT 240V320 9999 SCT050 33/16 Q1018 NOSIG=
LIMC 171350Z VRB04KT 9999 SCT050 32/16 Q1018 NOSIG=
LIMC 171320Z 11004KT 050V180 9999 SCT050 32/16 Q1019 NOSIG=
LIMC 171250Z 15006KT 070V200 9999 SCT050 33/16 Q1019 NOSIG=
LIMC 171220Z VRB04KT 9999 SCT050 31/16 Q1019 NOSIG=
LIMC 171150Z VRB06KT 9999 SCT050 31/16 Q1020 NOSIG=
LIMC 171120Z 19005KT 160V220 9999 SCT060 31/16 Q1020 NOSIG=
Aircraft Registration Data
Incident Facts
Date of incident
Aug 17, 2017
Classification
Incident
Airline
Alitalia
Flight number
AZ-9041
Departure
Milan Malpensa, Italy
Destination
Rome Fiumicino, Italy
Aircraft Registration
EI-DTB
Aircraft Type
Airbus A320
ICAO Type Designator
A320
Airport ICAO Code
LIMC
This article is published under license from Avherald.com. © of text by Avherald.com.
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