BH Air A320 at Verona on Sep 1st 2009, tail strike on takeoff
Last Update: December 20, 2017 / 15:51:39 GMT/Zulu time
Incident Facts
Date of incident
Sep 1, 2009
Classification
Accident
Aircraft Type
Airbus A320
ICAO Type Designator
A320
The cause of the accident was a human factor. In particular the occurrence was triggered by an aircraft loading other than approved by the load and trim sheet with respect to the positions of the passengers on board, which resulted in the center of gravity being aft of the limit certified for the takeoff mass of 56 tons.
The ANSV analysed that the occurrence can be characterized as a premature rotation during start of the takeoff run when the power levers were moved into the FLX/MCT detent. The investigation was able to ascertain that the mass and balance was outside the permitted envelope, the center of gravity was aft of the limit certified for the takeoff mass of 56 tons. This condition was caused by passengers in different locations than the load and trim sheet approved by the captain required, in addition the neutral trim setting in occordance with the approved load and trim sheet was thus not congruent with the actual position of the center of gravity. Therefore an uncontrolled rotation occurred in the initial phase of the takeoff run triggered by the pitch moment produced by the accelerating engines.
The ANSV analysed that there had been no time pressure, the aircraft arrived in Verona on schedule and without any anomaly. The aircraft departed the gate 15 minutes ahead of schedule reducing the planned transit time from 45 to 30 minutes. The ANSV wrote: "it should be stressed that the early departure showed the will of the flight crew to speed up transit and this precisely is the reason why the load and trim sheet was the last to arrive on board when the aircraft was already ready for departure." Based on the testimony by the ramp agent, who reported to have warned the flight crew, it is such conceivable that the warning by the ramp agent to re-balance the passengers was not understood or not considered. The testimony by the cabin manager stands in contrast to the ramp agent stating that the ramp agent had not provided any warning to move the passengers. The apparent communication problem might be the result of people of various nationalities communicating in English in an already excited state to depart.
The ANSV further analysed that the first officer, apparently pilot flying, did not push the stick half way forward to counter any pitch moment induced by the engine acceleration as standard operation recommends. However, the outcome of pushing the stick half way forward can not be predicted given that the aircraft was operated outside its CG limits. Following the unexpected pitch up by the aircraft at around 50 knots both pilots (dual input) pushed their side sticks fully forward which stabilized the pitch angle at 11 degrees, however, without returning the nose wheels onto the runway surface, the thrust levers were briefly moved back, the engines began to respond and spool down, then the thrust levers were pushed into the TOGA detent. The first officer returned his stick to the neutral position, the captain have a nose up input, which increased the pitch angle to 12.7 degrees causing the tail to contact the runway surface.
The ANSV analysed that obviously the captain intended to reject takeoff when the aircraft began to rotate unexpectedly at 50 knots, both pilots pushed the sticks forward, the thrust levers were moved aft, but then the captain decided otherwise and continued takeoff moving the thrust levers into the TOGA detent. The captain obviously realized following the decision to reject takeoff, that the thrust reduction would result in a rapid de-rotation resulting in a violent impact of the nose gear on the runway.
The decision to continue the flight to Rome was influenced by factors other than flight safety. The crew must have realized that a tail strike had occurred, the FCOM requires an immediate return to the point of departure. Considering the type of charter operation in the absence of any stand by aircraft at an airport without assistance by maintenance leads to the hypothesis that the crew, although aware of the tail strike, had underestimated the technical consequences trying to reach the final destination in order to avoid delay or cancellation of the flight and postponed the assessment of the damage to Rome. The subsequent cabin pressurization warning prevented the flight to Rome and prompted the crew to return to Verona. The lack of CVR recording available for the takeoff phase prevented to determine the decision making and thus verification or falsification of that hypothesis though.
The ANSV had earlier reported the CVR was successfully downloaded and contained 30 minutes of recording, however, only the last phases including landing of the accident flight, but not the takeoff phase, which had been overwritten already.
Incident Facts
Date of incident
Sep 1, 2009
Classification
Accident
Aircraft Type
Airbus A320
ICAO Type Designator
A320
This article is published under license from Avherald.com. © of text by Avherald.com.
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