Stobart AT72 at Dublin and Rennes on Jul 23rd 2015, cargo in wrong hold, flight outside CG limits

Last Update: February 11, 2018 / 20:50:57 GMT/Zulu time

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Incident Facts

Date of incident
Jul 23, 2015

Classification
Report

Airline
Stobart Air

Flight number
EI-3906

Departure
Dublin, Ireland

Destination
Rennes, France

Aircraft Registration
EI-FAV

Aircraft Type
ATR ATR-72-200

ICAO Type Designator
AT72

A Stobart Avions de Transport Regional ATR-72-212A on behalf of Aer Lingus, registration EI-FAV performing flight EI-3906 from Dublin (Ireland) to Rennes (France) with 57 passengers and 4 crew, was being prepared for departure. The loadsheet listed all cargo should in the forward cargo hold, however, all cargo had been loaded into the aft cargo hold. The aircraft departed, the captain felt during rotation that the aircraft was tail heavy. The aircraft climbed out and continued to Rennes. The captain advised the first officer that the landing would be more flat than normal due to the tail heavy condition. The aircraft landed safely. After landing the loading error was discovered.

Ireland's AAIU released their final synoptic report into the occurrence rated a serious incident concluding the probable causes of the serious incident were:

Passenger baggage was loaded into an incorrect hold.

Contributing Factors

- The passenger baggage was not loaded in accordance with the Load Instruction Report (LIR).

- The correct procedure for the completion of the LIR was not followed.

- The loading was completed under time pressure.

The AAIU stated: "The aircraft took off outside the certified Centre of Gravity (CG) limits", see graph below.

The AAIU analysed:

The loadsheet is designed to reflect how the mass and balance for the specific load has been distributed, including the number of passengers, seating arrangement and fuel load. The loadsheet, signed by the Dispatcher, reflected a correct loading arrangement and was accepted by the Commander. The LIR was presented to the Lead Agent which correctly documented how the passenger baggage was to be loaded-in this case all baggage was to be placed in the forward hold.

The preparation and loading of the aircraft took place in a short timeframe, not least because the aircraft was towed onto stand later than expected. The Lead Agent was aware that the flight was due to depart at 11.45 hrs but could not recall whether the Dispatcher passed him the LIR before or after he went to collect the outbound bags.

The Lead Agent allowed the catering to be loaded before the loading of the baggage was commenced and this decision placed additional time pressure on him to complete the baggage loading.

The Lead Agent had believed that the baggage was to be loaded in Hold 4 (Aft hold) but acknowledged that he did not check the LIR as per the required procedure and was under the belief that the Dispatcher had told him to load the baggage in the aft hold. He could not be absolutely sure of this as he had previously handled four other flights that morning and said he could have been mistaken.

In his statement, the Dispatcher commented that when he passed the load paperwork to the Commander through the access hatch, the hatch ‘seemed quite high’ but he stated that this did not give him any cause for concern at the time. The nose-high attitude of the aircraft may have indicated that the aircraft was tail-heavy.

The Aircraft Operator took a number of initiatives following the event including a review of its loadsheet and LIR checks, changes to its LMC procedure and visual check of aircraft holds by the dispatcher following loading. The Operator has also reintroduced zone distribution cards which are cross-checked by the Commander against the loadsheet.

In this occurrence and the occurrences reported since this event, the documented procedures in place to ensure correct loading and verification of that loading, were not followed. In all but one case, that involved incorrect paperwork, the Flight Crew identified loading errors prior to dispatch.

The Investigation acknowledges the on-going initiatives by the Operator to prevent similar events occurring and accordingly does not identify any issues that would support the making of a Safety Recommendation.
Aircraft Registration Data
Registration mark
EI-FAV
Country of Registration
Ireland
Date of Registration
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Manufacturer
ATR-GIE AVIONS DE TRANSPORT REGIONAL
Aircraft Model / Type
ATR 72-212 A
ICAO Aircraft Type
AT72
Year of Manufacture
Pem Subscribe to unlock
Serial Number
Iggh Subscribe to unlock
Maximum Take off Mass (MTOM) [kg]
Igkib Subscribe to unlock
Engine Count
H Subscribe to unlock
Engine
Djk diqAj Subscribe to unlock
Main Owner
PpnhjbgbigmmbmAjmnlpde efpdlq cfn Subscribe to unlock
Incident Facts

Date of incident
Jul 23, 2015

Classification
Report

Airline
Stobart Air

Flight number
EI-3906

Departure
Dublin, Ireland

Destination
Rennes, France

Aircraft Registration
EI-FAV

Aircraft Type
ATR ATR-72-200

ICAO Type Designator
AT72

This article is published under license from Avherald.com. © of text by Avherald.com.
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