Flybondi B738 at Iguazu on Jul 16th 2018, rejected takeoff after tail strike
Last Update: October 17, 2020 / 18:10:13 GMT/Zulu time
Incident Facts
Date of incident
Jul 15, 2018
Classification
Accident
Cause
Rejected takeoff
Airline
Flybondi
Flight number
FO-5111
Aircraft Registration
LV-HQY
Aircraft Type
Boeing 737-800
ICAO Type Designator
B738
Airport ICAO Code
SARI
The aircraft had arrived as flight FO-5450 from Mendoza,MD to Iguazu,MI (Argentina) landing on Iguazu's Catarates Airport's runway 31 at about 23:28L (Jul 16th 02:28Z).
The aircraft was due to depart as flight FO-5433 to Cordoba,CD (Argentina), the flight was cancelled however. According to Mode-S data the aircraft did not become airborne for that flight.
Argentina's JIAAC reported LV-HQY suffered an incident at 03:30Z (Jul 16th), there were no injuries, the damage to the aircraft is being assessed. The JIAAC have opened an investigation into the occurence.
It thus remained unclear whether the tail strike happened during landing on flight FO-5450 or on departure for flight FO-5433 which possibly could have prompted a rejected takeoff (which would have remained invisible to the Mode-S receiver in use). Aviation sources in Argentina are considering a mass and balance problem (which tend to lean towards the takeoff scenario as does the time stamp given by the JIAAC) and report structural damage.
The airline reported a technical flaw in the takeoff process for flight FO-5433 to Cordoba forced the aircraft to return to the apron, the flight was cancelled.
On Jul 18th 2018 Argentina's JIAAC released additional information stating that during the start of the takeoff phase the aircraft experienced a pitch up causing the rear lower area of the fuselage to contact the runway surface. The aircraft sustained substantial damage. The occurrence was rated an accident and is being investigated.
On Nov 16th 2019 the JIAAC released an interim report in Spanish stating the aircraft was departing runway 31 for flight FO-5111 to El Palomar,BA (Argentina) with the first officer (53, ATPL, 2,746 hours total, 106 hours on type) being pilot flying, the training captain (59, ATPL, 7,100 hours total, 2,974 hours on type) was pilot monitoring and acting as instructor. While the aircraft accelerated the aircraft suddenly experienced a pitch up event, the tail contacted the runway surface, prompting the crew to reject takeoff. The accident happened in visual meteorologic and night conditions.
The JIAAC reported the aircraft had undergone a reconfiguration of the cabin between Apr 20th and May 14th 2018, the cabin was configured for 189 passengers seats. The dispatcher computed and provided a load sheet, that the captain accepted, indicating the CG was at 22.2% MAC requiring 3.4 trim units nose up. Takeoff weight and CG were within permitted limits. However, the actual passenger distribution throughout the cabin did not match the dispatcher's documents, almost all the passengers took their seats in the aft cabin, which moved the CG to about 38% MAC outside of the permitted takeoff limitations. A Boeing simulation based on the FDR data estimated the CG near 40% MAC.
The JIAAC stated the investigation is ongoing.
On Oct 16th 2020 the Junta de Seguridad en el Transporte (JST, former JIAAC) released their final report in Spanish 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, a Spanish 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 investigation did not release a formal conclusion to the causes of the accident, but only listed numerous factors (findings) related to the accident as well as numerous findings not related to the accident but to operational safety. Within these findings the JST reported, that the Center of Gravity was between 38 and 40% MAC outside the permitted envelope, the actual distribution of passengers on board did not match the distribution used in the dispatch forms. As result the aircraft experienced a sudden pitch up causing the contact of the rear fuselage with the runway surface (tail strike).
The investigation found that Flybondi had delegated dispatch in Iguazu Falls to Flyseg S.A. who did use a different computer system not in line with Flybondi's systems. No specific procedures were in place to transmit information between the systems. No visual monitoring of passenger distribution was done though required by Flybondi's Operations Manual. Flybondi did not monitor the dispatch activity by Flyseg S.A. It was not possible to determine why the actual distribution of passengers and distribution as used on the dispatch systems were in disagreement.
A single inspection of the operation in Iguazo Falls by Authorities carried out of Jun 18th 2018, with no other inspections carried out, identified that the required familiarization flight by dispatchers had not been done. The volume of flights between Jun 18th and Jul 16th 20218 increased by 425% (from 32 to 136 flights). The accident flight was flight no. 70 of July 2018, the work hours of dispatch had increased to 60 hours a week, thereof 39 hours between July 13th 14:00L and July 16th 2018 02:00L. The service time thus did not comply with regulations.
The investigation listed findings to the operational safety like the operator's weight and balance manual (WBM) did not meet the actual configuration of the aircraft. Boeing had not been notified of changes done to the aircraft, therefore the WBM was not updated. In addition, the WBM made reference to the Boeing 737-200 while the operator was using a Boeing 737-800. The envelope in chapter 7 of the WBM used to manually determine the CG of LV-HQY thus was wrong.
The JST analysed that there were 65 passengers on board of the aircraft, 60 of them were seated aft of seat row 15. In additional 450kg of cargo was loaded in the aft cargo hold.
The loadsheet had computed a takeoff mass of 55,633 kg and had computed the CG at 22.2% MAC, however, the JST found the actual CG was between 38 and 40% MAC. The limit of the CG was at 26% MAC however. There are no systems on the aircraft that could warn of a mismatch between actual and computed CG.
When the engines were accelerated for takeoff the aircraft was accelerating through 5 knots over ground and the engines accelerating through 75% N1 the aircraft began to pitch up as result of the pitch up moments produced by the engine thrust until the aircraft's tail contacted the runway surface. Following the tail strike the crew rejected takeoff and returned to the apron.
The seat assignments of passengers was done according to sales specifications. The seats in the aft cabin were generally cheaper than those in the forward cabin and were therefore the first to be sold.
After completing the passenger registration the operator using their computer system informed dispatch about the assigned seats on the aircraft and the billed amount of luggage. This information was transmitted through a series of photos taken from the computer screen and transmitted by mobile phone, a procedure which was not established in the operations manual by Flybondi. The manual stated the dispatcher must be informed, however does not specify how this information is to be transferred.
Based on the information received from the operator the dispatcher created the load sheet on his computer system, which computed the CG to be within the permitted envelope for takeoff though actually it was way outside the envelope.
Due to the different computer systems in use the dispatcher had to manually transfer the data into his system which created the opportunity to introduce (unwanted) deviations as obviously occurred in this case. The evidence available to the investigation did not permit to identify the reasons of this deviation however.
According to the operational manual of Flybondi the dispatcher can perform a visual check of the aircraft while he walks up to the cockpit to hand the loadsheet to the captain. However, at the accident flight the dispatcher did not conduct such a visual check to compare the actual passenger distribution in the cabin with his loadsheet.
At the time of the accident the operations manual did not require to hand a copy of the loadsheet to the cabin crew and did not require that the cabin crew performed a cross check of the distribution of passengers.
The operator did not have in place a safety management system (SMS), at the time of the accident it was not a requirement to implement a SMS. The airline was growing rapidly increasing its operations by about five times between February and July 2018. A plan to implement a SMS had been agreed on, a risk management of operational security was to be introduced during phase 3 of the plan. As result there was a substantial increase of operations at Iguazu Falls without assessing the impact on operational safety.
There issues however begin with the monitoring by ANAC, the civil aviation authority. As part of the operator's certification ANAC defined a plan called MAC-TAC as "post certification surveillance", the investigation however did not receive any evidence indication this plan was put into effect.
Metars:
SARI 160500Z 05005KT CAVOK 21/17 Q1015=
SARI 160400Z 05004KT CAVOK 21/16 Q1015=
SARI 160300Z 05005KT CAVOK 23/18 Q1015=
SARI 160200Z 05004KT CAVOK 23/17 Q1014=
SARI 160100Z 05005KT CAVOK 23/17 Q1014=
SARI 160000Z 05004KT CAVOK 23/17 Q1013=
SARI 152300Z 36006KT CAVOK 23/17 Q1012=
Incident Facts
Date of incident
Jul 15, 2018
Classification
Accident
Cause
Rejected takeoff
Airline
Flybondi
Flight number
FO-5111
Aircraft Registration
LV-HQY
Aircraft Type
Boeing 737-800
ICAO Type Designator
B738
Airport ICAO Code
SARI
This article is published under license from Avherald.com. © of text by Avherald.com.
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