Airnorth Regional E120 at Darwin on Aug 6th 2016, incorrect loadsheet causes unexpected aircraft responses

Last Update: November 22, 2016 / 18:41:57 GMT/Zulu time

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Incident Facts

Date of incident
Aug 6, 2016

Classification
Incident

Flight number
TL-414

Aircraft Registration
VH-ANQ

ICAO Type Designator
E120

An Airnorth Regional Embraer EMB-120, registration VH-ANQ performing flight TL-414 from Darwin,NT to Groote Eylandt,NT (Australia), was departing Darwin's runway 11 when the crew noticed unexpected responses by the aircraft. After departure the flight crew reviewed the load sheet and observed that some luggage and cargo had not been included with the load sheet. The crew recalculated the aircraft performance and continued the flight to destination for a safe landing about 90 minutes later.

The ATSB reported that the center of gravity remained within limits and no structural limits were exceeded. The occurrence was rated an incident and is being investigated.

On Nov 22nd 2016 the ATSB released their final report releasing following safety message:

The NASA Aviation Safety Reporting System Hurry-Up Study examined 125 incident records that involved time related problems. The study found that in 63% of incidents the error took place in the pre-flight phase. The report suggested using the following strategies to reduce the frequency of time-related errors:

- Maintain an awareness of the potential for the ‘Hurry-Up Syndrome’ in pre-flight and taxi-out operational phases.

- When pressures to ‘hurry-up’ occur, particularly in the pre-flight operational phase, it is a useful strategy for pilots to take the time to prioritise their tasks.

- If a procedure is interrupted for any reason, returning to the beginning of that task and starting again will significantly reduce the opportunity for error.

- Practicing positive crew resource management technique will eliminate many errors -- effective crew coordination in ’rushed’ situations will catch many potential problems.

- Strict adherence to checklist discipline is a key element of pre-flight and taxi-out task execution.

- Defer paperwork and non-essential tasks to low workload operational phases.

The ATSB reported the first officer was undergoing training to become captain and therefore undertook all tasks normally performed by the captain, which included the completion of the aircraft trim sheet.

The ATSB wrote when the crew arrived at the aircraft: "They discovered that the refueller was running late and the aircraft servicing had not been completed. The aircraft load information also arrived about 10 minutes late. In an attempt to depart on time, the first officer (acting as the captain) completed the trim sheet more quickly than usual and did not conduct their usual double check to confirm that it was completed correctly. The completed trim sheet indicated 3° nose-up trim should be used for the take-off. The first officer did not pass the completed trim sheet to the captain (acting as the first officer) to sight as is required by the company standard operating procedure."

Subsequently the captain, pilot flying, commenced takeoff and during rotation felt the aircraft was out of trim. The captain applied trim correction and performed a normal rotation and climb out, then queried the trim sheet. The ATSB wrote: "The captain found that the first officer did not include 584 kg of baggage and freight in the take-off trim setting calculation. The captain and first officer recalculated the aircraft trim and found the correct trim setting for the take-off should have been 0.8° nose-up. The crew rechecked the trim sheet which showed the aircraft was within all weight and balance limitations."
Aircraft Registration Data
Registration mark
VH-ANQ
Country of Registration
Australia
Date of Registration
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Airworthyness Category
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TCDS Ident. No.
Manufacturer
EMBRAER-EMPRESA BRASILEIRA DE AERONAUTICA
Aircraft Model / Type
EMB-120 ER
ICAO Aircraft Type
E120
Year of Manufacture
Serial Number
Maximum Take off Mass (MTOM) [kg]
Engine Count
Engine
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Main Owner
KbkbibA hqkhq jAjbqne kbnpgqkpfjijfqmnbfqc mgdp dhh lpbbhnfjmhq lnlkjebb lkb Subscribe to unlock
Main Operator
Lgmpedqfqddhbnjnhldjdpbqfbbehjmhdlkpcepmgep hinmnpknkmnkqhbidqmji mbfjijhpqlg Subscribe to unlock
Incident Facts

Date of incident
Aug 6, 2016

Classification
Incident

Flight number
TL-414

Aircraft Registration
VH-ANQ

ICAO Type Designator
E120

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