Almost four years ago, the crew of an Alitalia Airbus A320-200 had to perform a rejected takeoff. The incident, which occurred on August 24th, 2017, resulted in a tail strike. This four-year-old case has been thoroughly investigated, with the final report only surfacing on April 15th, 2021. An imbalance of passengers seems to be the main cause of this tail strike and rejected takeoff.
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Flight details
According to The Aviation Herald, the Alitalia Airbus A320-200, registration EI-DTB was performing flight AZ9041. This would see the small jet fly from Milan Malpensa (MXP) to Rome Fiumicino (FCO) in Italy. However, this leg to Rome was the last of three, with flight AZ9041 actually beginning in Hamburg. Onboard were 103 passengers and six crew.
Once ready and cleared for takeoff, the jet accelerated down Malpensa’s runway 35R at 17:16. However, the crew rejected takeoff, vacating the runway via high-speed turn-off. This was located approximately 1,000 meters/3,300 feet down the runway.
Passengers deplaned and were re-accommodated by Alitalia on a replacement Airbus A320-200, registered as EI-DSV. This aircraft arrived in Rome with a delay of about four hours.
Investigation findings
On August 24th, 2017, Italy’s Agenzia Nazionale per la Sicurezza del Volo (ANSV) – or National Agency for the Safety of Flight in English, reported the rejected takeoff followed a tailstrike.
Much more recently, on April 15th, 2021, the ANSV released its final report on the incident. Published in Italian only, the ANSV states the following (translated to English):
“The cause of this serious incident is attributable to human/organizational factors. At takeoff, following an inappropriate distribution of passengers onboard, a serious imbalance of the aircraft occurred at the start of the take-off run.”
The assignment of seats in Hamburg
The reason for the imbalance was due to the multi-leg nature of this particular flight. On the first leg from Hamburg, 171 passengers were onboard. 68 of these were destined for Milan, with the remaining 103 bound for Rome. In Hamburg, staff had assigned seat rows 1-12 to the passengers to Malpensa and seat rows 13 and aft for Rome-bound passengers. Additionally, three ULDs (unit load devices) of luggage destined for Milan were put into the forward cargo hold.
Naturally, this arrangement would allow easier deplaning for passengers bound for Milan. However, the handler in Hamburg was not using a software system used by Alitalia- which was not capable of accepting seat conditions on multi-leg flights. This software required the handler to send the loading data via e-mail to dispatch/load control.
Therefore, the load controller wasn’t given the proper information to finalize the load sheet. Thus, without verification, it was assumed that there was a reasonable seat distribution in place.
The distribution for the Milan-Rome leg was four passengers in the forward section, 47 passengers in the middle, and 52 passengers in the aft section of the cabin. Additionally, the forward cargo hold, which contained baggage of those getting off in Milan, was emptied.
It was this series of events and decisions which led to an imbalance and resulting tailstrike when the A320 took off.
The report (translated) states the following four contributing factors to the incident:
- The irregular nature of the multi-leg flights performed by the operator
- A lack of procedures for load control and monitoring of load distribution due to insufficient information exchange between handlers and dispatch office. This was also due to the inadequacy of the module used to communicate the load for multi-leg flights
- A lack of visual checks of the passenger distribution onboard prior to takeoff compared to the load sheet.
- A lack of perception by the cabin crew of the criticality of the passenger distribution for the safety of the flight.
For the everyday traveler, this report is a good reminder of why flight attendants request that passengers remain in their assigned seats until after takeoff, even when an aircraft is fairly empty. An imbalance of weight can clearly have unfortunate results if not detected in time.
Did you know about passenger and load balancing for aircraft? Let us know in the comments.
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