What happened
On 23 July 2015, an ATR 72-212A, registration EI-FAV, was preparing for a scheduled commercial flight from Dublin Airport to Rennes, France. During the ground handling process, all 32 pieces of passenger baggage, weighing 421 kg, were placed in the aircraft's aft hold. However, the official loading documentation, including the Load Instruction Report (LIR) and the computer-generated loadsheet, incorrectly indicated that the luggage had been stowed in the forward hold.
As the aircraft departed Dublin, the pilot noticed a noticeable tail-heavy sensation during the takeoff roll. Despite this physical sensation, the flight crew performed a check of the loading paperwork, which showed the weight distribution as being within safe limits. The aircraft continued to its destination, where the error was only identified during the unloading process. There were no injuries and no damage to the aircraft.
The investigation
The AAIU investigation focused on the breakdown in communication and verification procedures between the handling company's staff and the flight crew. The investigation established that the aircraft arrived at its stand later than scheduled, creating significant time pressure on the ground crew. The Lead Agent, responsible for overseeing the loading, admitted to not checking the LIR and acted on a mistaken belief that the baggage should be placed in the rear compartment.
Furthermore, the Dispatcher, who was responsible for communicating the loading plan, did not visually verify the contents of the holds before departure. While the Dispatcher noted that the aircraft's tail strut appeared unusually close to the ground when passing the paperwork to the cockpit, this was not flagged as a potential weight and balance issue. The investigation also found that the loadsheet presented to the commander was mathematically correct based on the intended plan, but it failed to reflect the actual physical state of the aircraft.
Findings
- The aircraft was operated with a Centre of Gravity outside approved loading limits.
- The loading crew failed to follow the instructions provided in the LIR.
- Time constraints caused by a late arrival at the stand contributed to the loading error.
- The communication between the Dispatcher and the Lead Agent regarding the specific hold for baggage was ineffective.
- The flight crew relied on documentation that inaccurately represented the actual cargo distribution.
Safety action
Following the incident, the aircraft operator implemented several new safety protocols, including:
- Mandatory visual inspections of aircraft holds by ground staff after loading.
- The introduction of passenger distribution cards to be cross-checked by the commander.
- A redesign of the Load Instruction Report (LIR) to improve clarity.
- Updated procedures for verifying weight and balance changes during the loading process.