What happened
On 27 October 2002, an Airbus A320-214, registration G-OOAR, was preparing for a passenger charter flight from Kefallinia, Greece, to Zakinthos. During the takeoff roll, as the pilot advanced the thrust levers, the aircraft's nose pitched up abruptly. The commander immediately reduced thrust to idle and applied braking and forward side-stick input to bring the nose back down. The aircraft came to a halt on the runway with very little forward speed. While there were no injuries among the 69 passengers or 7 crew members, the aircraft sustained damage to a rear galley drain mast.
The investigation
The investigation focused on the aircraft's weight and balance. It was discovered that all passengers were seated behind row 13, a configuration that differed significantly from the official Load Form and Trim Sheet. The investigation established that the handling agent had used a specific seating plan that left the middle of the cabin empty, but the Load Form incorrectly indicated "Standard Loading," which implies an even distribution of passengers throughout the cabin.
Furthermore, the commander had requested that baggage be moved from the forward hold to holds 3 and 4 to avoid a forward center of gravity (CG) issue. While the crew believed they were following a plan for even distribution, the actual passenger placement, combined with the aft baggage placement, moved the CG significantly beyond the aft limit of the permitted envelope.
Findings
- The primary cause of the incident was a center of gravity located significantly beyond the aft limit.
- The handling agent's seating plan was not communicated to the flight crew, and the Load Form erroneously indicated standard, even passenger distribution.
- A misunderstanding occurred between the commander and the Flight Supervisor regarding passenger placement; the commander's instruction to move passengers from the front to the back resulted in all passengers being seated in the rear of the aircraft.
- The commander relied on inaccurate documentation provided by the handling agent without verifying the actual passenger distribution.
- The Flight Supervisor was unaware of the specific impact that moving passengers to the rear would have on the aircraft's stability.
Safety action
- The operator revised its Ramp Handling Manual to emphasize correct loading procedures for all aircraft types.
- Standard Operating Procedures (SOPs) were updated to improve the cross-checking of load and trim sheets by the flight crew.
- The Cabin Crew Safety Manual was amended to mandate that passengers be evenly distributed throughout the cabin, with a requirement for the Flight Supervisor to notify the captain of any deviations.