ATR 72 takeoff with center of gravity outside operational limits

Casualties unknown • FR

An ATR 72-212 A operated by Compagnie Aérienne Corse Méditerranée departed Toulouse Blagnac with its center of gravity outside of operational limits following a manual weight correction.

What happened

On October 24, 2008, an ATR 72-212 A, registration F-GRPI, operated by Compagnie Aérienne Corse Méditerranée, departed Toulouse Blagnac for Nice. During the pre-departure process, a passenger failed to board the aircraft, and no corresponding baggage was checked. To avoid delays, the pilot decided to manually adjust the final load sheet to account for the missing passenger's weight.

While the pilot updated the mass, the center of gravity (CG) was not recalculated. Shortly after the aircraft pushed back, an alert from the GAETAN flight management system notified the operational control center that the takeoff weight/balance was outside of limits. The crew, having already departed, was notified of the discrepancy but elected to continue the flight after determining that while the CG was outside operational limits, it remained within structural limits.

The investigation

The investigation focused on the breakdown in communication and the procedures used to finalize the load sheet. Investigators found that the ground agent (AET) was managing multiple aircraft due to staffing shortages and was unable to verify the specific details of the manual correction at the aircraft side. Furthermore, the ground agent's mobile system lost Wi-Fi connectivity in a different parking zone, preventing them from remotely diagnosing the system error that had blocked the printing of the mass and balance document.

At the gate, the boarding agent encountered a system error message stating "FORBIDDEN CAUSE: TOW LIMITS," but misinterpreted the alert and requested a password rather than investigating the weight and balance implication. This prevented the error from being flagged to the crew before departure.

Findings

  • The aircraft departed with a center of gravity outside of operational limits because the pilot failed to update the CG calculation after manually adjusting the mass for the absent passenger.
  • The crew did not adequately assess the risks of operating outside the manufacturer's recommended operational envelope.
  • A breakdown in communication occurred when the boarding agent misinterpreted the system's automated warning.
  • High workload and staffing shortages led the ground agent to prioritize a quick departure over verifying the accuracy of the manual load sheet adjustments.
  • Technical limitations, specifically poor Wi-Fi coverage in certain airport zones, prevented the ground agent from performing remote verification of the flight documents.

Probable cause

The primary cause was the crew's failure to account for the impact of a manual mass adjustment on the aircraft's center of gravity, compounded by a lack of communication regarding system alerts from ground personnel.

Frequently asked questions

What happened in the 2008-10-24 Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile Zone Sud - Bâtiment 153 200 rue de Paris Aéroport du Bourget 93352 Le Bourget Cedex - France T : +33 1 49 92 72 00 - F : +33 1 49 92 72 03 www.bea.aero Incident survenu le 24 octobre 2008 sur l’aérodrome de Toulouse Blagnac accident near FR?

An ATR 72-212 A operated by Compagnie Aérienne Corse Méditerranée departed Toulouse Blagnac with its center of gravity outside of operational limits following a manual weight correction.

What aircraft was involved and where did it happen?

The accident on 2008-10-24 involved a Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile Zone Sud - Bâtiment 153 200 rue de Paris Aéroport du Bourget 93352 Le Bourget Cedex - France T : +33 1 49 92 72 00 - F : +33 1 49 92 72 03 www.bea.aero Incident survenu le 24 octobre 2008 sur l’aérodrome de Toulouse Blagnac, at FR.

What was the probable cause of the accident?

The primary cause was the crew's failure to account for the impact of a manual mass adjustment on the aircraft's center of gravity, compounded by a lack of communication regarding system alerts from ground personnel.

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