What happened
On May 2, 2009, an ATR 72-212, registration F-OIQR, operated by Air Tahiti, was preparing for a scheduled passenger flight from Manihi to Fakarava in French Polynesia. During the ground operations, a ground agent responsible for the weight and balance calculations encountered difficulties generating the required documentation due to frequent satellite connection failures. Consequently, the loading instructions were communicated orally to the baggage handlers.
During the takeoff roll from Manihi, the pilot in command experienced abnormal physical effort required on the control column to initiate rotation. To manage the difficulty, the pilot utilized the stabilizer trim but still had to apply additional manual force to the yoke. Following takeoff, the crew noted a sensation of "floating" and a perceived loss of control surface effectiveness during the initial climb. The flight continued to the destination, but upon arrival, the pilot experienced similar sluggishness in the controls during the approach and landing phase.
Upon arrival at the parking stand, it was discovered that a cargo load of 221 kg, which was documented to be in compartment 3F, had actually been placed in compartment 2R.
The investigation
The investigation focused on the ground handling procedures and the accuracy of the weight and balance documentation. Investigators examined the communication between the ground agents and the baggage handlers, as well as the technical configuration of the aircraft's cargo holds. The investigation also reviewed the operational procedures for verifying cargo distribution at the station.
Findings
- The aircraft's center of gravity was outside the operational forward limit for both takeoff and landing.
- The takeoff stabilizer trim was set to 1.1 nose-up, whereas the actual cargo distribution required a setting of 2.2.
- The cargo was loaded incorrectly because a ground agent provided oral instructions to the baggage handlers that contradicted the written load plan.
- The agent intended to place cargo in the forward hold to simplify unloading at the next stop but failed to realize this would significantly shift the center of gravity.
- The second agent, responsible for verifying the load, performed a visual check based on the oral instructions rather than verifying the actual cargo against the written documents, which is a violation of established procedures.
- Environmental factors, including high noise levels from aircraft engines and the cramped conditions of the temporary ground facilities, contributed to the breakdown in communication.