What happened
On August 17, 2017, an Airbus A320-216, registration EI-DTB, was performing a non-scheduled commercial multi-leg flight from Milan Malpensa (LIMC) to Rome Fiumicino (LIRF). The aircraft was part of a rotation that had previously included stops in Hamburg and Milan.
As the aircraft began its takeoff roll on runway 35R, it experienced a sudden and significant longitudinal imbalance. This caused the aircraft to pitch up aggressively, resulting in the lower rear part of the fuselage making contact with the runway, known as a tail strike. The flight crew immediately aborted the takeoff and vacated the runway. There were no injuries to the 103 passengers or 6 crew members on board, though the aircraft sustained damage to the lower rear fuselage and the rear drain mast.
The investigation
The ANSV investigation focused on the aircraft's weight and balance configuration. Investigators analyzed flight data recorders (FDR and CVR), maintenance records, and meteorological reports. The investigation revealed that while the weather conditions were stable, the aircraft's center of gravity (CG) was significantly outside of certified limits, exceeding 45% of the Maximum Take-Off Weight (MACTOW).
The investigation traced the imbalance to a breakdown in the communication chain between ground handlers and the airline's load controller. Because the flight was a multi-leg operation involving an out-of-network airport (Hamburg), data was not transferred automatically via ACARS. Instead, the handler used a paper-based load distribution sheet sent via email. This specific form lacked a dedicated section for distinguishing passenger seat assignments between different legs of the flight. Consequently, the load controller in Rome entered a theoretical passenger distribution that did not reflect the actual state of the aircraft after the Milan stop.
After passengers disembarked in Milan, the actual passenger distribution was heavily weighted toward the rear of the aircraft, and previously loaded cargo units (ULDs) had been removed. This created a highly aft-heavy condition that was not reflected in the load sheet provided to the crew.
Findings
- The primary cause of the serious occurrence was an improper passenger distribution that led to a severe longitudinal imbalance.
- The lack of a robust procedure for verifying weight and balance during multi-leg operations allowed unvalidated data to persist.
- The paper-based communication method used between the Hamburg handler and the Rome load control office was inadequate for multi-leg flights as it did not account for seat changes between stops.
- The flight crew failed to perform a visual check of the actual passenger distribution against the load sheet prior to takeoff.
- The cabin crew did not perceive the safety risk posed by the visible imbalance of passengers in the rear of the cabin.