What happened
On September 1, 2009, an Airbus A320-212, registration LZ-BHC, was performing a scheduled flight from Verona Villafranca to Rome Fiumicino. The aircraft, operated by a Bulgarian carrier under a wet lease for an Italian operator, had previously arrived from Hurghada, Egypt.
During the takeoff roll at Verona, the aircraft experienced an uncommanded rotation. As the nose lifted, the tail of the aircraft struck the runway repeatedly. Despite the impact, the crew continued the takeoff, applying full power (TOGA) after an initial reduction in thrust. Shortly after liftoff, a stall warning activated for approximately five seconds.
As the aircraft climbed, the crew initially attempted to proceed to the destination. However, upon exceeding 9,750 feet, a cabin pressurization warning activated, forcing the crew to declare an emergency and return to Verona. Upon landing, significant structural damage was discovered on the lower part of the fuselage, forward of the rear pressure bulkhead.
The investigation
The ANSV investigation focused on the discrepancy between the approved Load and Trim Sheet and the actual weight distribution on board. While the ground handling agent prepared a load sheet in Verona that called for a balanced distribution of passengers across three cabin zones, the actual seating arrangement remained as it had been for the previous leg from Hurghably.
Investigators found that passengers destined for Rome had remained in their original seats, which were concentrated in the rear of the aircraft. The pilot in command had approved the Load and Trim Sheet without verifying that the passengers had actually been redistributed according to the new plan. Consequently, the actual center of gravity was located behind the certified aft limit for a takeoff mass of 56 tonnes.
Findings
- The primary cause of the incident was a mismatch between the actual passenger distribution and the approved Load and Trim Sheet, which resulted in an unsafe aft center of gravity.
- The crew did not verify that the passenger seating arrangement matched the requirements of the new load sheet.
- The aircraft's takeoff procedure was compromised by the lack of a proper forward sidestick input during the initial part of the takeoff roll.
- The crew's decision to continue the flight following the tailstrike, rather than immediately returning to the airport as prescribed by the Flight Crew Operating Manual (FCOM), increased the risk of further complications.
- There was a lack of specific airline procedures for managing passenger and cargo redistribution during multi-leg flights.