What happened
On January 12, 2003, a Boeing 737-800, registration PH-HZB, was preparing for a multi-leg flight departing from Rotterdam Airport. As the aircraft began its takeoff roll, the nose pitched upward abruptly. This movement continued until the aft fuselage and the tailskid assembly made contact with the runway. The crew immediately rejected the takeoff, during which the nose of the aircraft touched the ground a second time before the aircraft came to a halt. While there were no injuries among the 113 passengers and seven crew members, the aircraft sustained considerable damage, rendering it unable to continue the flight.
The investigation
The Dutch Safety Board examined the loading procedures and the aircraft's stability during the incident. The investigation focused on how the aircraft's center of gravity (CG) shifted during the takeoff roll. Investigators looked into the passenger boarding process, the software used for generating load and trim sheets, and the coordination between the airline and the ground handling agent, Aviapartner. The inquiry also reviewed the cockpit crew's response to information provided by the purser regarding the cabin's passenger distribution.
Findings
At the time of departure, nearly all passengers had been seated in the rear of the cabin. This uneven distribution was a result of the ground handling company assigning seats in the rear to facilitate easier boarding at a subsequent stop. This concentration of weight caused the aircraft's center of gravity to shift behind the allowable aft limit.
Several contributing factors were identified:
- The ground handling staff assigned seats in a manner that contradicted the required passenger distribution table.
- The cockpit crew lacked sufficient awareness regarding how extreme passenger weight imbalances affect the aircraft's center of gravity and controllability.
- The crew failed to take corrective action, such as reseating passengers, even after being notified of the uneven distribution by the purser.
- The airline's quality management system failed to provide adequate supervision of ground handling seat assignments and did not sufficiently address previous audit findings related to mass and balance issues.