Status: | Accident investigation report completed and information captured |
Date: | Tuesday 1 September 2009 |
Time: | 16:42 |
Type: | Airbus A320-212 |
Operating for: | Air Vallée |
Leased from: | BH Air |
Registration: | LZ-BHC |
MSN: | 349 |
First flight: | 1992-06-30 (17 years 2 months) |
Total airframe hrs: | 51963 |
Engines: | 2 CFMI CFM56-5A3 |
Crew: | Fatalities: 0 / Occupants: 7 |
Passengers: | Fatalities: 0 / Occupants: 87 |
Total: | Fatalities: 0 / Occupants: 94 |
Aircraft damage: | Substantial |
Aircraft fate: | Repaired |
Location: | Verona Airport (VRN) ( Italy)
|
Phase: | Takeoff (TOF) |
Nature: | Domestic Non Scheduled Passenger |
Departure airport: | Verona Airport (VRN/LIPX), Italy |
Destination airport: | Roma-Fiumicino Airport (FCO/LIRF), Italy |
Flightnumber: | DO5378 |
Narrative:Air Vallée flight 5378, an Airbus A320-212, experienced a tail strike during takeoff from Verona Airport, Italy.
The aircraft was operated under a wet lease agreement between Air Vallée and BH Air.
The aircraft was operating a multiple destination flight originated in Hurghada, Egypt (HEGN), having an intermediate stop in Verona and a final destination of Rome-Fiumicino (LIRF).
At departure from Hurgada, 77 passengers with destination Verona were seated in the forward and central cabin and 87 passengers with destination Rome Fiumicino were mainly seated in the central and aft cabin. Baggage and cargo with destination Verona were located in the forward (no. 1) compartment while those with destination Rome Fiumicino were located in the aft (no. 3) cargo compartment.
After landing in Verona only passengers, baggage and cargo with final destination Verona were disembarked.
Before takeoff from Verona the captain received an approved Load and Trim sheet from the handling agent and where the seating of the transit passengers was different from that of the incoming flight, equally balancing their distribution on board in the three cabin areas. This was not detected or not considered by the captain, as the passengers remained in the same seats they had occupied in the previous flight.
The captain decided that no refueling was necessary and the aircraft departed from Verona with 87 passengers seated, as per their original seats assignment in Hurgada, mainly in the center and aft cabin, and with remaining baggage and cargo in the after (no. 3) cargo compartment where it was originally loaded in Hurgada.
During the initial part of the take off run, as soon as the throttle levers were advanced to FLEX position, the aircraft started an uncommanded early rotation causing a tail strike on the runway.
The takeoff run was continued with subsequent degradation of flight control laws to alternate law and direct law. The aircraft lifted off at 113 kts and immediately after lift off a stall warning activation occurred for about 5 seconds.
The aircraft continued the takeoff and climb until the activation of the master warning related to pressurization system fault occurred, at this time the crew decided to return to Verona where the aircraft landed with no further problems.
Inspections on ground revealed extensive structural damages to the lower part of the tail fuselage compromising the pressurized compartment.
Probable Cause:
CAUSES (translated from Italian):
The cause of the accident is due to human factors. In particular, the incident was triggered by an uneven aircraft loading from the approved Load and Trim Sheet, relative to the position of the passengers on board, which resulted in a position of the center of gravity outside the rear limit of certification for the take-off for a mass of 56 t, the condition in which the A320 LZ-BHC was found.
The following factors contributed to the event:
- the absence of specific procedures for the aircraft operator, related to the loading of aircraft (passengers, baggage and cargo) in the case of flights with multiple destinations;
- the absence of pre-established and recognized mechanisms of notice to the captain that the allocation of seats on board between the original flight (Hurghada-Verona) and the final destination (Verona-Rome) had to be significantly modified to maintain the position of the center of gravity within the limits allowed for take-off;
- the absence of a verification of the actual correspondence between the aircraft loading condition indicated in the Load and Trim Sheet approved with respect to the actual configuration on board.
Furthermore, it is believed that the failure to timely stop the take-off procedure at the start of the anomaly in the aircraft's controllability contributed to a greater exposure to the criticality triggered by the loading of the aircraft different from the approved Load and Trim Sheet.
Accident investigation:
|
Investigating agency: | ANSV Italy |
Status: | Investigation completed |
Duration: | 8 years and 4 months | Accident number: | Final report | Download report: | Final report
|
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Classification:
Tailstrike
Runway mishap
Follow-up / safety actions
ANSV issued 2 Safety Recommendations
Issued: -- | To: ENAC | ANSV-1/1110-09/1/A/10 |
A procedure should be established requiring the originating station handling personnel of the operator:
- to consider the effect on the center of gravity by the disembarkation at the intermediate destinations, of passengers, baggage and cargo in order to distribute, when possible, passengers baggage and cargo so as to maintain the center of gravity within the operational envelope limits even after unloading; or, if such distribution is not possible,
- to advise the next station that a new seat assignment and loading location of baggage and cargo will be necessary. |
Issued: -- | To: ENAC | ANSV-2/1110-09/2/A/10 |
A procedure should also be established indicating ways and means to assure that the captain is correctly informed that changes will be necessary to the loading and passengers distribution before the subsequent flight, and that a positive check is performed of the effective execution of such changes (passengers, baggage and cargo). |
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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Verona Airport to Roma-Fiumicino Airport as the crow flies is 411 km (257 miles).
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.