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B738, Rotterdam Netherlands, 2003 (GND LOC HF)
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|On 12 January 2003, a Boeing 737-800 being operated by Dutch airline Transavia on a passenger charter flight initially going from Rotterdam to Maastrict-Aachen was obliged to reject its take off on Runway 24 at Rotterdam after it pitched nose-up just after take-off thrust had been selected. The pitch up movement only stopped when the aft fuselage and the tailskid assembly contacted the runway and only when the flight crew rejected the take-off did the aircraft nose gear regain ground contact. The aircraft was damaged and unfit for flight but able to taxi back to the terminal to allow the uninjured passengers to disembark.|
|Event Type||GND, HF, LOC|
|Flight Conditions||On Ground - Normal Visibility|
|Type of Flight||Public Transport (Passenger)|
|Flight Phase||Take Off|
|Location - Airport|
|Tag(s)|| Ineffective Monitoring|
Flight / Cabin Crew Co-operation
Procedural non compliance
|Tag(s)|| Aircraft Loading|
Temporary Control Loss
|Damage or injury||No|
|Injuries||Nonewarning.png"None" is not in the list of possible values (Few occupants, Many occupants, Most or all occupants) for this property.|
|Fatalities||Nonewarning.png"None" is not in the list of possible values (Few occupants, Many occupants, Most or all occupants) for this property.|
|Causal Factor Group(s)|
On 12 January 2003, a Boeing 737-800 being operated by Dutch airline Transavia on a passenger charter flight initially going from Rotterdam to Maastricht-Aachen was obliged to reject its take off on Runway 24 at Rotterdam after it pitched nose-up just after take-off thrust had been selected. The pitch up movement only stopped when the aft fuselage and the tailskid assembly contacted the runway and only when the flight crew rejected the take-off did the aircraft nose gear regain ground contact. The aircraft was damaged and unfit for flight but able to taxi back to the terminal to allow the uninjured passengers to disembark.
An investigation was carried out by the Dutch Safety Board. It was found that the incident flight had been the first leg of a planned multi sector flight. Nearly all the passengers boarding at Rotterdam Airport were allocated seats at the rear of the cabin and seated themselves there as allocated. This action by the Operator’s Ground Handling Contractor at Rotterdam, Aviapartner, was intentional and had the objective of simplifying boarding at the next stop. However, this drastically uneven passenger distribution led to the aircraft centre of gravity being situated far behind the applicable aft limit.
The Investigation identified several factors as contributing to this circumstance, in particular the lack of awareness of the flight crew of the effect on aircraft centre of gravity of passenger cabin loading; the aircraft loading procedure actually used by the Operator; and the failure of both the Operator and the Ground Handling Company’s Quality Systems to identify and ensure rectification of systemically deficient processes. A check during the Investigation on 23 other Transavia multi sector passenger flights originating at Rotterdam before stopping at Maastrict-Aachen to take on more passengers found that none were actually loaded as stated on the load and trim sheet. The Investigation concluded that this provided confirmation of Transavia’s “failing quality system.”
The Investigation concluded that the Probable Cause of the event was the “attempted take -off with the centre of gravity well behind the applicable aft limit”
Contributing Factors were defined and allocated by the Investigation as follows:
Transavia Airlines Flight Operations:
- Lack of action by the cockpit crew members involved. The passenger distribution was recognised by the Purser as deviating from standard. Her subsequent report to the flight crew did not result in any corrective action, despite the responsibility of the Captain to take all reasonable steps to ensure that the aircraft weight and balance is within limits.
- Lack of awareness from the flight crew concerned regarding the significant effect of passenger distribution on the centre of gravity of the aircraft.
Transavia Airlines Quality System:
- Inadequate response to audit results related to mass and balance and no evaluation of the effectiveness of the corrective actions.
- Inadequate occurrence reporting of passenger loading errors.
- Inadequate follow-up of the occurrence reports regarding passenger loading errors.
- Insufficient supervision over the seat assignments by ground handling companies.
- No assurance that Aviapartner was familiar with the ASM and was staffed by trained personnel who had sufficient knowledge of their responsibilities.
Aviapartner (Transavia contracted Handling Agent at Rotterdam)
- No training was given on the use of the passenger distribution table in the Airport Service Manual to its Passenger Services employees.
- Seat assignment was not according to the passenger distribution table in the Airport Service Manual.
The Final Report of the Investigation was published on 9 November 2006 and may be seen in full at SKYbrary bookshelf Tail strike during take-off, Boeing 737-800, registration PH-HZB, Rotterdam Airport, January 12th 2003. It contained Safety Recommendations as follows quoted verbatim:
Transavia is recommended to:
- Enhance its pilot’s awareness about the effect of passenger distribution on the centre of gravity of Boeing 737-800 aircraft, and
- Evaluate its quality system, in particular regarding the:
- supervision of contracted ground handling companies;
- results of audits, and the effectiveness of associated corrective actions;
- procedures about reporting safety-related occurrences.
Aviapartner is recommended to:
- Improve its quality system such that shortcomings regarding the dispatch of passengers become visible.
The Minister of Transport, Public Works and Water Management is recommended to:
- Orchestrate the draft of quality and safety regulations for ground handling companies by the European Aviation Safety Agency (EASA).