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B738, Stuttgart Germany, 2005

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Summary
On 23 April 2005, a Boeing 737-800 being operated by Turkish charter airline Sky Air on a passenger flight from Stuttgart to Dusseldorf tipped onto its tail when take off thrust was applied for the intended departure from Runway 25 in normal day visibility. The attempt to take off was immediately abandoned and the aircraft towed back to the gate for the 100 passengers to disembark. One of the cabin crew was slightly injured and the aircraft was ‘severely damaged’.
Event Details
When April 2005
Actual or Potential
Event Type
Ground Operations, Human Factors
Day/Night Day
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft BOEING 737-800
Operator Sky Airlines
Domicile Turkey
Type of Flight Public Transport (Passenger)
Origin Stuttgart Airport
Intended Destination Dusseldorf
Take off Commenced Yes
Flight Airborne No
Flight Completed No
Flight Phase Take Off
TOF
Location - Airport
Airport Stuttgart Airport
HF
Tag(s) Ineffective Monitoring,
Aircraft acceptance
GND
Tag(s) Passenger Loading
Outcome
Damage or injury Yes
Aircraft damage Major
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) Aircraft Operation,
Air Traffic Management,
Airport Management
Investigation Type
Type Independent

Description

On 23 April 2005, a Boeing 737-800 being operated by Turkish charter airline Sky Air on a passenger flight from Stuttgart to Dusseldorf tipped onto its tail when take off thrust was applied for the intended departure from Runway 25 in normal day visibility. The attempt to take off was immediately abandoned and the aircraft towed back to the gate for the 100 passengers to disembark. One of the cabin crew was slightly injured and the aircraft was ‘severely damaged’.

Investigation

An Investigation was carried out by the German BFU. Cockpit Voice Recorder (CVR) data was available but Flight Data Recorder (FDR) data was not. It was established that the aircraft had previously arrived in Stuttgart from Hurghada and 100 of the 196 arriving occupants had disembarked with their luggage prior to the reminder departing for Dusseldorf. Since the remaining luggage was all in one rear hold, to maintain the aircraft centre of gravity within Aircraft Flight Manual (AFM) limits would have required that a significant number of the passengers moved to seats further forward. According to the load and trim sheet certified and accepted by the aircraft commander, 42 passengers were seated in the forward bay of the passenger cabin (seat rows 1-15) and the remaining 47 in the rear bay (seat rows 16-33). In fact, all 89 passengers were seated in the rear bay.

Despite the cabin crew alerting the Captain to their perception of an unusual distribution of occupied seats in the cabin, the latter took no action. The assigned load master had also alerted the supervising ramp agent to the tail heavy appearance of the aircraft whilst it was still on the ramp but the latter had also not taken any action. As the aircraft taxied, the same person observed that nose wheel contact was so minimal that the nose landing gear was drifting outwards during turns and informed the Airside Duty Manager who had no direct communication with the aircraft and took no other action.

Shortly after the aircraft had begun the take off roll, it pitched backwards and the tail struck the runway. The take off was rejected and the aircraft pitched back onto the nose landing gear and came to a stop. The tail strike which occurred “caused severe structural damage in the aft fuselage area”.

It was established that the centre of gravity as loaded had been “beyond the permitted tolerance”. It was noted that there had been previous similar serious incidents involving Turkish-operated aircraft in Germany.

The formal Findings of the Investigation were that:

  • The Cause of the tail strike was the extreme tail-heavy aircraft balance, caused by the remaining passengers and their luggage in the aft part of the aircraft.
  • A Contributory Factor was the insufficient situational awareness of all persons involved, except for the load master.

As a result of the Investigation, four Safety Recommendations were issued:

  • The Luftfahrt-Bundesamt (German CAA) shall perform increased inspection of the aircraft loading of Turkish airline companies. (07/2005)
  • The Turkish CAA aviation authorities shall order an examination of the crews within the concerned Turkish airline company, concerning the operational knowledge of aircraft, especially concerning the loading and if necessary a special training to improve awareness of situations. (08/2005)
  • By agreement with the Deutsche Flugsicherung GmbH (DFS - the German ANSP) the Stuttgart airport shall establish a radio communication with the corresponding frequencies between the traffic supervisor on duty and the tower, the ground and the ramp control, in order to prevent direct danger. (03/2006)
  • The (Stuttgart Airport Operator) shall implement actions, enabling the visibility of the traffic control over the whole asset. (04/2006)

The Final Report was published September 2010: AX002-0/05


Further Reading