The narrowbody was accelerating down the runway when it experienced an uncommanded pitch up
An Alitalia Airbus A320 tipped up and suffered a tail strike during take-off at Milan/Malpensa in 2017 because of the improper distribution of passengers, a report by Italian air accident investigators (ANSV) has found.
The jet, EI-DTB (c/n 3815) – which was bound for Rome/Fiumicino airport on August 17 – had begun to accelerate along runway 35R at the facility when at 42kts, it suddenly pitched up causing the underside of the rear fuselage to scape on the ground.
The crew subsequently aborted the take-off and returned to the parking area where the passengers disembarked.
The damage to the narrowbody was identified to be contained to an area stretching around 1.8 metres by 30cm. The incident caused approximately 0.4mm to be shaved off the aircraft skin and following repairs, the jet was released into service.
The flight in which the event occurred represented the fourth and final leg of an unscheduled charter operation – which was being flown for a cruise company – that started and finished in Rome.
The first two sectors consisted of a multi-leg flight which went from Rome (FCO) to Milan (MXP) and then onto Hamburg (HAM). The northern Italian city served as an intermediate stop to board additional passengers for the German metropolis.
The return rotation was identical but instead involved the disembarkation of travellers. A total of 171 passengers boarded in Hamburg, 68 of which had Milan as their destination, while the remaining 103 were due to fly on to the Italian capital.
The handler at the German airport pre-accepted the 171 passengers, assigning seats after row 12 for those destined for Rome and seats from one to 12 for those disembarking in Milan.
In addition, baggage scheduled to be taken off at MXP was all placed in the forward cargo hold. This was done to facilitate a quicker turnaround at the northern Italy airport.
Investigators said Hamburg was outside the Alitalia’s network and as a result, the aircraft’s load data was not automatically transferred to the jet via ACARS. Instead, handlers sent a paper load sheet via email to the company’s cargo controller in Rome.
The ANSV said the form was not designed for multi-leg flights, in the sense that it did not include the space to indicate the condition of seats for two separate destinations.
The operator’s cargo controller needed the missing information to finalise the production of the load sheet and entered a “reasonable” – but not validated – seating configuration, assuming distribution would be the same on board for both destinations.
This action caused no problems on the first sector because the aircraft was heavily loaded, and the passengers occupied almost all the available seats.
The Rome-based load controller did not expect the unvalidated data to be considered valid by the MXP handler for the production of a load sheet at the intermediate stop. It indicated that the distribution of passengers for the final leg was 33 forward, 39 central and 31 at the back of the cabin, while the actual configuration was just four people at the front, 47 in the middle and 52 aft.
The ANSV concluded that a “significant contributing factor” to the incident was the cabin and flight crew’s failure to conduct a visual assessment of the distribution of passengers before take-off.
The sporadicity with which multi-leg flights were operated by the company was also partially to blame as was the “lack of perception” by cabin crew of the criticality for flight safety represented by the distribution of passengers.
After the incident, the report said Alitalia took corrective actions including conducting a briefing to flight crew which emphasised the importance of increasing “defensive barriers” in case of flights beyond routine operations.
In addition, training was carried out for all load controllers and modifications were made to the paper load sheet form including notes to check the actual seating assignments on multi-leg flights.