Rilasciato report finale ANSV su tail strike A320 Alitalia a Malpensa in data 17 agosto 2017


enrico

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On Apr 15th 2021 the ANSV released their final report in Italian only.

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The report concludes the probable causes of the serious incident were:

human/organizational factors, an inappropriate distribution of passengers caused a serious imbalance of the aircraft at the start of the takeoff run.

Contributing factors were:

- the sporadicity of the multi leg flights performed by the operator
- lack of procedures for locd control and monitoring of load distribution due to insufficient information exchange between handlers and dispatch office, also due to the inadequacy of the module used to communicate the load for multi leg flights
- the lack of visual checks of the passenger distribution on board prior to takeoff compared to the load sheet
- the lack of perceiption by the cabin crew of the criticality of the passenger distribution for the safety of the flight


The ANSV reported the aircraft did not receive any structural damage, an abraded surface of about 1.80 meters by 30cm was noted at the bottom of the fuselage and an abrasion at the drain mast though.

The ANSV analysed weather did not play any role in the occurrence. The data downloaded from the black boxes did not show any anomaly or mistake by the operating flight crew nor did they provide any evidence of a malfunction of the aircraft.

The aircraft had operated a multi-leg daily rotation from Rome Fiumicino to Milan Malpensa to Hamburg (Germany) to Milan Malpensa to Rome Fiumicino.

The ANSV analysed 171 passengers had departed Hamburg, 68 of which were destined for Milan and 103 for Rome. The handler in Hamburg assigned seat rows 1-12 to the passengers to Malpensa and seat rows 13 and aft to the passengers to Rome. In addition three ULDs of luggage destined for Milan were put into the forward cargo hold. This distribution was intended to facilitate unloading and refitting at Malpensa, however, the handler in Hamburg was not using the software system used by the operator requiring to send the loading data in e-mail using the A320 LDS paper form to dispatch/load control.

The software module was not designed to accept the seat conditions on multi-leg flights distinct for two or more destinations. The load controller thus did not have the information to finalize the load sheet and assumed a reasonable but unverified seat distribution. This did not cause any problem on the sector HAM-MXP, however, the controller did not anticipate that the MXP handler would consider the seat distribution as valid. The load sheet thus assumed 33 passengers in the forward section of the aircraft, 39 in the middle section and 31 in the aft section of the cabin. However, the actual distribution was 4 passengers in the forward, 47 passengers in the middle and 52 passengers in the aft section of the cabin. In addition the forward cargo hold became emptied in MXP.

In this weight distribution, when the crew applied thrust for takeoff, the aircraft became sufficiently unbalanced so that the tail contacted the runway surface. The crew immediately rejected takeoff, the maximum speed over ground reached was 42 knots.

The ANSV had concluded in a similiar way about a similiar occurrence in 2009, see Accident: BH Air A320 at Verona on Sep 1st 2009, tail strike on takeoff. Germany's BFU had also released similiar conclusions in 2014, see Report: Sky Airlines B738 at Stuttgart on Apr 23rd 2005, tail strike at low speed, rejected takeoff.

 
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Seaking

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On Apr 15th 2021 the ANSV released their final report in Italian only (editorial note: to serve the purpose of global prevention of the repeat of causes leading to an occurrence an additional timely release of all occurrence reports in the only world spanning aviation language English would be necessary, an Italian only release does not achieve this purpose as set by ICAO annex 13 and just forces many aviators to waste much more time and effort each in trying to understand the circumstances leading to the occurrence. Aviators operating internationally are required to read/speak English besides their local language, investigators need to be able to read/write/speak English to communicate with their counterparts all around the globe.)
[\quote]
 

belumosi

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[QUOTE = "Seaking, post: 1924122, membro: 150803"]
Le solite figure di merda
[/CITAZIONE]
Guarda il contenuto della pagina inglese dell'ANSV, magari cerca anche qualcosa con il motore di ricerca. :mad:

 
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Seaking

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[QUOTE = "Seaking, post: 1924122, membro: 150803"]
Le solite figure di merda
[/CITAZIONE]
Guarda il contenuto della pagina inglese dell'ANSV, magari cerca anche qualcosa con il motore di ricerca.

Proverò ma mi fido di quello che scrive Simon, di solito molto attento.
 

belumosi

Socio AIAC
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Proverò ma mi fido di quello che scrive Simon, di solito molto attento.
Ero ironico! Nel sito in inglese non c'è nulla!
Solo dati di contatto. E il motore di ricerca è out.
Una cosa vergognosa.
Ho aggiunto lo smile al messaggio precedente per evitare di essere preso sul serio.
 
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B77W

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In realtà lo scrive sotto praticamente qualunque rapporto d'inchiesta che non sia di paesi anglofoni, perché le versioni in inglese vengono generalmente pubblicate dopo diverso tempo.
Ha ragione, sia chiaro, è solo per dire che la figura di m. è abbastanza globale.
 
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OneShot

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Mi sono "divertito " a simulare il centraggio di un 320 simile, assumendo i dati riportati daa AvH e aggiungendo 600kg in stiva (la 3e la 4 equamente distribuiti, stando a quanto descritto i bagagli per MXP erano davanti).
Qui il risultato (che poteva essere leggermente migliore se i bagagli erano meno, ne ho messi solo 50 al peso standard di 13kg, ma di gran lunga peggiore se i bagagli fossero stati 100 tutti alla stiva 4!)
Le solite figure di merda
Mi sono "divertito " a simulare il centraggio di un 320 simile, assumendo i dati riportati daa AvH e aggiungendo 600kg in stiva (la 3e la 4 equamente distribuiti, stando a quanto descritto i bagagli per MXP erano davanti).
Qui il risultato (che poteva essere leggermente migliore se i bagagli erano meno, ne ho messi solo 50 al peso standard di 13kg, ma di gran lunga peggiore se i bagagli fossero stati 100 tutti alla stiva 4!)IMG-20210418-WA0000.jpgIMG-20210418-WA0000.jpg