Aviation safety investigations & reports

Aircraft loading and in-flight controllability issue involving Fairchild SA227, VH-HPE Rockhampton Airport, Queensland, on 11 May 2020

Investigation number:
AO-2020-027
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

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What happened

On 11 May 2020, a Fairchild SA227-DC Metro 23 (Metro) aircraft, registered VH-HPE and operated by Toll Aviation, was being loaded for its scheduled freight service from Townsville to Rockhampton then Brisbane, Queensland. The pilot was the only person on board.

The pilot completed a load and trim sheet, which indicated that the planned load was not within the allowable centre of gravity limits. It was agreed that 126 kg of freight would be moved from compartment three to the nose compartment. The revised load and trim sheet indicated the centre of gravity to be within the limits. During the flight to Rockhampton, the pilot observed that the aircraft felt tail heavy, but did not experience any controllability issues.

Due to the concern of an aft centre of gravity, the additional freight loaded at Rockhampton was limited, which was still within the calculated allowable centre of gravity limits. On take-off from Rockhampton, the pilot reported that the aircraft had a strong pitch-up tendency and that strong forward pressure on the flight controls was required to maintain the correct pitch attitude. During the cruise, the autopilot would not consistently maintain level flight. The pilot disconnected the autopilot and with full nose-down trim applied, the pilot had to maintain forward pressure to control the pitch attitude of the aircraft. The aircraft continued to Brisbane and the pilot reported that no problems were experienced during the approach and landing.

What the ATSB found

The ATSB found that, the ground handlers at Townsville did not accurately weigh the freight relocated into the nose compartment, but rather, it was estimated by feel. This resulted in an inaccurate load and trim sheet, and the centre of gravity being further aft than expected. Therefore, when additional freight was loaded in Rockhampton, this unknowingly moved the centre of gravity beyond the rear limit, leading to the pitch-up tendency experienced by the pilot.

Although not contributory, the operator’s paper-based load planning tool used by ground handlers for the Metro did not account for the centre of gravity position. Rather, this was later determined by the pilot on the load and trim sheet, which was potentially completed after loading had commenced. This increased the chance of freight having to be relocated and the potential for loading errors to occur.

It was also identified that the operator’s ground handling manual did not contain sufficient procedural detail to facilitate the accurate redistribution of freight. In particular, there was no guidance on conducting last-minute changes or taking into account the centre of gravity when preparing a load plan to ensure that an aircraft would be correctly loaded.

What has been done as a result

Following the incident, the operator amended their ground handling processes and included increased direction to ensure that freight would be accurately redistributed in the event of a last-minute change. The operator has since relinquished their Civil Aviation Safety Authority’s Air Operator’s Certificate and divested their flying operations to another operator. The new Metro aircraft operator also considered the findings of this investigation, reviewed their ground handling manual and incorporated amendments to ensure that an aircraft would be correctly loaded.

Safety message

This incident demonstrates the critical nature of load control and the requirement to ensure an aircraft is correctly loaded and the centre of gravity is within the allowable limits. It also emphasises the importance of providing ground handlers with sufficient and detailed procedures to allow them to accurately conduct load control duties and minimise the potential for error.

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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Glossary

Sources and submissions

Appendices

About the ATSB

Summary

The ATSB is investigating a loading evening involving a Fairchild SA227, VH-HPE, near Rockhampton Airport, Queensland, on 11 May 2020.

The aircraft was loaded incorrectly, resulting in the centre of gravity being outside of the rear limit. During take-off and cruise, the pilot experienced control issues which required constant pressure to be kept on the flight controls to maintain straight and level flight.

As part of the investigation, investigators will be interviewing the pilot and ground staff, reviewing flight data recorders and examining operational records.

Should any safety critical information be discovered at any time during the investigation, the ATSB will immediately notify operators and regulators so appropriate and timely safety action can be taken.

A final report will be published at the conclusion of the investigation.

Safety Issue

Go to AO-2020-027-S1-02 -

Guidance in the ground handling manual

The operator's ground handling manual did not contain detailed procedural guidance for facilitating accurate redistribution of freight and ensure that an aircraft would be correctly loaded.

Safety issue details
Issue number: AO-2020-027-S1-02
General details
Date: 11 May 2020   Investigation status: Completed  
Time: 1815 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): near Rockhampton Airport, Queensland   Investigation phase: Final report: Dissemination  
State: Queensland   Occurrence type: Loading related  
Release date: 09 December 2021   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Fairchild Industries Inc  
Aircraft model SA227-DC  
Aircraft registration VH-HPE  
Serial number DC-823B  
Operator Toll Aviation  
Type of operation Air Transport Low Capacity  
Sector Turboprop  
Damage to aircraft Nil  
Departure point Rockhampton, Queensland  
Destination Brisbane, Queensland  
Last update 09 December 2021