FACTUAL INFORMATION1
History of the flight
At 1503 Coordinated Universal Time (UTC) on 9 December 2004, the pilot in command of an Airbus Industrie A330-301 aircraft (A330), registered VH-QPC, commenced the take-off from Singapore on a scheduled regular public transport service to Darwin, NT. The pilot in command reported that the aircraft felt nose heavy during rotation2, but that after the aircraft was trimmed, a more normal feel was restored. Following the flight it was found that the aircraft's take-off centre of gravity3 (CG) was forward of the manufacturer's forward limit.
The decision by the operator to operate the domestically configured aircraft on an international service was not communicated to the company department that had responsibility for updating the aircraft's flight document library. As a result, the take-off performance charts for the departure from Singapore were unavailable for use by the flight crew. The flight crew reverted to calculating the aircraft's take-off performance using the aircraft's Performance Supplement Manual.
The operator maintained two distinct weight and balance profiles for application in its A330 operations. The profiles were:
- an international profile, employing a basic index4 (BI) of about 292, and used in conjunction with an international weight and balance template
- a domestic profile, with a BI of about 192, and used in conjunction with a domestic weight and balance template.
The aircraft's international weight and balance profile was created a number of months before the occurrence flight. During that process a corrupted international profile was created. The system and the operator did not recognise that there was an error in the data in the new profile. There was no requirement for the audit of that profile as it was created from existing certified data. Subsequently, the aircraft's corrupted international profile remained undetected during the intervening months of domestic operations leading up to the occurrence flight.
A number of company defences were promulgated to ensure that the operator's aircraft were correctly loaded:
- the Flight Administration Manual placed responsibility with all flight crew members to ensure that company aircraft were operated within their CG limits
- the Route Manual Supplement required that, before accepting a provisional load sheet, the crew 'should' confirm their aircraft's critical load data against other aircraft documentation
- the Flight Crew Operating Manual specified that the pilot in command was responsible for the final check of an aircraft's load sheet data.
The copilot reported extracting the aircraft's basic weight5 (BW) and BI parameters from a fleet weight and balance folder that was located in the operator's Singapore flight dispatch office. The parameters were then provided to the local load control staff in order for them to produce the loadsheet6 for the flight.
The flight crew reported that, in this instance, neither the copilot nor the second officer could recall having checked the aircraft's critical load data, and that the pilot in command did not check the aircraft's load sheet.
There was no evidence that the load control staff completed the required independent check of the BW and BI parameters for the aircraft and, as a result, an international BI was unwittingly applied to what remained, effectively, the aircraft's domestic weight and balance template.
Aircraft information
No evidence was found of a defect in the aircraft or its systems that may have influenced the circumstances of the occurrence.
The load sheet indicated to the flight crew and load control staff that the aircraft had been correctly loaded in order for the aircraft's CG to remain within limits for all phases of the flight. The investigation determined that the aircraft's CG was located forward of the manufacturer's forward limit for the take-off.
The manufacturer stated that the CG for the take-off did not exceed the aircraft's structural and landing gear limitations, and that the aircraft was 'sufficiently manoeuvrable' at all times. However, an out of limits forward CG increases the risk of there being insufficient elevator authority for a pilot to rotate an aircraft during take-off, or to flare an aircraft for landing. The result would be that take-off and landing distances would be greater than planned by the pilot.
There was no capability for the aircraft's systems to warn the flight crew of an out of limits CG while on the ground. Airborne warning of an out of limits aft CG was possible.
- Only those investigation areas identified by the headings and subheadings were considered to be relevant to the circumstances of the occurrence.
- Positive, nose-up pitch of the aeroplane about the lateral axis immediately prior to becoming airborne.
- The point at which an aircraft would balance if suspended. It must be located within specific limits for safe flight.
- In simplified terms, the position of the aircraft's centre of gravity before fuel and payload are added.
- Mass of the aircraft, including of the aircraft's fixed equipment and residual fluids.
- A performance planning document that annotated the aircraft's weight, centre of gravity for take-off and landing, and the loading requirements for the flight.