On January 12th 2003, Transavia Airlines flight HV1277 , a passenger aircraft was scheduled for a three leg charter flight from Rotterdam Airport (EHRD) via Maastricht-Aachen Airport (EHBK) and Arrecife, Lanzarote Airport (GCRR) to Amsterdam Airport Schiphol (EHAM).

Scheduled departure time for flight HV1277 from Rotterdam to Maastricht was 1400 hrs. The flight had an air traffic control (ATC) departure restriction (slot time) of 1410 hrs.

The scheduled arrival time at the end of the schedule at Amsterdam was 0030 hrs on January 13th. The crew reported for duty at 1145 hrs at Transavia airlines flight dispatch in the main office at Amsterdam where the flight preparation took place.

A briefing and documents for the flights were received, including computer generated load and trim sheets, for all legs to be flown. A total of 114 passengers was used for the flight preparation of the first leg. At this stage the cockpit crew made the decision to take additional fuel at Rotterdam to enable a quicker turnaround at Maastricht.

Transavia Airlines flight HV1277

The crew consisted of a captain, a first officer (F/O) and five cabin attendants. It was the first day of a work cycle for the pilots. They had been off duty for several days (captain two days, F/O one week).

Both pilots and four cabin attendants travelled to Rotterdam by taxi and arrived at Rotterdam 55 minutes before the scheduled departure time. One cabin attendant reported at Rotterdam. After arrival at Rotterdam the crew continued directly to the aircraft parked on the apron in front of the terminal.

A Transavia airlines technician, based at Rotterdam, carried out the pre-flight inspection.

Transavia Airlines flight HV1277 was released to service without technical complaints. Some ice was observed on sections of the wings. The pilots expected that the ice would melt when adding additional fuel at Rotterdam. However, the ice remained on the wings after refuelling and therefore the aircraft was de-iced.

The F/O stated that the captain had a minor argument with an employee of the ground handling company about the de-icing process, because the employee had stated that de-icing could not be finished before the scheduled departure time.

The purser stated that the captain of Transavia Airlines flight HV1277 wanted to depart on time and that it seemed as if he was in a hurry.

She also stated that this could have been the result of previous experiences with the ground handling company. During the post occurrence interview the captain stated that he was not in a hurry

According to post occurrence interviews with both pilots, the atmosphere in the cockpit of Transavia Airlines flight HV1277 was good and the cooperation between them was friendly and professional.

This was confirmed by cockpit voice recorder (CVR) data. Both pilots stated that they were well rested and fit for duty.

Aviapartner, a ground handling company, was contracted by Transavia airlines at Rotterdam from December 10th 2002.

Aviapartner Passenger Services personnel at Rotterdam had planned the passenger distribution the previous day.

It was common practice for multi leg flights that planning was done in consultation with the ground handling company at the next station.

According to the Passenger Services personnel the planning, for the flight under consideration, was done such that passengers were seated starting from the rear of the cabin to keep the front seats empty in order to facilitate boarding at Maastricht.

The computer generated load and trim sheet used by the crew assumed the passengers to be equally spread throughout the cabin. One hundred and thirteen passengers boarded the aircraft for the flight to Maastricht. An Aviapartner load controller informed the cockpit crew verbally about the actual passenger count and the weight and distribution of the baggage. Because the load and trim sheet stated 114 passengers instead of the actual 113 passengers on board, it was altered to the actual number of passengers. The baggage figures were also changed from 1,792 kg to the actual 2,021 kg on board. A copy of the load and trim sheet was handed to the ground handling staff.

The purser stated during the post-occurrence interview that she had counted the passengers and noted that four passengers were seated in the first row while the remaining passengers were seated primarily in the aft part of the cabin, after row thirteen.

She reported this to the cockpit crew. According to her the captain subsequently looked into the cabin from his position in the cockpit and took no further action. According to the captain the purser had mentioned that the passengers were seated from row eleven and aft. There was no reaction from the F/O to the remark of the purser. The purser stated also that this was the first time she experienced that passengers were seated from row thirteen and aft without reseating them.

After all passengers had boarded the aircraft, doors were closed at approximately 13:57 hrs. The F/O performed the pilot flying (PF) duties from the right hand seat whilst the captain performed the pilot not flying (PNF) duties. After the engines were started the aircraft taxied to runway 24, flaps 5 were selected and the pilots completed preparations for take-off.

The F/O of Transavia Airlines flight HV1277 stated that the taxi-out was uneventful and that the only notable event was that the nose wheel skidded for a moment when the aircraft lined up on the runway. His explanation was that he had turned the tiller too quickly.

At 1407 hrs the take-off was initiated.

The cockpit crew of Transavia Airlines flight HV1277 stated that when the aircraft started to roll, the nose immediately pitched up. The movement stopped when the aft fuselage and the tailskid assembly contacted the ground.

CVR data revealed that the captain instructed the F/O to reject the take-off. The thrust levers were pulled back and brake pressure was applied causing the aircraft’s nose gear to touch the ground again. The captain informed ATC that the take-off had been rejected.

After the aircraft came to a complete stop the parking brake was set and a call “cabin crew remain seated” was given by the captain. The captain requested the fire brigade to inspect the aircraft. The purser came to the cockpit. CVR data revealed that both pilots expressed their uncertainty about what had caused the pitch up movement.

The purser mentioned that she thought that the aircraft might be too heavy in the rear. She asked the captain to inform the passengers via the passenger address (PA) system about the presence of the fire brigade trucks. After the captain had done this the purser informed the passengers again to be sure that everybody had understood the message from the captain.

CVR data revealed that at a later stage the purser came to the cockpit again and told the captain that she had informed him earlier that four passengers were seated in the first row and the remaining passengers were seated aft from row twelve/thirteen. CVR data also revealed that the captain acknowledged that the purser had informed him about the passenger seating.

After the fire brigade had inspected the aircraft no fire or fire hazard was observed. The aircraft taxied back to the apron and the engines were shut down.

After the passengers had left the aircraft, the captain and the purser debriefed the passengers in the terminal. Thereafter the captain arranged a debriefing for the entire crew.

The pilots stated in the post occurrence interview that during and immediately after the occurrence they had no idea what had caused the pitch up movement of the nose of the aircraft. During the post occurrence interview the F/O described the event as an aggressive nose up movement.

Cause and contributing factors : attempted take-off with the centre of gravity well behind the applicable aft limit.

Contributing factors :

Transavia airlines Flight operations:

• Lack of action by the cockpit crew members involved. The passenger distribution was recognized by the purser as deviating from standard. Her subsequent report to the cockpit crew did not result in any corrective action, despite the responsibility of the captain to take all reasonable steps to ensure that the aircraft weight and balance is within limit;
• Lack of awareness from the cockpit crew concerned regarding the significant effect of passenger distribution on the centre of gravity of the aircraft.

Quality system:

• Inadequate response to audit results, related to mass and balance. No evaluation of the effectiveness of the corrective actions;
• Inadequate occurrence reporting of passenger loading errors;
• Inadequate follow-up of the occurrence reports regarding passenger loading errors;
• Insufficient supervision over the seat assignments by ground handling companies;
• No assurance that Aviapartner was familiar with the ASM and was staffed by trained personnel who had sufficient knowledge of their responsibilities.

Aviapartner

• No training was given on the use of the passenger distribution table in the ASM to it Passenger Services employees;
• Seat assignment was not according the passenger distribution table in the ASM