Wizz Air A321 CG was off the chart
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There's no going back to manual loadsheets. In the race for efficiency that the LCCs lead, every little bit of the process which can be optimised will be optimised - and that involves time spent doing calculations with a pen and paper. Not to mention that use of performance software allows for greater integration of the process into the overall operational system if done correctly. And, frankly, manual loadsheets are not immune to errors either.
So, I don't think that it's a matter of whether the software should be there. It should and it will. But the lessons learned from this case should result in more and better safeguards within it. The computer programme used for loading is not an Excel sheet cooked up by someone off the street. It's a very mature piece of software which has passed all the necessary approvals and has an excellent track record globally. However, that shouldn't mean that the support team shouldn't have some thoughts about how to prevent this from happening again.
This is not entirely a matter of mass and balance. It wouldn't have happened if the cabin crew had noticed the unusual load distribution. Having 160 people in the first 30 rows and nobody in the last 9 rows should ring a bell - and be immediately reported to the Captain as unusual. So, improved cabin crew training should also be on the cards.
So, I don't think that it's a matter of whether the software should be there. It should and it will. But the lessons learned from this case should result in more and better safeguards within it. The computer programme used for loading is not an Excel sheet cooked up by someone off the street. It's a very mature piece of software which has passed all the necessary approvals and has an excellent track record globally. However, that shouldn't mean that the support team shouldn't have some thoughts about how to prevent this from happening again.
This is not entirely a matter of mass and balance. It wouldn't have happened if the cabin crew had noticed the unusual load distribution. Having 160 people in the first 30 rows and nobody in the last 9 rows should ring a bell - and be immediately reported to the Captain as unusual. So, improved cabin crew training should also be on the cards.
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You can make all the excuses that you want, but the fact that this happened to Wizz, as opposed to Ryan or Easy, doesn't surprise anyone.
Sure, at better, safer, more experienced 320 operaters things happen. But when it does, it's surprising, and dealt with.
With Wizz, nope, no way I'd put my family on there.
Sure, at better, safer, more experienced 320 operaters things happen. But when it does, it's surprising, and dealt with.
With Wizz, nope, no way I'd put my family on there.
Report: Easyjet A320 at Lisbon on Sep 16th 2019, wrong performance calculation results in late takeoff
Report: Easyjet A319 at Nice on Aug 29th 2019, takeoff with insufficient thrust, both pilots made same error
Report: Easyjet Europe A320 at Lisbon on May 7th 2019, takeoff with insufficient thrust
Report: Easyjet A320 at Lisbon on Apr 24th 2019, takeoff with insufficient thrust
Incident: Easyjet Europe A319 at London on Sep 30th 2018, error in takeoff calculation
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To those that state that ‘d be cabin crew task to check the distribution of the pax , according to my flights with wizz ,they are very prone and aggressive to check and remove pax that did not pay for the proper seat instead . And probably most of them dont’ even know the danger related to improper pax distribution CG wise in a plane. But is not their fault , is company culture.
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"The unusual passenger distribution was not noticed by the cabin crew or dispatcher|
"unusual passenger distribution"
nothing unusual per se here. the lc-system recalculated per new registration and redistributed pax to all 4 zones I read 42 in 0D.
having said that, definitely someone failed to notify the gate supervisor to change (paper ?) boarding passes for 42 known pax, (time consuming, creating frustrations and delays),
or allocate 42 seats at random, again creating frustrations and delays,
or if free-seating was decided, (justified by the excess capacity) someone failed to alert the cabin crew supervisor (to block seat-rows) and advise all pax.
the report is unclear in this.
"not noticed"
'by the dispatcher'
meaning the person preparing the loadsheet, load-controller/planner (usually far from the gate/aircraft) ? Well they never come on board to verify their work nor they are required to.
supervision of loading and pax boarding is supervised by the ramp agent / loading supervisor, usually handling 3-4 flights simultaneously !
'by the cabin crew'
no EASA or FAA legislation - to my knowledge - exist, mandating this short of checks by cabin crew.
it is a matter to be dealt with by the CC Training Dept and that points to company culture.
in the old days cabin crew were better trained and also received a copy of the loadsheet, even LCC, so there was better awareness.
nothing unusual per se here. the lc-system recalculated per new registration and redistributed pax to all 4 zones I read 42 in 0D.
having said that, definitely someone failed to notify the gate supervisor to change (paper ?) boarding passes for 42 known pax, (time consuming, creating frustrations and delays),
or allocate 42 seats at random, again creating frustrations and delays,
or if free-seating was decided, (justified by the excess capacity) someone failed to alert the cabin crew supervisor (to block seat-rows) and advise all pax.
the report is unclear in this.
"not noticed"
'by the dispatcher'
meaning the person preparing the loadsheet, load-controller/planner (usually far from the gate/aircraft) ? Well they never come on board to verify their work nor they are required to.
supervision of loading and pax boarding is supervised by the ramp agent / loading supervisor, usually handling 3-4 flights simultaneously !
'by the cabin crew'
no EASA or FAA legislation - to my knowledge - exist, mandating this short of checks by cabin crew.
it is a matter to be dealt with by the CC Training Dept and that points to company culture.
in the old days cabin crew were better trained and also received a copy of the loadsheet, even LCC, so there was better awareness.
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When I was a despatcher during the 1980's, and as well as checking the holds after loading, I made it my job to check the cabin for pax distribution and cross-check, then head into the cockpit for the load sheet sign off. I wasn't required to check the cabin, I just did it because I was taught by someone who took me right back to basic math and the effects of weight versus balance. I carried over that mentality to everyone I trained.
Empty aircraft prevent challenges sometimes simply by design. If they had a T tail, they were worse than the engine/wing configuration we see these days. BAC1-11's were notorious for needing at least 400kg ballast in the forward hold in order to get the ZFW just within limits. Once fuel is added to the centre tank, the C of G comes forward, but not by much. The centre fuel was often "trapped" and not used in trip fuel calculations.
Pax day trip flights on 1-11's were also a challenge simply because the pax had no luggage.
Everything in those days was done with a pen, ruler, calculator and a piece of paper they call a load & trim sheet. The only computer aid we had was the calculator (and our brain).
Empty aircraft prevent challenges sometimes simply by design. If they had a T tail, they were worse than the engine/wing configuration we see these days. BAC1-11's were notorious for needing at least 400kg ballast in the forward hold in order to get the ZFW just within limits. Once fuel is added to the centre tank, the C of G comes forward, but not by much. The centre fuel was often "trapped" and not used in trip fuel calculations.
Pax day trip flights on 1-11's were also a challenge simply because the pax had no luggage.
Everything in those days was done with a pen, ruler, calculator and a piece of paper they call a load & trim sheet. The only computer aid we had was the calculator (and our brain).
In those good old days the dispatcher was fully responsible for ramp and load control. Now in the name of efficiency load control is sitting somewhere in a windowless office, possibly off-airport, and the ramp agent gets a loading instruction, completely disconnected from W&B. There are less and less dinosaurs around who actually understand the process from start to end...
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I'd be curious to find out where the exact rotation point was from RWY 26 - there is not a lot of room for error at LTN, with terrain at the end of the runway also. Considering in the last few years where there has been a significant increase in air traffic from the airport, crew / ATC are not requesting full length departures in most cases reducing the available run to around 1900m if I recall correctly.
In the absence of an FDR/QAR trace, we're unlikely to know the answer to that.
If it's any help, FR24 shows the aircraft passing over the 08 (as was) piano keys at approximately 125 ft AGL.
If it's any help, FR24 shows the aircraft passing over the 08 (as was) piano keys at approximately 125 ft AGL.
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Dannyboy39
1771m to be precise. Full length is 2162m.
However, full length doesn’t necessarily mean that there would be more stopping margin or runway available after VR. The flex temperature will probably be higher, resulting in an increased TOR and ASD. Selecting TOGA will give you more margin on full length compared to an intersection of course, but in this case, the crew selected TOGA after VR. The remaining runway length could have been the same with a full length TO.
1771m to be precise. Full length is 2162m.
However, full length doesn’t necessarily mean that there would be more stopping margin or runway available after VR. The flex temperature will probably be higher, resulting in an increased TOR and ASD. Selecting TOGA will give you more margin on full length compared to an intersection of course, but in this case, the crew selected TOGA after VR. The remaining runway length could have been the same with a full length TO.
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I’m surprised there hasn’t been more focus on the (to me) lack of procedural integrity within the ground handling processes taking place here, this ‘oversight’ has been around for decades when disparate systems are used at check in and at load control.
A gap very much appears to exist between the check-in side and the ground operations (load control) wing in that there seems to be two ‘systems’ in play and that either one computer system is managing only one portion of this integrated/overarching process or, two separate computers are managing each side independently and without sufficient integrity of ‘hand off’. It does seem to be the latter as it is accounted for in the first two of the seven ‘Safety Actions’ noted in the report coupled with the airline offering online check-in and ‘software’ was used to produce the loadsheet.
It is reasonable to deduce from the report is that what was missing here was a ‘passenger distribution’ communicated by passenger services to load control when they handed over the details of the passenger breakdown and baggage numbers nor was it solicited from passenger services by load control. How that handover was executed is also not apparent in the report; was it a phone call, radio call, was it the physical passing of a print out from the check-in system with passenger data on, was it a view of the passenger data held in the check in system taken by load control? I note there are no safety actions directed at any computer system improvement which may indicate that the data was available but somehow failed to be communicated across the parties.
It would be interesting to see the relevant sections of the Ground Operations Manual and/or Passenger Handling Manual to see if this process is outlined adequately.
This simple information exchange, if conducted with integrity, should -would- have discovered the seating problem causing the undesirable balance condition and providing some opportunity to get ahead of the curve of this problem and being able to take appropriate action in advance of departure.
It also means that load control quite probably produced, not necessarily intentionally, but certainly by omission a flight safety document based upon assumption and not fact (I’m trying to be careful with language here) and as such could be subject to UK ANO Section 256(6) and its affixed scheme of penalty (L5). The balance of the evidence suggests load control assumed a passenger distribution. It is of course possible that the Excel solution automatically ‘assumes’ a certain passenger distribution (personally I fail to see any good reason as to why it should do) yet on the basis that no software demands have been made in the safety actions this does not seem to be likely; a look at the Excel ‘screen shot’ in the report suggest those cells are vacant for input and therefore not automatically calculated within Excel to determine an assumed seating distribution from the total passenger number - that data was most likely entered via a keyboard and based upon assumption and not fact.
Let’s also not overlook that fact that this same scenario and therefore exact same risks can extend into all versions of a ‘system’ other than a fully integrated one; those being (a) manual check in, manual load control, (b) manual check in, automated load control and (c) automated check in, manual load control not just this scenario of automated check in, automated load control performed on two different (and not integrated) computer systems. Yes I will refer to the use of an Excel spreadsheet as an automated system despite my surprise at the fact of its use for these purposes, which therein lies another problem in most part created by the LCC solution providers - they generally ignore this significant component of airport operations yet still still call their check-in and boarding solutions a ‘Departure Control System’, when they really are not.
Excel is not an acceptable solution when a fully functional load control solution with an open API (to any/all check in systems) could be developed and on the market for comparatively very little money and competing with the likes of the major ‘DCS” providers who LCC’s usually steer clear of due to cost. Airlines who are customers of most (if not all) LCC solution providers in today’s market should not just note this they should demand it from their “DCS” provider. Far cheaper than a chunk of metal at the end of a runway.
A gap very much appears to exist between the check-in side and the ground operations (load control) wing in that there seems to be two ‘systems’ in play and that either one computer system is managing only one portion of this integrated/overarching process or, two separate computers are managing each side independently and without sufficient integrity of ‘hand off’. It does seem to be the latter as it is accounted for in the first two of the seven ‘Safety Actions’ noted in the report coupled with the airline offering online check-in and ‘software’ was used to produce the loadsheet.
It is reasonable to deduce from the report is that what was missing here was a ‘passenger distribution’ communicated by passenger services to load control when they handed over the details of the passenger breakdown and baggage numbers nor was it solicited from passenger services by load control. How that handover was executed is also not apparent in the report; was it a phone call, radio call, was it the physical passing of a print out from the check-in system with passenger data on, was it a view of the passenger data held in the check in system taken by load control? I note there are no safety actions directed at any computer system improvement which may indicate that the data was available but somehow failed to be communicated across the parties.
It would be interesting to see the relevant sections of the Ground Operations Manual and/or Passenger Handling Manual to see if this process is outlined adequately.
This simple information exchange, if conducted with integrity, should -would- have discovered the seating problem causing the undesirable balance condition and providing some opportunity to get ahead of the curve of this problem and being able to take appropriate action in advance of departure.
It also means that load control quite probably produced, not necessarily intentionally, but certainly by omission a flight safety document based upon assumption and not fact (I’m trying to be careful with language here) and as such could be subject to UK ANO Section 256(6) and its affixed scheme of penalty (L5). The balance of the evidence suggests load control assumed a passenger distribution. It is of course possible that the Excel solution automatically ‘assumes’ a certain passenger distribution (personally I fail to see any good reason as to why it should do) yet on the basis that no software demands have been made in the safety actions this does not seem to be likely; a look at the Excel ‘screen shot’ in the report suggest those cells are vacant for input and therefore not automatically calculated within Excel to determine an assumed seating distribution from the total passenger number - that data was most likely entered via a keyboard and based upon assumption and not fact.
Let’s also not overlook that fact that this same scenario and therefore exact same risks can extend into all versions of a ‘system’ other than a fully integrated one; those being (a) manual check in, manual load control, (b) manual check in, automated load control and (c) automated check in, manual load control not just this scenario of automated check in, automated load control performed on two different (and not integrated) computer systems. Yes I will refer to the use of an Excel spreadsheet as an automated system despite my surprise at the fact of its use for these purposes, which therein lies another problem in most part created by the LCC solution providers - they generally ignore this significant component of airport operations yet still still call their check-in and boarding solutions a ‘Departure Control System’, when they really are not.
Excel is not an acceptable solution when a fully functional load control solution with an open API (to any/all check in systems) could be developed and on the market for comparatively very little money and competing with the likes of the major ‘DCS” providers who LCC’s usually steer clear of due to cost. Airlines who are customers of most (if not all) LCC solution providers in today’s market should not just note this they should demand it from their “DCS” provider. Far cheaper than a chunk of metal at the end of a runway.
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vilas
Yes. Something along those lines. Somebody set the FCU too high, and then it all went downhill from there. Only instead of turning EVERYTHING off, they continued to mess around with the FCU and wound up landing very, very long.
Had they disconnected everything, it would have been nothing more than a minor disturbance.
Yes. Something along those lines. Somebody set the FCU too high, and then it all went downhill from there. Only instead of turning EVERYTHING off, they continued to mess around with the FCU and wound up landing very, very long.
Had they disconnected everything, it would have been nothing more than a minor disturbance.
Last edited by andrasz; 15th Oct 2020 at 09:47.
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However, that still does not negate the passing or asking of the seating distribution when passenger breakdown figures are passed from passenger services to load control when you have a non-integrated EDP system in play - that remains (in my opinion) the fundamental process breakdown and the primary cause of this error and eventual problem.
As for,
"Load Control then had to manually re-distribute pax to get W/B within limits, just forgot to tell gate & crew about it."
If this (as you posit) is correct it suggests that a seating distribution was passed and entered in the load control software solution which then presented the out of trim circumstances to load control, if true, then as such the first thing one would do as a load controller is tell passenger services of that issue immediately and the need to reseat or whatever other corrective action was required. Failure to do so would be criminal - for want of a better word. To actually go on to prepare and present a load sheet under those circumstances knowing full well the action you took to produce it and to not tell anyone else ... well.
As for,
"Load Control then had to manually re-distribute pax to get W/B within limits, just forgot to tell gate & crew about it."
If this (as you posit) is correct it suggests that a seating distribution was passed and entered in the load control software solution which then presented the out of trim circumstances to load control, if true, then as such the first thing one would do as a load controller is tell passenger services of that issue immediately and the need to reseat or whatever other corrective action was required. Failure to do so would be criminal - for want of a better word. To actually go on to prepare and present a load sheet under those circumstances knowing full well the action you took to produce it and to not tell anyone else ... well.
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Icarus the handling system IS integrated, any check-in entries will correctly be passed on to the L/C module (as it happened in this case). As for your assessment of the subsequent events, I agree entirely, there is a good reason pinkair is firmly on my no-fly list (actually several good reasons...).