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B739 Tail Tipping Incident (W&B Index) NAI - 1174 PDF
B739 Tail Tipping Incident (W&B Index) NAI - 1174 PDF
Date 15.5.2016
Aircraft B 737-900ER
Registration UR-PSK
This report has been translated to the English language for other parties'
convenience, and should adhere to the Original report in the Hebrew language
- In any case of abstruseness or miss-understanding, the original report in the
Hebrew language is taking over.
Although the occurrence was not classified as serious incident, due to the Ukrainian National
Investigation Bureau request, the investigation focused on weight and balance and LLBG ground
handling vis-à-vis the aircraft manufacturer and operator instructions, was conducted.
1.4 Weather
METAR LLBG 152050Z VRB02KT CAVOK 28/13 Q1010 NOSIG
Weather – Fair.
Visibility: above 10 km.
BGN Ground Wind: variable 2 knots.
Temperature: 28°C.
The manual for the 737-800, 737-900 and 737-900ER includes an additional section
specific to tipping precautions during enplaning and deplaning, and advises operators to:
Set horizontal stabilizer trim to positive 4 units
Load the forward cargo hold first and unload it last
Sequence passenger deplaning, cargo unloading, and airplane servicing to avoid
large aft movement of the airplane center of gravity
Monitor passenger deplaning
An absolute tail tipping, with no wind influence, occurs when the aircraft's C.G. moves
aft of the main landing gear tire ground contact point.
Aircraft C.G. is normally expressed in terms of "mean aerodynamic chord percentage"
(%MAC).
The front edge of the MAC is located 627.1" aft of the "0" point (located 130" aft of the
aircraft's nose).
The MAC extends 155.8" and ends 782.9" aft of the "0" point.
The main undercarriage are not vertical and the main landing gear tire ground contact
point varies:
Compressed (heavy aircraft) - 706.2"
Extended (light aircraft) - 708.3"
The absolute tail tipping point, zero wind, is located at 50.8% MAC.
On 24.9.2001, Boeing issued all B737-800 and -900 operators a Service Letter, 737-SL-
25-100, addressing the issue of B737 ground stability. This service letter was issued
after Boeing received reports from various operators about perceived near tipping
events during enplaning and deplaning of 737-800 and 737-900 airplanes. The Service
Letter has been revised, most recently Revision E on 25.2.2016, to include charts and
additional guidance, and to expand applicability to the 737-900ER.
On this Revision Boeing recommended the use of tail stand as a precaution measure if
any of the below conditions is deviated from.
15 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents
Boeing updated their master weight and balance manuals and added more safety
recommendations and guidelines.
According to Boeing service letter 737-SL-25-100-E, there are a number of risk factors
that under accumulating terms, may cause tipping of the aft doorsill towards the stand
pavement (quote):
Large movement of the aft doorsill relative to the ground or tipping might occur under
the accumulation of the most adverse conditions such as:
a) Low airplane weight combined with aft center of gravity.
b) Very low fuel load or full main tanks with empty center tank.
c) The aft half of the main cabin full and the forward half empty of passengers during
enplaning and deplaning.
d) Aft lower cargo hold full and forward lower cargo hold empty.
e) Location and number of crew, and ground service personnel on the airplane.
f) Large airplane nose-up horizontal stabilizer trim.
g) External conditions such as inclined ramps and weather conditions.
The service letter contains charts, specific to each aircraft series, with which operators
can plan their ground handling operations in a manner that would most likely prevent
tail tipping. Also included is a list of precautions that that can be taken:
a) Set horizontal stabilizer trim to positive 4 units
b) Load the forward cargo hold first and unload it last
c) Sequence passenger deplaning, cargo unloading, and airplane servicing to avoid
large aft movement of the airplane center of gravity
d) Monitor passenger deplaning
Tail tipping process is gradual. It has a tendency to "radicalize" because the aircraft's
C.G. is located above the main undercarriage axis. C.G. movement backwards diverts
more weight towards the main undercarriage, increases the weight on them and causes
their location relative to the MAC move slightly forward. At a 61 tons weight, the
approximate weight of the aircraft during the investigated incident after some of the
passengers disembarked, the nose wheel strut starts to extend and reaches full extension
at about 42% MAC. If the CG continues to move aft then the load on the nose gear will
decrease, and will go to zero as the CG approaches 50.8%. If the CG moves aft of
50.8% the nose wheel rises above the pavement and the tail gradually tips.
Chapter "D" - LOAD PLANNING DATA, paragraph 3, allegedly deals with "special
load". Quote:
3. SPECIAL LOAD
Caution:
The FWD cargo compartment may never be off loaded first.
Due to special features of B-739, ensure that the FWD cargo compartment is loaded
first and unloaded last to prevent the CG from shifting AFT of the Main Landing
Gear (MLG).
This rule, effective to the date of the investigated incident, did not set weight values to
abide with (e.g. is 20 kgs/ 1 piece of baggage enough?) or specific position (bay 1 or 2).
There is no reference to timing pax boarding/disembarkation with cargo bay
loading/offloading.
AHM 560 was also updated after the incident and now contains a request ("please") to
load at least 500 kgs in the forward hold first and to unload it last. The procedure does
not specify if this load is to be placed in bay 1 or 2.
Quote:
Please, load at least 500 kg of total baggage weight at FWD cargo compartment first,
and unload it last.
The investigation team conducted a simulated computation with the assistance of ELAL
Israel airlines C.L.C. weight and balance system.
ELAL operates similar B 737-900 ER, with a few differences:
A 2-class cabin layout, 16/156, a total capacity of 172 passengers.
The cabin is divided into 5 areas (for balance calculations).
An additional lavatory and partition between "C" class and "Y" class.
The aft emergency exit doors are not operative.
As the passengers were located in the aft part of the cabin, the forward cabin
layout's relevance is limited.
The data used during this calculation:
4 tons of fuel.
Bays 1/2 – empty.
Bay 3 - 2.8 tons + 2 porters (total 3 tons).
86 pax divided into 5 cabin areas as follows: A/0, B/13, C/13, D/26, E/34.
43 male and 43 female.
Factors examined and found to have none or negligible contribution to the incident:
Stand slope- negligible contribution.
Wind: no significant wind measured at the time of the incident.
Horizontal stabilizer position: 7.8 units- negligible contribution.
3.2 The primary factor contributing to the tail tipping was the accumulation of a
large number of passengers in the aft part of the cabin, whilst the front part was
empty, with the contribution of the forward cargo compartment being empty and the
aft compartment full.
3.3 Effective to the time of the incident, UIA had a general and insufficient tipping
avoidance procedure. The procedure was written in two separate manuals and
stated that the forward compartment "is to be" loaded first and unloaded last, without
determining a minimum weight or specifically which bay it "is to be" loaded in.
These procedures stated that the loading order is to prevent shifting of the center of
gravity aft of the main landing gear, without providing the ground handling
personnel practical measures to control it.
UIA did not sufficiently implement the guidelines provided by the Boeing service
letter. These procedures did not contain any reference to timing passenger
disembarkation with cargo compartments offloading, suggested explicitly in
paragraph C of this service letter.
3.4 The ramp manager acting on behalf of the QAS handling agent did not issue the
airport porters with specific offloading instructions and did not supervise the process
before moving to the jetty, even though he was aware of the procedure according to
which the forward compartment is to be offloaded last.
3.5 The UIA cabin crew did not monitor the process of passenger disembarkation
and did not stop the passengers at the forward part of the cabin when a "jam" created
in the center. There is no certainty that the cabin crewmembers of this flight or in
UIA generally, are aware of this requirement.
3.7 IATA ground stability procedures are general and not binding. IATA procedures
are defines as "recommendations" while some of the directives suggest they are
binding.
3.8 Boeing's ground stability guidelines are of general nature. Even though the
specific aircraft type is known to be sensitive to tipping, the manufacturer's
guidelines are general and leave it to the operators to decide if and how to enhance.
3.9 UIA acted promptly and correctly by instantly updating its ground stability
procedures. Nonetheless, the procedure update does not specify, within the forward
compartment, if the required weight is to be loaded in bay 1 or 2, while bay 1 is
preferable for ground stability. The updated procedure does not address the issue of
timing passenger boarding or disembarkation relative to cargo hold loading.
3.10 IAA procedures do not require offloading the aft hold first.
4.3 To verify the IAA ground handling procedures strict adherence with IATA (AHM)
par. 431 procedure, dealing with off-loading of aft compartment first, unless
otherwise specified by the ramp manager in charge.
Responsibility: IAA
4.4 Due to lack in understanding and clarity of several operators about tail tipping
tendency in specific circumstances.(the published guide lines are general and leave a
slight margin for possible error to the operator), there is a need to publish detailed
and specific instructions for planning and deplaning passengers, loading and
unloading cargo
Responsibility: Boeing Comp.
Sincerely