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be 'predominantly in the middle and rear sections'. These instructions resulted in a non-standard
distribution, which was contrary to the information on the Load Form, which the commander used to
complete the Trim Sheet. This contradictory situation did not comply with the company's Standard
Operating Procedures (SOPs). The FS and commander did not appreciate the effect of the subsequent
alteration on the aircraft's CG, and the latter did not know where, ultimately, the passengers were sat.
The handling agent enquired as to the reason for the movement of the passengers but did not question
it. Effectively, each of the commander, FS and handling agent were in possession of some of the
information but none of them had the full picture. In view of his responsibility, the commander
needed to be in possession of all the relevant information.
The result of the commander asking the FS to move the passengers at the front of the cabin towards
the rear was that all the passengers were subsequently seated behind Row 13. This created a CG
which was sufficiently beyond the aft limit that, when take-off thrust was selected and the aircraft
started its take-off roll, the aircraft pitched up rapidly due to the couple created by the increasing
engine thrust.
Amendments to the Operator's Procedures
In the light of this incident the operator has introduced changes to the company procedures. The
Ramp Handling Manual, which is distributed to handling agents, has been revised to emphasis the
correct loading procedures for all the aircraft types operated by the company. This includes the
'standard loading procedures' for Airbus A320 flights carrying less than a full load of passengers,
which require the passengers to be distributed evenly throughout the cabin.
The company SOPs for the Airbus A320 have been amended to improve the cross checking of the
load sheet and trim sheet by the commander and FO including the instruction that they make every
effort to ensure that the paperwork accurately reflects the actual loading.
A revision to the Cabin Crew Safety Manual, which applies to the Airbus A320, A321 and Boeing
757, has also been drafted. This states that;
Standard passenger loading for ALL aircraft is for passengers to be EVENLY DISRIBUTED
THROUGHOUT THE ENTIRE CABIN. On completion of boarding, the Flight Supervisor is
to check that passengers are seated in this manner. In the event that this is not the case, the
Flight Supervisor must inform the captain without delay and prior to engine start. The
captain will then take the appropriate action to verify that the distribution is suitable or
redistribute accordingly.
This subject is to be included and expanded on during Cabin Crew recurrent training and all future
FS courses.
Airbus A320-214, G-OOAR
6
Recommendation 2003-104
It is recommended that Air 2000 review the advice given to handling agents at outstations to ensure
that the commanders of the company's aircraft are in possession of all the relevant loading information
before they compile a Trim Sheet.
Recommendation 2003-105
It is recommended that Air 2000 review the training given to Flight Supervisors for the Airbus A320
with regard to passenger distribution in the cabin and its effect on the CG of the aircraft.
Airbus A310-300, N835AB, 31 May 1998 at 1515 hrs
AAIB Bulletin No: 4/99 Ref: EW/C98/5/9 Category: 1.1
Aircraft Type and Registration: Airbus A310-300, N835AB
No & Type of Engines: 2 Pratt & Whitney PW4152 turbofan engines
Year of Manufacture: 1992
Date & Time (UTC): 31 May 1998 at 1515 hrs
Location: Stand M24 at London Heathrow Airport
Type of Flight: Public Transport
Persons on Board: Crew - 12 - Passengers - 204
Injuries: Crew - Nil - Passengers - Nil
Nature of Damage: Damage to left engine cowl
Commander's Licence: Airline Transport Pilot's Licence
Commander's Age: 52 years
Commander's Flying Experience: 17,499 hours (of which 1,459 were on type)
Last 90 days - 195 hours
Last 28 days - 70 hours
Information Source: AAIB Field Investigation
History of the flight
Approximately one hour into a scheduled passenger flight from Kingston, Jamaica, to Heathrow
Airport the YELLOW hydraulic system failed as a result of a loss of fluid quantity. The appropriate
Electronic Centralised Aircraft Monitoring system (ECAM) drill was completed and this was
supplemented by reference to the Flight Crew Operations Manual (FCOM). Upon arrival at
Heathrow, where the meteorological conditions were CAVOK with a light westerly wind, a manual
landing with the flaps/slats set to 30/40 degrees was completed on Runway 27 where the surface
was dry. Reverse thrust was used during the landing run and gentle braking was applied in the later
　
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