State of Israel

Ministry of Transport and Road Safety

Aviation Accidents and Incidents Investigation

Safety Investigation Report

Incidents File No. 45-16

- Aircraft tail tipping during offloading -

Date 15.5.2016

Aircraft B 737-900ER

Registration UR-PSK

Incidents Site LLBG

For Safety Purposes Only

 The Investigations conducted by the Israeli Investigation Office (IAIAI) are in
accordance with Annex 13 to the ICAO Convention on International Civil
Aviation, and the Israeli Aviation Law 2011, chapter 7, and its respective
Aviation regulations.

The sole objective of the investigation of an accident or incident under these

Regulations is the prevention of future accidents and incidents. It is not the
purpose of such an investigation to apportion blame or liability.

Accordingly, it is not appropriate that AIAI reports should be used to assign

fault or blame or determine liability, since neither the investigation nor the
reporting process has been undertaken for that purpose.

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.

2 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

 State of Israel
Ministry of Transport and Road Safety
Aviation Accidents and Incidents Investigation

Safety Investigation Report

Incident File No. 45-16

Synopsis of the Incident

During offloading of a Boeing 737-900ER aircraft, operated by Ukraine International Airlines
(UIA) at gate B3 in Ben-Gurion international airport (LLBG), the aircraft tail started tipping and
the nose started rising. The aircraft's nose movement upwards stopped when the forward-left
entry door engaged the gate canopy.
The entry door and the gate canopy suffered damages. There were no injuries or casualties.
The return flight to Kiev was canceled.

The aircraft involved in the incident

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.

3 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

1. Factual Information

1.1 The History of the flight (UTC)

Background
The aircraft, a 737-900ER, registration mark UR-PSK, operated by Ukraine
International Airlines, departed Kiev Borispil airport (UKBB) on a scheduled passenger
flight number PS 781 to Ben Gurion airport (LLBG), on 15.5.2016.
There were 212 passengers and 7 crewmembers on board.
The aircraft cargo holds contained passengers checked luggage consisting of 186 pieces
with a total weigh of 3,144 kg.
The takeoff fuel at takeoff was 12,800 kg.
According to the load sheet, the MACTOW/MACZFW were almost similar- 23.3%
MAC.
According to the load sheet, the difference between the Take Off Weight and the
limiting calculated value that was the Maximum Landing Weight was 103 kg
"Underload Before Last Minute Change" (LMC).
After LMC, which included offloading 3 passengers and 3 pieces of baggage, the
aircraft weight was corrected and manually subtracted by 341 kg.
The occurrence
The flight landed uneventful at LLBG and the crew taxied the aircraft to gate B3 where
the jetty was connected to the aircraft, at 20:24. Israel Airport Authority (IAA) handling
personnel and a representative of the handling agent (QAS) approached the aircraft and
started dealing with its offloading. Luggage conveyors were connected to both forward
and aft cargo doors.
As of 20:25 until 20:28, all the luggage contained in the forward cargo compartment,
composed of 18 bags and 2 strollers, has been completely emptied. The ramp agent
boarded the gate in order to receive the passengers.
At 20:29, 3 bags were offloaded from the aft cargo compartment. The aft compartment
offloading was interrupted due to a technical malfunction of the conveyor. At the same
time, the captain descended from the aircraft to the ramp in order to conduct his
preflight walk around.
During the cargo compartments offloading, the passengers started to disembark through
the forward left door (L1) to the jetty. During the disembarkation, a delay occurred,
when the forward part of the cabin emptied quickly while the aft part of the cabin
remained full. There is no specific figure about the exact number of passengers left in
the aft part of the cabin and exactly in which cabin area they were gathered.

4 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

 At 20:30, the nose landing gear strut started to expand gradually, the aircraft nose
started to rise and the aircraft's tail started tipping toward the ramp. The aircraft nose
rising stopped when the aircraft's L1 door engaged the gate canopy.
The passenger disembarkation process came to a stop. The porters that were in the
process of offloading exited the aft cargo compartment to the adjacent conveyor. After
approximately two minutes, the cabin crew regained composure and started guiding the
passengers, which gathered in the aft part of the cabin, to move forward. The aircraft
nose started moving slowly down onto the ramp and the event came to its end.
The porters continued offloading the aft cargo compartment.
On 17.5.2016, the aircraft was towed to the apron, adjacent to ELAL maintenance area,
for repair.
The aircraft's door was repaired at ELAL shop by ELAL technicians in cooperation with
dispatched UIA technicians. The repaired door was later installed in another UIA
aircraft, registration UR-PSI, which was at the time being maintained by ELAL.
The aircraft involved in the investigated incident was released to line operations 3
weeks later, on 5.6.2016 after being fitted with a door which was removed from aircraft
UR-PSI.

5 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

 The aircraft during the event

Damage to the aircraft door

6 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

 Damage to the gate canopy

Unharmed tail-skid wear shoe

7 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

 1.2 The Pilots
The crew specifics were not reviewed as the event characteristics primarily involve
ground handling.

1.3 The Aircraft

 Boeing 737-94XER.
 Owned by ALAFCO.
 Registration mark - UR-PSK.
 Leased by UIA in July 2013.
 Single class (Y) configuration, total capacity 215 passengers.
 First flight- May 2009.

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.

1.5 The Parking stand

 Gate B3.
 Adjacent to terminal 3 at LLBG.
 Jetty that connects to the front/ left (L1) door of B737 series.
 Stand slope - 0.36 deg.

1.6 Security camera data decoding

 Soon after the aircraft entered the parking stand, IAA ground handling crew
approached the stand and connected conveyors to both cargo compartments doors.
 The gate jetty connected to the aircraft L1 door.
 The captain was observed doing his walk around.
 Offloading the luggage started, with the forward compartment first and was
completed within 3 minutes.
 After offloading several bags from the aft compartment, the offloading was
interrupted.

8 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

  The aircraft nose was observed to rise slowly. Its movement stopped when the left
forward door came in contact with the inner part of jetty canopy.
 The aircraft tail came close to the pavement but did not have actual contact.
 Porters that were inside the aft compartment exited and stepped down to the
conveyor.
 After approximately two minutes, the aircraft nose started lowering slowly and the
nose wheel settled on the pavement.
 The porters re-entered the aft compartment and continued offloading the luggage.

1.7 The investigation method

 Verbal and written cooperation with the Ukrainian National Investigation Bureau
for incidents and accidents of civil aircraft, through correspondence.
 Preliminary interview with the captain, conducted by Israel Chief Investigator
immediately after the incident.
 Security camera footage decoding.
 Analysis of the incident report.
 Weight and balance data analysis in accordance with the load sheet.
 UIA relevant handling procedures review.
 Comparison of UIA procedures to ELAL ground stability procedures, which
operates similar type of aircraft (with different cabin layout).
 Review of internal investigation, held by the handling agent QAS (part of
SWISSPORT GROUP).
 Review of internal IAA investigation.
 Review of IATA relevant ground handling procedures.

9 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

2. Analysis

2.1 Aircraft loading- general

Passenger (or cargo) aircraft loading is performed according to rules that enable the safe
operation of the aircraft, especially during takeoff, but also during climb, cruise, descent
and landing phases. Center of gravity movement during flight with passengers is created
solely due to fuel consumption. Reduction of total fuel quantity is a predictable process,
so is its influence on the center of gravity.
All types of aircraft have a specific center of gravity limits envelope set forth in the
relevant AFM.
The primary limit to aircraft loading is weight.
There are three relevant weight limits:
 MAZFW - Maximum Allowable Zero Fuel Weight.
 MATOW - Maximum Allowable Takeoff Weight.
 MALW - Maximum Allowable Landing Weight.
The weight limits are defined by the manufacturer, in the aircraft certification and AFM.
The MAZFW is a structural limit.
The MATOW is in general a structural limit but may be limited further by takeoff
performance, weight and center of gravity limits and balance landing performance or by
other company considerations, such as landing fees.
The MALW is in general a structural limit but may be limited further by weight and
center of gravity limits and landing performance.
The most limiting weight is determined for each flight, for which, the difference
between it and the aircraft design data is the least. This difference is referred to as
"Underload Before Last Minute Change".
In order not to exceed or to reach the center of gravity limit envelope set in the AFM,
the operator usually creates a narrower envelope.
Aircraft load planning is conducted by qualified personnel, usually using a
computerized planning system.
It is customary with most operators to use average weights for passengers, usually
divided to male/ female/ child/ infant. These weights are changed from time to time.
Normally there are differences between "summer" weight and "winter" weight (due to
clothing used and contained in the checked luggage).
Luggage sent to the aircraft compartments is usually weighed.
Carry-on luggage, limited by weight and size, is not usually weighed.
Last minute changes (LMC) are usually done using average values and not according to
actual passenger and luggage weight.
10 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents
 Each aircraft has a defined "0" point, in order to calculate moments. This point in the
737-900 series aircraft is located 130 inches aft of the airplane nose, approximately at
the circuit breaker panel at the aft wall of the flight deck.
The Index is a value used to calculate the aircraft Center of Gravity.
The "0" Index point is defined in the center of the aircraft fuselage. From this point, we
calculate the influence of each component located in the aircraft, in terms of weight and
distance from Index "0" point. The moment of a component is defined as a positive or
negative Index value, relative to the ZERO point.
The aircraft undergoes from time to time a weighing procedure (the first is performed at
the manufacturing plant) and it serves to define the basic weight and index.
The index method is convenient to use because in case of location modification of
several components, the influence can easily be defined, by adding or reducing the
index.
For example: each fuel quantity, as distributed in the aircraft tanks, has an influence on
the Center of Gravity location. Moreover, also each passenger has an influence on the
Center of Gravity location. Therefore there are two main options for calculation – by
Cabin Area Trim and by Seat Row Trim. The second method is of course more
accurate.
A combination of weight and index defines the C.G as a percentage of the "mean
aerodynamic chord" of the wing - MAC (see paragraph 2.4).
The computerized planning system has a defined criteria in order to keep the aircraft
weight and center of gravity within limits during all phases of flight. Exceedance of a
defined criterion does not allow a computerized load sheet issuance.
Moreover, some operators define other planning guidelines for various causes such as
fuel efficiency or ground stability (ideal trim area).
The load sheet contains all the required data and is presented to the pilot in command
(PIC) before each flight, to his approval and signature.
According to the company, the PIC and designated ground personnel have the authority
to make "last minute changes" (LMC) on the calculation sheet, if the actual loading of
the A/C differs from the loading data expressed on the issued load sheet (e.g. a
passenger last minute "no show", cargo located not in the planned cargo compartment
etc).

11 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

 Loading/unloading manner of the aircraft cabin and compartments, has an influence on
A/C ground stability. Ground stability differs between various A/C types. The A/C type
involved in this incident, B737-900, is especially sensitive due to its fuselage length.
Aircraft loading has influence on fuel consumption during flight. Loading an aircraft
with aft center of gravity creates a "nose down" elevator and horizontal stabilizer
demand thus increasing lift and reducing drag. The result is fuel saving. The fuel saving
potential differs between A/C types, may be significant with wide body A/C such as
B744 and minimal with narrow body A/C such as B737, but the cumulative saving in
terms of fuel cost and gas emissions might be significant.

2.2 Ground stability procedures- general

Aircraft manufacturers supply a basic Weight and Balance Manual for each aircraft
supplied.
Different manufacturers use to highlight the basic rules of the manual and to publish
them.
Regarding ground stability, the manufacturer supplies several guidelines in order to
prevent cases, causing tail tipping. In the basic weight and balance manual provided by
Boeing for the B737 series (and other series), the manufacturer advises the operators to
"use good judgment" during ground operations and defines the main factors influencing
ground stability to consider:
 Aircraft empty weight and center of gravity.
 Parking stand slope and aircrafts pitch angle.
 Fuel quantity.
 Pax number and distribution throughout the cabin.
 Aircraft cargo compartments loading.
 Snow accumulation.
 Wind.
 Horizontal stabilizer position.

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

12 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

 2.3 Ground operations procedures- general
According to IATA airport handling manual (AHM) par. 431, aircraft loading and
unloading should be conducted in a manner that would prevent tipping.
This paragraph states generally that the forward cargo compartment should be loaded
first and unloaded last.
These rules are set as "recommendations" although they contain directives such as
"shall/ must" or guidance such as "should".
Quotes from the procedure:
AHM 431
AIRCRAFT GROUND STABILITY—TIPPING
RECOMMENDED that:
1. DEFINITION
A critical aft center of gravity situation may lead to tail tipping of the aircraft
during handling or towing operations. Precautions must be taken to eliminate this
possibility as it can occur on many aircraft types.
2. PRECAUTIONS
In order to avoid the risk of tail tipping the following precautions shall be taken:
2.1 Load Planning
When planning the load distribution, sufficient load should be allocated in the
compartments forward of the center of gravity to ensure ground stability.
Particular attention must be paid to the distribution of the transit load on
multi-sector flights. The distribution of the load remaining in the compartments
at the next station must be such that it meets the above condition.
2.2 Loading/Off-Loading
Unloading should commence with aft compartments. Loading should
commence with forward compartments. The same sequence applies for forward
and aft galleys. Passenger distribution shall not be used to ensure ground
stability.
Note: In certain cases, a tail support stanchion or nose tether can be used as
recommended or required by aircraft manufacturers.
3. GROUND STABILITY CHECKS
Methods to ensure ground stability include use of tables or graphs to determine the
weight required in forward compartments to counteract weight to be loaded in aft
compartments, or calculation of center of gravity for comparison against the
applicable tipping and/or towing limit.

13 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

 Method 1—a scale or table determining the distribution of the loads weightwise,
showing the weight required in the forward compartments to secure ground
stability and the load which can be placed in the aft compartments.
Method 2—calculation of the dead load index/%MAC dead load weight which shall
be forward of the dead load limit on the center of gravity envelope on the balance
chart and transmitted on the LDM.
The IATA "ground operations manual (IGOM) states the following:

4. AIRCRAFT GROUND STABILITY

Loading or offloading may cause the aircraft to become unstable or could cause the
aircraft to tip.
Respect aircraft ground stability requirements during loading and offloading. In
general:
(a) Offload aft holds before forward holds
(b) When loading, load forward holds before aft holds
For cargo aircraft, a tail support stanchion or nose tether may be required to be
fitted during loading and offloading.

These rules are not implemented in LLBG ground handling procedures.

At LLBG, aircraft loading/unloading is conducted by IAA ground handling
personnel (porters) according to directions given by a ramp manager designated by
the operator.

2.4 Boeing 737-900 ground stability

Boeing 737-900 series aircraft have 4 cargo bays. Bay 1 - 2 as part of the forward cargo
compartment and 3 - 4 as part of the aft cargo compartment. There is no division
between cargo bays 1 - 2 or 3 - 4 apart from a safety net that is normally fitted after the
cargo/ checked baggage is loaded, in order to prevent items prom shifting between bays.
Cargo bay 1 (bays 11 - 12) is located opposite the forward compartment door and to the
forward bay wall.
Cargo bay 2 is located adjacent to cargo bay 1, from aft of the forward cargo
compartment doorpost towards the aft compartment wall.
Cargo bay 3 is located from the front of the aft cargo compartment doorpost towards the
front of the aft cargo bay wall.

14 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

 Cargo bay 4 is located opposite the aft cargo door and towards the aircraft's tail cone.
The influence of any luggage/cargo item weight on the aircraft's C.G. is relative to the
location of each item in a specific cargo bay, due to the moment created by weight and
balance arm (expressed in terms of "index"). The influence of 400 kgs placed in bay 11
on the forward C.G. is much greater than 400 kgs placed in bay 2. Bay 11 contains
approximately 25 pieces of luggage (bulk)/ approximately 400 kgs.

B737-900 CARGO COMPARTMENTS - SCHEMATIC

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.

16 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

 B737-900 ER tipping chart in kgs

17 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

 2.5 Tail tipping events and avoidance
Tail tipping events are not common, however are known have to happened in the
industry. Most events, especially with narrow body aircraft, conclude with light damage
if any at all, and therefore there is a difficulty finding statistical data about occurrence
rates.
Cargo aircraft are typically more sensitive than passenger aircraft to tail tipping,
because during loading and offloading heavy loads, movements throughout the cargo
decks' create significant changes to aircraft C.G.
Tail support and tying down of the nose wheel, in order to prevent tipping, are
commonly used during cargo ground operations.
Passenger aircraft sensitivity differs between a/c types and is relative, generally, to
fuselage length.
Boeing 737-800 aircraft are considered to be relatively sensitive to tail tipping in
relation to previous 737 variants. Due to the increased fuselage length, the 737-900 is
considered to be even more sensitive to tail tipping. For this reason, Boeing developed
the enhanced guidance and the available tail support pole for these models.
Some operators reported ground stability issues with B737-900 series.
Dealing with ground stability issues is normally through procedures and operator
instructions as to the order and timing of cargo hold loading/unloading and passenger
embarkation/disembarkation.
On January 2015, United Airlines issued a bulletin to their employees, addressing this
matter and informed them about tipping events that occurred during ground operations.
On January 2016, United Airlines stated their intention to start using tail support in
order to prevent tipping with B737-800/900.
Other operators are currently using tail support with B737-800/900 series.
Tail support used by Delta Airlines

18 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

 2.6 UIA B737-900 loading
UIA has a RAMP HANDLING MANUAL.
Chapter 9 of this manual generally deals with ground stability of all A/C types operated
by the company.
This manual has separate paragraphs to deal with different A/C types.
A general paragraph, dealing with passenger boarding/disembarkation states that cabin
crew duties to this respect (quote):

9.10.2.3 Boarding and disembarkation of passengers

The process of boarding and disembarkation of passengers shall always be controlled
by cabin crewmembers to ensure that passengers move forward evenly, that no large
gaps are formed between passengers in the forward and aft parts of the cabin, and that
passengers do not move backwards under any circumstances. Cabin crewmembers must
always be ready to stop the disembarkation by preventing the passengers in the forward
part of the cabin from leaving the aircraft in case of deviation of this process from
normal conditions.
UIA uses a type and registration mark specific Aircraft Handling Manual 560.
This manual contains 4 chapters:
A: GENERAL/ ADMINISTRATIVE
B: GENERAL INFORMATION
C: AIRCRAFT DATA
D: Data for load planning (Load Planning Data)
APPENDIX: Weight and Balance Information Form

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.

19 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

 UIA B 737-900 are operated as a single "Y" class, containing 215 seats.
The aircraft cabin contains 37 seat rows, divided for weight and balance, to 4 areas.
Remark: rows 23 to 37 are located behind the main landing gear position.

UIA uses average weights as follows:

Regular scheduled flight (including carry-on luggage), male / female 84 kgs, child 35
kgs, infant 0 kgs.
Checked baggage is weighed.
Pilots (including personal luggage) - 85 kgs.
Cabin crew (including personal luggage) – 75 kgs.
The aircraft DRY OPERATING WEIGHT contains 2/5 crew, pantry and a full potable
water tank.
The "0" index point is located 658.3" aft of the "0" point (between row 19/20, adjacent
to the aft overwing exit door.
The involved aircraft (UR-PSK) EMPTY WEIGHT/INDEX: 45,939 kgs / 49.9
Due to fuel efficiency considerations, the load planning policy is to create a relative aft
center of gravity 23-25% MACZFW.
Remark: UIA is not exceptional putting fuel efficiency as a prime consideration during
load planning. Information provided by one of the major handling agents operating in
LLBG and ELAL C.L.C that provide weight and balance services to charted aircraft,
indicates that many operators have no specific ground stability procedures apart from
general statements and that there is, generally, a preference to creating an aft C.G. for
achieving better fuel efficiency.
At 23.5.2016, 8 days after the incident an update the ground stability procedure
contained in the RAMP HANDLING MANUAL was published. Quote (the highlighted
lines are the additions made after the incident):

Ground Stability Limit

The aircraft CG of 43% MAC or higher is considered to be dangerous for aircraft
ground stability.
The absolute tipping limit for the 737-800 and 737-900ER aircraft is at 50.8% MAC,
and is at 53.8% MAC for the 737-300 and 737-500 airplanes, considerably aft of the
ground stability limit. Some of the major factors affecting the tipping and stability limits

20 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

 will include, but are not limited to the following items:
o Airplane empty weight;
o Airplane attitude;
o Fuel loading;
o Passenger loading;
o Cargo loading;
o Ramp slope;
o Runway surface condition;
o Snow loads;
o Wind loads.

Always load the forward hold first, and unload it last.

Make sure that sufficient load (at least 500 kg) is loaded in the forward compartments
before loading of the aft compartments.

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.

2.7 Flight PS 781 weight and balance

According to flight PS 781/15 load sheet, the aircraft was loaded as follows:
215 passengers (full capacity) + 1 infant.
7 crewmembers (2 pilots + 5 cabin crew).
ZERO FUEL WEIGHT - 66,947 kgs.
Takeoff fuel- 12,800 kgs (approximately 5 tons in the center tank).
TAKEOFF WEIGHT- 79,947 kgs.
The most limiting weight was the landing weight, 71,350 kgs.
Underload before LMC- 103 kgs.
Cargo holds were loaded as follows:
Bay # 1 - empty
Bay # 2 - 339 kgs. (18 pieces of luggage + 2 strollers)
Bay # 3 - 2,805 kgs. (166 pieces of luggage).
Bay # 4- empty

21 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

 A total of 186 pieces of checked luggage + 2 strollers, in the front cargo compartment.
At the last minute, four passengers and 3 pieces of luggage were subtracted.
LMC consisted off:
4 passengers - minus 336 kgs.
3 pieces of luggage - minus 45 kgs.
The LMC did not specify the cabin location from which the passengers were missing
nor the cargo hold from which the baggage was removed.
Center of gravity data:
MACZFW - 23.36%.
MACTOW - 23.33%.
Trip fuel – 8,500 kgs.

At the parking stand, after the flight:

Total fuel approximately 4 tons (main tanks only, center empty).
Remark: Fuel in the center tank generally shifts the center of gravity forward. Fuel in
the main tanks generally shifts the center of gravity backwards.
Four tons of fuel contained in the main tanks shift the center of gravity by
approximately one (1) unit of index backwards.
The Ukrainian National Bureau for incidents and accidents of civil aircraft conducted a
simulated weight and balance calculation of the aircraft on stand after landing, at the
time of the occurrence.
The data used during this calculation:
 Bay 1 - empty
 Bay 2 - empty
 Bay 3 - 2.8 tons + 2 porters
 Bay 4 – empty
 8 front cabin rows empty (48 pax)
 All other rows to full capacity.
 Two ground porters in the aft compartment.
 One pilot on the flight deck.
 4 tons of fuel.
According to the above data, the aircrafts C.G was located at 41.78% MAC, distant
from the absolute tipping C.G located at 50.8% MAC.

22 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

 Investigation team remarks:
 According to the chart attached to par. 2.6, taking into account the actual A/C
weight (approximately 61 tons) and calculated C.G, the nose wheel strut should be
fully extended!
 The number of passengers on board accounted for in this calculation was not
based on an actual "head count".
 According to the passengers on board taken into account for this calculation, the
passengers seated in rows 9-21 are shifting the C.G. forward.
 The first 8 rows contain only 46 passengers and not 48.

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.

The actual C.G calculated: 44.6% MAC.

Remarks:
 According to the data used for this simulation, some passengers still shift the C.G.
forward.
 According to the chart attached to par. 2.4, taking into account the actual A/C
weight (approximately 61 tons) and calculated C.G (44.6%) the aircraft nose gear
strut should be fully extended. Therefore, it is most probable that the actual pax
number and location was even further aft, in order for the aircraft C.G to exceed
the absolute tipping limit of 50.8% MAC.

23 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

 2.8 The incident scenario
The investigated incident in which a B 737-900 tail tipped during offloading is a classic
case of the "Swiss cheese" scenario.
 The aircraft loading was planned with an aft C.G of 23.3% MAC according to the
operator's policy. Cargo Bay # 2 contained only 339 kgs of baggage, and bay # 3
contained 2,805 kgs.
 IAA porters approached the aircraft and placed conveyors adjacent to both cargo
doors.
 According to IAA debriefing, the handling agent's ramp manager did not issue the
porters specific instructions about the offloading order before going up to the jetty
to attend the passenger disembarkation.
 The porters started offloading the aircraft but due to a technical malfunction with
the conveyor used to offload the aft cargo compartment, it was not offloaded apart
from the first 3 bags, until the front cargo compartment was totally emptied. The
information about the disruption of the aft compartment offloading was not passed
on to the front compartment team or to the ramp manager.
 At the same time passengers started to disembark through the jetty. While the
front part of the cabin emptied quickly, a "jam" occurred, somewhere in the mid
cabin, and a large number of passengers were held in the aft part of the cabin.
 The aircraft fuel tanks contained 4 tons of fuel, shifting the A/C C.G slightly
backwards.
 Accumulation of all the above factors created the rare situation in which the
aircraft's nose started to rise and the aircraft tipped.

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.

24 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

3. Conclusions
3.1 The incident is classified as management, with the prime responsibility resting on
the operator's management, with at the time of the occurrence, a contribution of the
ramp manager and the aircraft's cabin crew.

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.

25 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

 3.6 It is highly probable that the fact the fact that the forward compartment was
offloaded first was not the factor that exclusively caused the aircraft to tip, even
though it contributed to it. The aircraft's tipping was caused primarily due to the
position of the passengers in the aft part of the cabin.

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.

26 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents

4. Recommendations
4.1 To establish and implement a specific ground stability procedure, containing the
minimum weight required to be loaded in the forward compartment, specifying in
which bay it should be loaded and a requirement to timing of passenger boarding or
disembarkation relative to cargo hold loading or unloading.
Responsibility: UIA

4.2 Due to considerably relatively sensitive tail tipping possibility in certain

circumstances (such as: planning/deplaning/ off-loading/up-loading/refueling phase)
of a/c model B737-800/900, there is a need to find/use known technical solutions
suggested by the manufacturer (such as in Boeing AMM ref "E" amendment), or
alternative solution that will eliminate/mitigate the possibility of tail tipping.
Responsibility: UIA

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

Itzhak Raz (Razchik), Adv.

Chief Investigator
Date: 2.2.2017 Reference: 02386017
Return of objects seized during a safety investigation
In accordance with Section 114(b)(5)-(7) of the Law of Flight, 2011, the chief investigator shall return seized objects, aside for the wreckage of
aircraft, within 45 days from the date of publication of the final investigation report. The objects shall be returned to those from whom they were
seized, or to their owners. The wreckage of aircraft shall not be returned, unless requested by the owners of the aircraft and at their expense. A
request for their return must be addressed to the chief investigator no later than 45 days from the date of publication of the report.
A person who wishes that seized objects not be returned to their owners may present an appropriate request to the magistrates court within
whose jurisdiction the object was seized.

27 Office of the Chief Investigator – Investigation of Aviation Accidents and Incidents