Narrative:

This center of gravity violation occurred; I believe; as a result of basic confusion. The general consensus is that the aircraft's out of center of gravity condition resulted when ground personnel confused load control's initial instruction to move 1 passenger forward; and communicated this to the cabin crew as needing to move 1 passenger aft. The flight crew discovered that the flight was tail heavy when rotation occurred with uncharacteristically light control pressures. I became aware of this particular flight almost before our turnover had been completed. The PIC was on the radio; asking for a verification of his fuel load. I had to look this up; as his release had been prepared by the dispatcher I was relieving. Shortly after that; the PIC called again; informing me something to the effect he had no passenger in zone 1; and 6 passenger in zone 2. I wrote this down; and gave the slip to the load controller responsible for the flight; who was swamped with other loading issues at that time. Another dispatcher pointed out to me that the flight was airborne; adding a whole additional dimension to the urgency of this situation. On advice of load control; I instructed the flight crew to recount the passenger on board; row by row; and get the result back to us. Initially; it didn't match the 'final' numbers we had in our computer. The crew only reported to row 10; so we needed to prompt them to report the passenger seated in row 11. Initially; they had reported 2 people in that zone; but there was an infant in a child seat; which we count as a 1/2 weight in our FAA approved loading procedure. Load control; using company-supplied software; determined that moving one of the adults from row 11 to row 1 would resolve the out-of-balance condition. The aircraft landed without incident; and a bag audit revealed a further loading discrepancy: the load manifest documentation was off by 2 bags. Copies of the original bag card; computer display; cabin count; and audit results were faxed to operations; assembled; and handed over to the duty manager. While this incident was itself resolved without any particularly adverse consequences; during and immediately after its occurrence; a number of concerns emerged: 1) a conflict was revealed between acceptable mac % numbers as generated by our weight and balance software; and the limitations cited in the aom (a control document). 2) only the takeoff mac % is calculated or displayed by the computer -- not the landing mac %. The SF340 can burn out of center of gravity en route. 3) no one seemed to be able to account for the differences between computed mac % limits and the aom's limits; or seemed to know which would take precedence: not the chief pilot on duty; nor either dispatch supervisor; nor the duty manager; nor any of the personnel on duty in maintenance control. 4) no one seemed to be confident regarding any procedure for documenting this occurrence; or where a prescribed procedure might be found. 5) both the PIC and I became fixated; for a period of time during which the aircraft was still aloft; with the 'bureaucratic' issues raised by the out of center of gravity condition and had to be 'coached' to concentrate on flying the airplane. 6) our company's new fuel policy -- with its emphasis on carrying only the fuel strictly necessary for regulatory compliance -- appears to heighten flight crew anxiety; even in sits where the actual fuel on board is quite sufficient for extensive holding or flight to distant alternates (and; as a result; clear focus on incipient emergencys may be harder to achieve). 7) fear of being 'violated' may motivate some flight crew members to become preoccupied with potential disciplinary consequences when the appropriate concern should be with getting the aircraft safely on the ground. 8) CRM/drm can break down in the face of conflicts among flight crew agendas; company policies; goals; and objectives; and safety of flight. I believe I was deficient in failing to recognize that the aircraft was aloft from the outset. All I would have had to do was point and click on a couple of menus; and I could have 'located' the flight almost instantly. A heightened awareness of the aircraft's phase of flight; fuel on board (in mins); and the current conditions (including crash fire rescue equipment status) at the destination airport would have undoubtedly contributed to a more rational (and appropriate) prioritization of effort on my part. No one would deliberately risk a replay of the earlier aft center of gravity accident; and yet these 'near miss' weight and balance problems continue to plague our operation.

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Original NASA ASRS Text

Title: DISPATCHER OF SF340 LEARNS A FLT IS AIRBORNE WITH AN ILLEGAL CTR OF GRAVITY AND IS CONCERNED THAT REPEATED WT AND BAL ANOMALIES AT HIS ACR MAY PROVE HAZARDOUS.

Narrative: THIS CTR OF GRAVITY VIOLATION OCCURRED; I BELIEVE; AS A RESULT OF BASIC CONFUSION. THE GENERAL CONSENSUS IS THAT THE ACFT'S OUT OF CTR OF GRAVITY CONDITION RESULTED WHEN GND PERSONNEL CONFUSED LOAD CTL'S INITIAL INSTRUCTION TO MOVE 1 PAX FORWARD; AND COMMUNICATED THIS TO THE CABIN CREW AS NEEDING TO MOVE 1 PAX AFT. THE FLT CREW DISCOVERED THAT THE FLT WAS TAIL HVY WHEN ROTATION OCCURRED WITH UNCHARACTERISTICALLY LIGHT CTL PRESSURES. I BECAME AWARE OF THIS PARTICULAR FLT ALMOST BEFORE OUR TURNOVER HAD BEEN COMPLETED. THE PIC WAS ON THE RADIO; ASKING FOR A VERIFICATION OF HIS FUEL LOAD. I HAD TO LOOK THIS UP; AS HIS RELEASE HAD BEEN PREPARED BY THE DISPATCHER I WAS RELIEVING. SHORTLY AFTER THAT; THE PIC CALLED AGAIN; INFORMING ME SOMETHING TO THE EFFECT HE HAD NO PAX IN ZONE 1; AND 6 PAX IN ZONE 2. I WROTE THIS DOWN; AND GAVE THE SLIP TO THE LOAD CTLR RESPONSIBLE FOR THE FLT; WHO WAS SWAMPED WITH OTHER LOADING ISSUES AT THAT TIME. ANOTHER DISPATCHER POINTED OUT TO ME THAT THE FLT WAS AIRBORNE; ADDING A WHOLE ADDITIONAL DIMENSION TO THE URGENCY OF THIS SIT. ON ADVICE OF LOAD CTL; I INSTRUCTED THE FLT CREW TO RECOUNT THE PAX ON BOARD; ROW BY ROW; AND GET THE RESULT BACK TO US. INITIALLY; IT DIDN'T MATCH THE 'FINAL' NUMBERS WE HAD IN OUR COMPUTER. THE CREW ONLY RPTED TO ROW 10; SO WE NEEDED TO PROMPT THEM TO RPT THE PAX SEATED IN ROW 11. INITIALLY; THEY HAD RPTED 2 PEOPLE IN THAT ZONE; BUT THERE WAS AN INFANT IN A CHILD SEAT; WHICH WE COUNT AS A 1/2 WT IN OUR FAA APPROVED LOADING PROC. LOAD CTL; USING COMPANY-SUPPLIED SOFTWARE; DETERMINED THAT MOVING ONE OF THE ADULTS FROM ROW 11 TO ROW 1 WOULD RESOLVE THE OUT-OF-BAL CONDITION. THE ACFT LANDED WITHOUT INCIDENT; AND A BAG AUDIT REVEALED A FURTHER LOADING DISCREPANCY: THE LOAD MANIFEST DOCUMENTATION WAS OFF BY 2 BAGS. COPIES OF THE ORIGINAL BAG CARD; COMPUTER DISPLAY; CABIN COUNT; AND AUDIT RESULTS WERE FAXED TO OPS; ASSEMBLED; AND HANDED OVER TO THE DUTY MGR. WHILE THIS INCIDENT WAS ITSELF RESOLVED WITHOUT ANY PARTICULARLY ADVERSE CONSEQUENCES; DURING AND IMMEDIATELY AFTER ITS OCCURRENCE; A NUMBER OF CONCERNS EMERGED: 1) A CONFLICT WAS REVEALED BTWN ACCEPTABLE MAC % NUMBERS AS GENERATED BY OUR WT AND BAL SOFTWARE; AND THE LIMITATIONS CITED IN THE AOM (A CTL DOCUMENT). 2) ONLY THE TKOF MAC % IS CALCULATED OR DISPLAYED BY THE COMPUTER -- NOT THE LNDG MAC %. THE SF340 CAN BURN OUT OF CTR OF GRAVITY ENRTE. 3) NO ONE SEEMED TO BE ABLE TO ACCOUNT FOR THE DIFFERENCES BTWN COMPUTED MAC % LIMITS AND THE AOM'S LIMITS; OR SEEMED TO KNOW WHICH WOULD TAKE PRECEDENCE: NOT THE CHIEF PLT ON DUTY; NOR EITHER DISPATCH SUPVR; NOR THE DUTY MGR; NOR ANY OF THE PERSONNEL ON DUTY IN MAINT CTL. 4) NO ONE SEEMED TO BE CONFIDENT REGARDING ANY PROC FOR DOCUMENTING THIS OCCURRENCE; OR WHERE A PRESCRIBED PROC MIGHT BE FOUND. 5) BOTH THE PIC AND I BECAME FIXATED; FOR A PERIOD OF TIME DURING WHICH THE ACFT WAS STILL ALOFT; WITH THE 'BUREAUCRATIC' ISSUES RAISED BY THE OUT OF CTR OF GRAVITY CONDITION AND HAD TO BE 'COACHED' TO CONCENTRATE ON FLYING THE AIRPLANE. 6) OUR COMPANY'S NEW FUEL POLICY -- WITH ITS EMPHASIS ON CARRYING ONLY THE FUEL STRICTLY NECESSARY FOR REGULATORY COMPLIANCE -- APPEARS TO HEIGHTEN FLT CREW ANXIETY; EVEN IN SITS WHERE THE ACTUAL FUEL ON BOARD IS QUITE SUFFICIENT FOR EXTENSIVE HOLDING OR FLT TO DISTANT ALTERNATES (AND; AS A RESULT; CLR FOCUS ON INCIPIENT EMERS MAY BE HARDER TO ACHIEVE). 7) FEAR OF BEING 'VIOLATED' MAY MOTIVATE SOME FLT CREW MEMBERS TO BECOME PREOCCUPIED WITH POTENTIAL DISCIPLINARY CONSEQUENCES WHEN THE APPROPRIATE CONCERN SHOULD BE WITH GETTING THE ACFT SAFELY ON THE GND. 8) CRM/DRM CAN BREAK DOWN IN THE FACE OF CONFLICTS AMONG FLT CREW AGENDAS; COMPANY POLICIES; GOALS; AND OBJECTIVES; AND SAFETY OF FLT. I BELIEVE I WAS DEFICIENT IN FAILING TO RECOGNIZE THAT THE ACFT WAS ALOFT FROM THE OUTSET. ALL I WOULD HAVE HAD TO DO WAS POINT AND CLICK ON A COUPLE OF MENUS; AND I COULD HAVE 'LOCATED' THE FLT ALMOST INSTANTLY. A HEIGHTENED AWARENESS OF THE ACFT'S PHASE OF FLT; FUEL ON BOARD (IN MINS); AND THE CURRENT CONDITIONS (INCLUDING CFR STATUS) AT THE DEST ARPT WOULD HAVE UNDOUBTEDLY CONTRIBUTED TO A MORE RATIONAL (AND APPROPRIATE) PRIORITIZATION OF EFFORT ON MY PART. NO ONE WOULD DELIBERATELY RISK A REPLAY OF THE EARLIER AFT CTR OF GRAVITY ACCIDENT; AND YET THESE 'NEAR MISS' WT AND BAL PROBS CONTINUE TO PLAGUE OUR OP.

Data retrieved from NASA's ASRS site as of January 2009 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.