Late changes before takeoff

Presented by Nicolas Bardou / Flight Safety Director Accident / Incident Investigator

18th Flight Safety Conference

Berlin, 19-22 March 2012

Content
Background Case studies Conclusion

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18th Flight Safety Conference

Berlin, 19-22 March 2012

Background
Late changes before departure

Disturbance during check lists Weather change Runway change Taxiway access change Updated / late takeoff data

Last minute changes are small changes operated under h i gh

pressure and may have big consequences

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18th Flight Safety Conference

Berlin, 19-22 March 2012

Content
Background Case studies Way forward

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18th Flight Safety Conference

Berlin, 19-22 March 2012

Case study 1 - Description

A340-500, preparing for a 14hrs flight Gross weight error 260t instead of 360t (-100t error) Leading to the following consequences

Data Computed values T Flex (C) 74 (+31 ) V1 (kt) 143kt (-6kt) VR (kt) 145kt (-16kt) V2 (kt) 154kt (-19kt) Green Dot (kt) 225kt (-40kt)
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Correct values 43 149kt 161kt 173kt 265kt

18th Flight Safety Conference

Berlin, 19-22 March 2012

Case study 1 - Description

While entering values in the FMS, crew was constantly interrupted Crew noted that the Temp looked high, and intended to check later

Data T Flex (C) V1 (kt) VR (kt) V2 (kt) Green Dot (kt)

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Correct values 43 149kt 161kt 173kt 265kt

Entered values 74 143kt 145kt 154kt 225kt (+31 ) (-6kt) (-16kt) (-19kt) (-40kt)

18th Flight Safety Conference

Berlin, 19-22 March 2012

Case study 1 - Consequences

Takeoff was initiated applying MCT/FLEX At rotation speed, almost no response following stick input Full Back Stick applied nose raised, tailstrike Aircraft did not lift off TO/GA applied Aircraft took off after the end of the RWY ATC was notified of tailstrike, IFTB performed after jettison

Vr

RUNWAY

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18th Flight Safety Conference

Berlin, 19-22 March 2012

Case study 1 - Consequences

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18th Flight Safety Conference

Berlin, 19-22 March 2012

Case study 1 What did we learn?

Important to recognise large errors in weight, temp, speeds (rough order of magnitude) In case of doubt, re-check using available means

Important to recognize when a checklist or procedure has been interrupted Best practice = restart
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18th Flight Safety Conference

Berlin, 19-22 March 2012

Case study 1: What did we learn?

Additional checks will be introduced in Takeoff Securing Pack 1
Weight check ZFW entry within defined range per A/C type Speed check V1#Vr<V2 Speeds consistent with weight, thrust & conf Trim & S/F conf setting consistency check

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AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

18th Flight Safety Conference

Berlin, 19-22 March 2012

Content
Background Case studies Way forward

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18th Flight Safety Conference

Berlin, 19-22 March 2012

Case study 2 - Description

A340-300, conf 2, 230t, Flex T/O Reported wind 3kt tailwind Takeoff speeds computed with full runway length Using airports databases not up to date

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18th Flight Safety Conference

Berlin, 19-22 March 2012

Case study 2 - Description

Takeoff was initiated applying MCT/FLEX At Vr, rotation was initiated and during climb, a bang was heard As no adverse effect was noticed flight was continued Inspections after landing revealed that engines chopped the top off
the trees
Vr
BANG !

RUNWAY

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18th Flight Safety Conference

Berlin, 19-22 March 2012

Case study 2 - Slow silent changes

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18th Flight Safety Conference

Berlin, 19-22 March 2012

Case study 2 - Slow silent changes

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18th Flight Safety Conference

Berlin, 19-22 March 2012

Case study 2 What did we learn?

Important to obtain updated weather information Charts had not been updated

Re-compute for a shorter runway

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18th Flight Safety Conference

Berlin, 19-22 March 2012

Case study 2: What did we learn?

Runway length check function in TakeOff Securing pack 2

current runway

Lift-off distance Remaining RWY distance

If lift-off distance > Remaining RWY distance ECAM warning

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AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

18th Flight Safety Conference

Berlin, 19-22 March 2012

Content
Background Case studies Way forward

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AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

18th Flight Safety Conference

Berlin, 19-22 March 2012

Case study 3 - Description

CPT taxied A340-300, F/O would do the takeoff Night time & no traffic ahead Aircraft was taxied along the runway

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18th Flight Safety Conference

Berlin, 19-22 March 2012

Case study 3 - Description

CPT only is trained & allowed to taxi per airline policy Aircraft made a premature turn onto a taxiway parallel to runway Rolling takeoff was started on the taxiway ATC instructed the crew to abort takeoff Max ground speed was 75kt

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18th Flight Safety Conference

Berlin, 19-22 March 2012

Case study 3 - Description

High workload in cockpit during the turn
CAPTAIN F/O Public Address Packs off WXR radar Note the FOB Packs off, Line-up checklist Line-up checklist Adjust thrust for turn Stow EFB made difficult due to water Taxi (Left hand) bottle Stow EFB (on the left) with his RH Prepare for takeoff

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18th Flight Safety Conference

EXPEDITE TAXI

Berlin, 19-22 March 2012

Case study 3 - Description

High workload in cockpit during the turn

CLEARED FOR TAKEOFF CLEARED FOR TAKEOFF

CAPTAIN F/O Public Address Packs off WXR radar Note the FOB Packs off, Line-up checklist Line-up checklist Adjust thrust for turn Stow EFB made difficult due to water Taxi (Left hand) bottle Stow EFB (on the left) with his RH Prepare for takeoff

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18th Flight Safety Conference

Berlin, 19-22 March 2012

Case study 1 What did we learn?

Important to take ALL changes into account Important to recognize when a checklist or procedure requires more time Crew interpreted early ATC clearance as an instruction

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18th Flight Safety Conference

Berlin, 19-22 March 2012

Case study 2: What did we learn?

A/C position check function in TakeOff Securing pack 2
Power application on taxiway: ON TAXIWAY

ECAM

Power application from wrong runway: NOT ON FMS RUNWAY

FMS departure runway
ECAM

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AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

18th Flight Safety Conference

Berlin, 19-22 March 2012

Content
Background Case studies Conclusion

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AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

18th Flight Safety Conference

Berlin, 19-22 March 2012

Conclusion
Disturbances before departure
Weather Runway change Taxi routing Workload ATC pressure Multitasking Cabin crew MEL Runway state Fuel figures Updated cargo Late Pax De-icing Ground tech

Last minute changes will always happen Pressure is always present Next presentation highlights disturbances occurring during flight

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18th Flight Safety Conference

Berlin, 19-22 March 2012

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