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Late changes before takeoff
Presented by
Nicolas Bardou / Flight Safety Director Accident / Incident Investigator
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Berlin, 19-22 March 201218th Flight Safety Conference
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Background
Case studies
Conclusion
Content
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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 underh i g hpressure and may have big consequences
Berlin, 19-22 March 201218th Flight Safety Conference
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Background
Case studies
Way forward
Content
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Data Computed values Correct valuesT Flex (C)
V1 (kt)
VR (kt)
V2 (kt)Green Dot (kt)
Case study 1 - Description
Berlin, 19-22 March 201218th Flight Safety Conference
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74 (+31)143kt (-6kt)
145kt (-16kt)
154kt (-19kt)
225kt (-40kt)
43
149kt
161kt
173kt
265kt
A340-500, preparing for a 14hrs flight
Gross weight error260t instead of360t (-100t error)
Leading to the following consequences
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Data Correct values Entered valuesT Flex (C)
V1 (kt)
VR (kt)
V2 (kt)Green Dot (kt)
Case study 1 - Description
Berlin, 19-22 March 201218th Flight Safety Conference
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74 (+31)143kt (-6kt)
145kt (-16kt)
154kt (-19kt)
225kt (-40kt)
43
149kt
161kt
173kt
265kt
While entering values in the FMS, crew was constantly interrupted
Crew noted that the Temp looked high, and intended to check later
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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
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Vr
RUNWAY
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Case study 1 - Consequences
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Case study 1 What did we learn?
Berlin, 19-22 March 201218th Flight Safety Conference
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Important to recognise large errorsin 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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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
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Background
Case studies
Way forward
Content
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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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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 offthe trees
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Vr
RUNWAY
BANG !
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Case study 2 - Slow silent changes
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Case study 2 - Slow silent changes
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Case study 2 What did we learn?
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Important to obtain updatedweather information
Charts had not been updated
Re-compute for a shorter runway
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Case study 2: What did we learn?
Runway length check function in TakeOff Securing pack 2
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If lift-off distance > Remaining RWY distance
Remaining RWY distance
Lift-off distancecurrent runway
ECAM warning
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Background
Case studies
Way forward
Content
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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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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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Case study 3 - Description
High workload in cockpit during the turn
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F/O
Packs off
Note the FOB
Line-up checklist
Stow EFB made difficult due to water
bottle
Prepare for takeoff
CAPTAIN
Public Address
WXR radar
Packs off, Line-up checklist
Adjust thrust for turn
Taxi (Left hand)
Stow EFB (on the left) with his RH
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High workload in cockpit during the turn
F/O
Packs off
Note the FOB
Line-up checklist
Stow EFB made difficult due to water
bottle
Prepare for takeoff
CAPTAIN
Public Address
WXR radar
Packs off, Line-up checklist
Adjust thrust for turn
Taxi (Left hand)
Stow EFB (on the left) with his RH
Case study 3 - Description
Berlin, 19-22 March 201218th Flight Safety Conference
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EXPEDITE TAXI
CLEARED FOR TAKEOFF
CLEARED FOR TAKEOFF
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Case study 1 What did we learn?
Berlin, 19-22 March 201218th Flight Safety Conference
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Important to take ALL changes into
account
Crew interpreted early ATC
clearance as an instruction
Important to recognize when a
checklist or procedure requires moretime
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Case study 2: What did we learn?
A/C position check function in TakeOff Securing pack 2
Power application on taxiway: ON TAXIWAY
Power application from wrong runway: NOT ON FMS RUNWAY
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ECAM
FMS departure
runway
ECAM
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Background
Case studies
Conclusion
Content
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Conclusion
Disturbances before departure
Last minute changes will always happen
Pressure is always present
Next presentation highlights disturbances occurring during flight
Berlin, 19-22 March 201218th Flight Safety Conference
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Weather
Runway change
Taxi routing
Workload
ATC pressure
Multitasking
Cabin crew
MEL
Runway state
Fuel figures
Updated cargo
Late Pax
De-icing
Ground tech
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Berlin, 19-22 March 201218th Flight Safety Conference
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