Easyjet Europe A320 at Lisbon on May 7th 2019, takeoff with insufficient thrust

Last Update: January 16, 2020 / 18:30:39 GMT/Zulu time

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Photo of Easyjet Europe OE-IJL, Airbus A320 — Easyjet Europe OE-IJL, Airbus A320 (Photo credit: Mike Burdett / Flickr / License: CC by-sa)

Incident Facts

Date of incident
May 7, 2019

Classification
Report

Airline
Easyjet Europe

Flight number
U2-3764

Departure
Lisbon, Portugal

Destination
Paris Charles de Gaulle, France

Aircraft Registration
OE-IJL

Aircraft Type
Airbus A320

ICAO Type Designator
A320

An Easyjet Europe Airbus A320-200, registration OE-IJL performing flight U2-3764 from Lisbon (Portugal) to Paris Charles de Gaulle (France), was planning to depart from Lisbon's runway 21. During preflight calculations both pilots completed calculations for takeoff from intersection U5 (Takeoff Run Available (TORA): 2450 meters), subsequently recomputed the takeoff from intersection with taxiway S1 (TORA less than from U5), however, inadvertently selected position S, which in fact was taxiway S4 or full length of the runway (TORA 3805 meters). Without checking the TORA to be less than for taxiway U5 for this computation the crew accepted the calculation results for takeoff from U5 or S1. The aircraft subsequently lined runway 21 up at taxiway U5 and commenced takeoff, the commander felt the takeoff was "wrong", however, TOGA was not selected. The aircraft became airborne and crossed the end of the runway at 75 feet AGL and continued to Paris, where the aircraft landed without further incident.

14 days earlier the same mistake had happened to an Easyjet crew, see Report: Easyjet A320 at Lisbon on Apr 24th 2019, takeoff with insufficient thrust.

On Jan 16th 2020 the AAIB released their bulletin into both occurrences concluding:

Both aircraft took off using incorrect performance data for the intersection used. In each case, a selection error was made in the EFB which led the crew to believe that they had calculated performance information for a departure from S1 when in fact they had selected the full length of the runway. In both cases, the procedural barrier of cross-checking the runway distance against the aerodrome ground chart failed to prevent to error. Human performance limitations mean it is difficult for pilots to recognise and react to reduced performance (acceleration) once the takeoff has begun, so robust adherence to procedures is a key defence against such incidents occurring.

The AAIB analysed:

During pre-flight preparation, both flight crew selected PSNSTMP in the EFB as the reference point for the takeoff performance calculation believing it to be where Taxiway S1 crossed Runway 21 whereas it was actually the reference point for the full length of the runway. The use of takeoff Positions gave rise to the situation where two points on Runway 21 could be construed by the crew as being ‘Position S’ within the EFB performance software.

The operator’s SOPs required the crew to crosscheck the takeoff distance shown in the EFB against the equivalent distance shown on the aerodrome ground chart, but this crosscheck did not capture the error. Consequently, a lower thrust setting than required was used for the takeoff from S1 because it had been calculated for the full length of the runway (which had an additional 1,395 m available). After lifting off, the aircraft passed the upwind end of the runway at 100 ft aal.

Another aircraft from the same operator, although operating under a different AOC, had an identical serious incident 14 days later. In both cases the pilots were confused by the EFB intersection selections because they did not refer to taxiway names, and the selection PSNSTMP could be confused between two runway intersections, S1 or S4.

The AAIB reported following safety actions were taken as result of the occurrences:

As a result of these serious incidents the following safety action was taken:

- The aircraft operator issued a notice to its flight crew clarifying the takeoff positions available on Runway 21 at Lisbon Airport.

- A NOTAM was issued highlighting ‘confusing runway holding point naming’
and reminding crews that ‘Position S’ referred to the full length of Runway 21.

- The aircraft operator issued a description of the events and their causes to its flight crew to raise awareness of the risks of using the wrong intersection and distance for takeoff.

- The aircraft operator engaged with the aircraft manufacturer to review
future developments that could offer extra protections against events such
as those covered in this report.

- The airport authority undertook to rename taxiways so that Taxiway S
intersected the runway at only one point; S4 (full length).