British Airways A319 at London on Oct 2nd 2019, departed from wrong intersection without adjusting takeoff performance

Last Update: March 12, 2020 / 18:30:00 GMT/Zulu time

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Photo of British Airways G-EUOG, Airbus A319 — British Airways G-EUOG, Airbus A319 (Photo credit: airlines470 / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Oct 2, 2019

Classification
Report

Airline
British Airways

Flight number
BA-1340

Departure
London Heathrow, United Kingdom

Destination
Leeds, United Kingdom

Aircraft Registration
G-EUOG

Aircraft Type
Airbus A319

ICAO Type Designator
A319

A British Airways Airbus A319-100, registration G-EUOG performing flight BA-1340 from London Heathrow,EN to Leeds,EN (UK) with 96 passengers and 6 crew, had prepared departure from Heathrow's runway 27L intersection N2W (TORA 3,380 meters). During single engine taxi out the pilot monitoring mistakenly requested departure from intersection N4E (TORA 2,702 meters), which was quickly approved by ATC and a quick line up clearance. The crew started the other engine in a hurry. The takeoff performance was not discussed between the crew. After line up the pilot flying realized that the data for N4E had not been entered in the FMGC and queried the pilot monitoring. Misunderstanding the intention the question the pilot monitoring replied he was happy to depart. The aircraft commenced takeoff and continued for a safe landing in Leeds.

The AAIB released their bulletin into the serious incident stating that the takeoff performance did not become a theme between the crew until after landing, when the misunderstanding between the crew became apparent.

The AAIB described the sequence of events:

The crew completed pre-flight preparations for a flight from London Heathrow Airport to Leeds Bradford Airport. Both crew members were conscious that it was a very short flight and in preparation for this they discussed the destination as well as the departure during the pre-flight preparations. The aircraft taxied out using a single engine for a departure from Runway 27L at Heathrow.

The figures for the takeoff performance had been calculated from N2W. During the taxi out, the PM mistakenly requested N4E for departure which gave a TORA 678 m shorter than from N2W. Both intersections are shown in Figure 1. This was not intentional from the PM. The new intersection was rapidly approved by ATC leaving the crew little time to complete their pre-departure duties. The crew started the second engine and were
cleared to line up for departure. Aircraft performance from the new intersection was not discussed or entered into the Flight Management Guidance Computer (FMGC).

As the aircraft lined up on the runway, the Pilot Flying (PF) realised that the figures for N4E had not been entered into the FMGC and asked the PM if he was happy to continue with the departure. The PM did not realise that the question related to takeoff performance but instead assumed it was about completion of the rapid engine start and departure process.

Since he was content that both were complete, he replied positively. From his experience, the PF felt that the performance was adequate and, given that the PM also seemed happy, he elected to continue. The takeoff was unremarkable. The calculated takeoff performance included a thrust reduction and the PF did not select full thrust during the takeoff.

With such a short sector, the event was not discussed in flight but the post-flight debrief revealed a different understanding between the two pilots. The PM had not realised that he had asked for a different intersection from the one used in the performance calculation. The crew reported the incident to the operator as soon as they were able.

Both crew felt that the rushed departure contributed to them commencing the take off with incorrect performance figures in the FMGC. They commented that either declining the rapid line-up clearance or informing ATC they were not ready could have prevented this incident from occurring. Heathrow is also their home base and both crew members had departed from N4E on previous flights, so the use of the intersection was not unusual.

The AAIB analysed:

As a result of a mistaken request for a different intersection the crew departed with aircraft performance figures calculated for a runway length 678 m longer than was actually available.

Rushing to complete the pre-takeoff procedures, familiarity with the airport, and the lack of a shared mental model between the crew contributed to what could have been a significant event. Fortunately, the aircraft was light, with a limited payload and fuel for only a short flight, so the takeoff was unremarkable and the takeoff performance was not compromised.