Belair A320 at Basel on Oct 6th 2014, takeoff with incorrect power setting
Last Update: December 9, 2015 / 16:46:09 GMT/Zulu time
On Dec 9th 2014 the French BEA reported in their weekly bulletin, that the takeoff was performed with the power setting for the full length departure although the aircraft entered the runway at taxiway G. The occurrence was rated a serious incident and is being investigation by Switzerland's SUST.
On Dec 9th 2015 the Swiss SUST released their final report concluding the probable causes of the serious incident were:
The serious incident is attributable to the fact that the aircraft did not achieve the necessary performance on take-off, because the flight crew performed the take-off from a taxiway intersection with an engine power which had been calculated for the entire length of the runway.
The following factors contributed to the serious incident:
- Procedures which require checking essential items in silence, which means that cross-checking cannot take place in the spirit of a closed loop.
- The decision to an intersection take-off was made at short notice.
- Additional cross-checking of the data entered into the flight guidance system during the line up, which had been recently introduced, was ineffective be-cause the flight crew were unaware of it.
The SUST reported that the crew was preparing for a takeoff from runway 33 taxiway D, but received information that runway 15 was active. Hence the crew briefed for a departure from runway 33 taxiway D and a full length departure from runway 15.
Upon requesting taxi the crew queried for runway 33 but was advised to expect a delay of 20 minutes for the departure after which the crew opted for runway 15. Along taxi to runway 15 the crew was instructed to give way to an Easyjet aircraft departing runway 15 from taxiway G. The commander (39, ATPL, 6,447 hours total, 3,523 hours on type) of Belair proposed to use Golf as well well, the first officer (30, ATPL, 3,771 hours total, 2,856 hours on type) agreed and the crew advised they were ready for departure from taxiway G, too. Tower queried one more time about Golf, received confirmation, instructed the next arrival to reduce to minimum speed, queried with Easyjet whether they had commenced their takeoff roll then instructed Belair to line up runway 15 at Golf and wait.
The Belair crew was surprised by this clearance having expected to be cleared for line up only after the arriving traffic.
Shortly afterwards the crew received clearance for takeoff and commenced their takeoff run with the power setting that had been computed for a full length departure with V1=Vr=V2 at 157 KIAS. During the takeoff roll the commander recognized that takeoff power had not been set for what was necessary for an intersection takeoff and activated TOGA while accelerating through 140 KIAS, about 1150 meters before the runway end.
The SUST wrote: "By looking at his electronic flight bag (EFB), he could see that the aircraft had already reached the speeds for an intersection take-off (V1 and VR 136 kt and V2 138 kt). He then rotated immediately. At this time the aircraft was approximately 790 m from the end of the runway and had an IAS of 150 kt. After a further 250 metres, the aircraft reached a height of 35 ft. The sub-sequent climb indicated a pitch of up to 19.5 degrees, aircraft nose up (ANU). The onward flight was uneventful."
The SUST analysed:
The commander then also calculated the take-off data for a take-off from the Golf intersection on runway 15 on his EFB, while the copilot calculated the take-off da-ta for a take-off from the Hotel intersection on his EFB. Although this concept was generally proactive, this created a challenging situation for the flight crew. The flight crew had prepared four take-off variants. A full-length take-off on runway 15 was entered in the primary flight plan; a take-off from the Delta intersection on runway 33 was entered in the secondary flight plan, a take-off from the Golf inter-section on runway 15 was entered on the commander's EFB, and a take-off from the Hotel intersection on runway 15 was entered on the copilot's EFB.
In the present case, a decision in favour of an intersection take-off in accordance with the operating procedures would have meant that the commander should have performed another independent calculation on his EFB for a take-off from the Hotel intersection and the copilot perform the same for a Golf intersection take-off and that the two calculated results would then have had to be compared. In a further step, the PF should have entered these results into the FMGS and this should have been cross-checked by the PNF. It is evident that these steps take a certain period of time and should not be performed while taxiing. The crew were therefore probably already aware before leaving the stand that they were not in a position to make a short-notice decision on an intersection take-off while taxiing.
While taxiing, the crew made a short-notice decision to take-off from the Golf in-tersection on runway 15. The flight crew did not perform the aforementioned steps. It cannot be excluded that the flight crew had not intended to perform a second independent calculation of the intersection take-off data, because they had already calculated the intersection take-off data on their EFBs at the stand and intended only to enter the previously calculated take-off data into the FMGS in the event of an intersection take-off.
The reason the take-off data was not entered into the FMGS may be that the flight crew's decision to use the Golf intersection for the take-off was relatively short-notice and the crew therefore came under time pressure. A possible con-tributing factor is the fact that the procedure sequence while taxiing stipulates that the copilot must only cross-check the entry of the take-off data in the event of a runway change, and then only in silence. If he had ticked this procedure item before the decision to use the Golf intersection, this check would have been inef-fective. In this case, the commander was not able to identify this, as no verbal communication takes place regarding this point. Furthermore, it is obvious that in the case of the „TAKEOFF BRIEFING ... CONFIRM” item the commander did not address the planned intersection take-off, although this is stipulated in the rele-vant procedure sequence (cf. Figure 4).
The time pressure undoubtedly increased when the flight crew received an unex-pectedly early line-up clearance; at this time they were still under the impression that the approaching aircraft would land before they took off. The line-up on taxi-way Golf took place without the aircraft stopping. The take-off roll was also initi-ated without stopping at the take-off point (rolling take-off). Doubt remains as to whether the „BEFORE TAKEOFF” checklist items, which according to operating procedures should have been worked through, were worked through in their en-tirety under this time pressure. The pilots could have realised that they had not entered the intersection take-off data for the take-off no later than the last item in the „TAKEOFF RUNWAY ... CONFIRM” procedure.
The SUST continued analysis: "Because of his experience from numerous take-offs at EuroAirport Basel Mul-house Freiburg, the commander realised during the take-off roll that the relation-ship between the acceleration and the position on the runway was unusual. He then set TOGA power, which was appropriate to the situation and created a bet-ter basis for the subsequent climb. The commander looked at the speeds he had displayed on his EFB and realised that the aircraft had already reached the speeds calculated for a take-off from the Golf intersection (V1, VR, V2). For this reason, he immediately initiated lift-off by rotating the aircraft. The subsequent climb was performed with significant pitch. This exceeded the maximum pitch specified by the flight director (17.5 °) by up to 2 °, which is probably due to the reaction to the situation. However, this high pitch had no negative effect on the climb."
The SUST concluded analysis with respect to the flight crew actions: "The actions and reactions of the flight crew to realising the incorrect engine pow-er setting facilitated the successful take-off. According to the present calculations, it would however not have been possible to bring the aircraft to a standstill on the runway in the event of a rejected take-off that had bee initiated at high speed."
This article is published under license from Avherald.com. © of text by Avherald.com.
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