Atsb transport safety investigation report
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- Take-off performance calculation and entry errors: A global perspective
- CONTENTS THE AUSTRALIAN TRANSPORT SAFETY BUREAU ix TERMINOLOGY USED IN THIS REPORT x
- 2 TAKE-OFF PERFORMANCE PARAMETERS 22
- 5 SAFETY FACTOR ANALYSIS 69
- 7 CONCLUSION 87 8 REFERENCES 89
- Report No.
- Author(s)
- Reference Number
- THE AUSTRALIAN TRANSPORT SAFETY BUREAU
- Purpose of safety investigations
- Developing safety action
- TERMINOLOGY USED IN THIS REPORT Occurrence
 ATSB TRANSPORT SAFETY INVESTIGATION REPORT
Aviation Research and Analysis Report – AR-2009-052 Final
Aviation Research and Analysis Report AR-2009-052 Final
Take-off performance calculation and entry errors: A global perspective Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau Postal address: PO Box 967, Civic Square ACT 2608 Office: 62 Northbourne Avenue Canberra, Australian Capital Territory 2601 Telephone: 1800 020 616, from overseas +61 2 6257 4150 Accident and incident notification: 1800 011 034 (24 hours) Facsimile: 02 6247 3117, from overseas +61 2 6247 3117 Email: atsbinfo@atsb.gov.au Internet: www.atsb.gov.au © Commonwealth of Australia 2011 In the interests of enhancing the value of the information contained in this publication you may download, print, reproduce and distribute this material acknowledging the Australian Transport Safety Bureau as the source. However, copyright in the material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you want to use their material you will need to contact them directly. ISBN and formal report title: see ‘Document retrieval information’ on page 7 CONTENTS THE AUSTRALIAN TRANSPORT SAFETY BUREAU ix TERMINOLOGY USED IN THIS REPORT x ABBREVIATIONS xi
Objectives 14 Report outline 14 Methodology 15 Data sources 15 Error analysis 16 Contributing safety factor analysis 17 Limitations 18 2 TAKE-OFF PERFORMANCE PARAMETERS 22 The parameters 22 Take-off reference speeds (V speeds) 22 Aircraft weights 23 FLEX or assumed temperature 23 The process 23 Typical errors 26 Typical consequences 26 3 AUSTRALIAN DATA 28 Summary of occurrences 28 Australia in perspective 32 Performance parameter 32 Error action 32 Device 33 Consequence 34 Change in conditions 34 Summary of Australian data 35
Summary of occurrences 37 Boeing 727: August 1989 37 Boeing 757: January 1990 38 Douglas DC-8: March 1991 38 Boeing 767: August 1999 39 Boeing 747: December 2001 42 Airbus A330: June 2002 42 Boeing 747: March 2003 43 Boeing 747: March 2003 44 Airbus A321: September 2003 46 Boeing 747: October 2003 48 Airbus A340: July 2004 51 Boeing 747: October 2004 52 Airbus A340: August 2005 54 Embraer 190: July 2006 55 Boeing 747: December 2006 57 Airbus A340: March 2007 58 Boeing 747: June 2007 59 McDonnell Douglas MD83: September 2007 61 Airbus A330: October 2008 62 Boeing 767: December 2008 63 International perspective 65 Performance parameter 65 Error action 65 Device 66 Consequence 67 Change in conditions 67 Summary of international data 68
All safety factors 69 Individual actions 70 Local conditions 71 Risk controls 73 Organisational influences 75 Safety factor map 75
Risk controls 77 Procedures 77 Automation 78 Tools and materials 80 Local conditions 81 Task/experience recency 81 Individual actions 83 Monitoring and checking 83 Using equipment 84 Detecting degraded take-off performance 85
APPENDIX A: ATSB SAFETY FACTOR TAXONOMY 94 APPENDIX B: LIST OF AUSTRALIAN OCCURRENCES 98 APPENDIX C: LIST OF INTERNATIONAL OCCURRENCES 100 APPENDIX D: ADDITIONAL OCCURRENCES 102
DOCUMENT RETRIEVAL INFORMATION
THE AUSTRALIAN TRANSPORT SAFETY BUREAU The Australian Transport Safety Bureau (ATSB) is an independent Commonwealth Government statutory agency. The Bureau is governed by a Commission and is entirely separate from transport regulators, policy makers and service providers. The ATSB's function is to improve safety and public confidence in the aviation, marine and rail modes of transport through excellence in: independent investigation of transport accidents and other safety occurrences; safety data recording, analysis and research; fostering safety awareness, knowledge and action. The ATSB is responsible for investigating accidents and other transport safety matters involving civil aviation, marine and rail operations in Australia that fall within Commonwealth jurisdiction, as well as participating in overseas investigations involving Australian registered aircraft and ships. A primary concern is the safety of commercial transport, with particular regard to fare-paying passenger operations. The ATSB performs its functions in accordance with the provisions of the Transport Safety Investigation Act 2003 and Regulations and, where applicable, relevant international agreements. Purpose of safety investigations The object of a safety investigation is to identify and reduce safety-related risk. ATSB investigations determine and communicate the safety factors related to the transport safety matter being investigated. The terms the ATSB uses to refer to key safety and risk concepts are set out in the next section: Terminology Used in this Report. It is not a function of the ATSB to apportion blame or determine liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner.
Central to the ATSB’s investigation of transport safety matters is the early identification of safety issues in the transport environment. The ATSB prefers to encourage the relevant organisation(s) to initiate proactive safety action that addresses safety issues. Nevertheless, the ATSB may use its power to make a formal safety recommendation either during or at the end of an investigation, depending on the level of risk associated with a safety issue and the extent of corrective action undertaken by the relevant organisation. When safety recommendations are issued, they focus on clearly describing the safety issue of concern, rather than providing instructions or opinions on a preferred method of corrective action. As with equivalent overseas organisations, the ATSB has no power to enforce the implementation of its recommendations. It is a matter for the body to which an ATSB recommendation is directed to assess the costs and benefits of any particular means of addressing a safety issue. When the ATSB issues a safety recommendation to a person, organisation or agency, they must provide a written response within 90 days. That response must indicate whether they accept the recommendation, any reasons for not accepting part or all of the recommendation, and details of any proposed safety action to give effect to the recommendation. The ATSB can also issue safety advisory notices suggesting that an organisation or an industry sector consider a safety issue and take action where it believes it appropriate. There is no requirement for a formal response to an advisory notice, although the ATSB will publish any response it receives. TERMINOLOGY USED IN THIS REPORT Occurrence: accident or incident. Safety factor: an event or condition that increases safety risk. In other words, it is something that, if it occurred in the future, would increase the likelihood of an occurrence, and/or the severity of the adverse consequences associated with an occurrence. Safety factors include the occurrence events (e.g. engine failure, signal passed at danger, grounding), individual actions (e.g. errors and violations), local conditions, current risk controls and organisational influences. ABBREVIATIONS ACARS Aircraft communications addressing and reporting system ADREP Accident/incident data reporting system (ICAO) ATC Air traffic control ATIS Automatic terminal information service ATSB Australian Transport Safety Bureau BLT Boeing laptop tool CAA Civil Aviation Authority (United Kingdom) CDU Control display unit CTOP Computer take-off programme DTG Distance-to-go ECAM Electronic centralised aircraft monitoring system ECCAIRS European Coordination Centre for Accident and Incident Reporting System FADEC Full authority digital engine control system FMC Flight management computer (Boeing) FMGC Flight management guidance and envelope computer (Airbus) FMGS Flight management and guidance system (Airbus) FMS Flight management system (Boeing) FOVE Flight operations versatile environment computer system (Airbus) GWC Gross weight chart IATA International Air Transport Association ICAO International Civil Aviation Organization kg Kilogram/s kts Knots lbs Pound/s LPC Less paper cockpit (Airbus) m Metre/s MAC Mean aerodynamic chord MCDU Multifunction control and display unit MCP Mode control panel MTOW Maximum take-off weight MTTL Module table take-off and landing charts n Number
RNP Required navigation performance SOP(s) Standard operating procedure(s) TODC Take-off data calculation TO/GA Take-off/go-around thrust TOPMS Take-off performance monitoring system(s) TOS Take-off securing function (Airbus) TOW Take-off weight TORA Take-off run available TSB Transportation Safety Board (of Canada) WAAS World aircraft accident summary (Ascend) V1 Decision speed V2 Take-off safety speed VR Rotation speed ZFW Zero fuel weight Directory: media media -> Applications to Drill media -> Unicef voices of Youth Chat Theme: Children and aids nigeria and Zimbabwe 13 October 2006 Background media -> Tsunami Terror Alert: Voices of Youth media -> Biblical Eschatology Presentation by: D. Paul Beck May 4, 2016 Ground Rules media -> Guide to completing the collection using the Omnibus system media -> The milk carton kids media -> Events Date and Location media -> The Gilded Age: The First Generation of Historians by H. Wayne Morgan University of Oklahoma, April 18, 1997 media -> Analysis of Law in the United Kingdom pertaining to Cross-Border Disaster Relief Prepared by: For the 30 June 2010 Foreword media -> Cuba fieldcourse 2010 Download 0.67 Mb. Share with your friends:
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