Atsb transport safety investigation report
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- Summary of Australian data
- Boeing 727: August 1989
Australia in perspectiveDue to the small number of occurrences identified in this study, minimal data analysis was conducted. Furthermore, the 10 incidents analysed were based on the pilots’ reported account of the event without verification from other sources. Performance parameterThe specific take-off performance parameter leading to the occurrences was identified in 10 of the 11 occurrences. Of these 10, half were related to errors involving V speeds (n = 5). This was followed by aircraft weights, accounting for three occurrences. Of this, two were related to the ZFW and one related to the aircraft’s TOW. There were two occurrences where an erroneous FLEX temperature was used (Figure 3). Figure 3: Take-off performance parameter 
Error actionFigure 4 describes the nature of the action, or inaction that subsequently led to the erroneous take-off performance parameters. Take-off performance parameters entered incorrectly or not updated, each accounted for three of the 11 occurrences identified. This was followed by those involving the use of an incorrect manual or the wrong figure, each accounting for two occurrences. The take-off performance data for one occurrence was not checked after a change in flight conditions. Figure 4: Error action
DeviceThe type of device or aircraft system that was used, or should have been used to calculate and/or enter the take-off performance parameters was identified in 10 of the 11 occurrences. There was insufficient information for one occurrence to determine the device. The most prevalent device was the FMC, accounting for just over a quarter of the occurrences. This was followed by documentation (aircraft performance manuals) and the MCDU, each accounting for two occurrences. The use of the ACARS, laptop computer, and take-off data card all recorded one occurrence each (Figure 5). Figure 5: Device
ConsequenceOf the 11 occurrences identified, six had some consequence or effect on flight, ranging in severity from the crew noting that the aircraft felt different to that normally experienced, to the aircraft sustaining substantial damage from a tailstrike. In two cases, TO/GA thrust was applied by the crew and one occurrence resulted in a rejected takeoff being conducted. In one occurrence, the error was identified prior to the aircraft departing and the remaining four occurrences had no effect on flight (Figure 6). No injuries were reported in any of the Australian occurrences reviewed in this report. Figure 6: Consequence
Change in conditionsA change in operational or environmental conditions was recorded in six of the 11 occurrences. This change necessitated the crew to either check, amend and/or update the take-off performance parameters previously calculated. These included: the ambient temperature increasing above the FLEX temperature a change from an RNP departure to a visual departure a change from a full-length runway departure to an intersection departure MAC TOW re-calculation using a ZFW work-around an unserviceable ACARS printer requiring verbal transcription a change in V speed/s due to a wet runway.
Figure 7: Summary of Australia data, 1 January 1989 to 30 June 2009 
4INTERNATIONAL DATAA total of 20 occurrences were identified between the period 1 January 1989 and 30 June 2009 where the calculation or entry of erroneous take-off performance parameters were cited as contributing to commercial jet aircraft accidents and incidents involving foreign registered aircraft outside Australian territory. Below is a summary of each occurrence. Some information contained in the original report may not be presented here; for a detailed description of each event refer to the relevant investigation report. Summary of occurrencesBoeing 727: August 1989
History of the flightOn 25 August 1989, a Boeing Company 727-231 aircraft, registered N52309, was to be operated on a scheduled passenger service from New Orleans to New York, US with seven crew and 142 passengers on board. In preparation for departure, the flight engineer completed his portion of the take-off data sheet and handed it to the captain. The captain anticipated a departure from runway 10 (9,228 ft in length) and calculated the take-off performance parameters accordingly. The crew received a taxi clearance from air traffic control (ATC), with runway 19 (7,000 ft in length) the assigned runway for takeoff. The use of runway 19 was also mentioned in the automatic terminal information service (ATIS). During the takeoff, the aircraft became airborne from the safety area of the departure end of runway 19. The aircraft’s left main landing gear struck a lighting control box.
Contributing factorsThe following factors were identified throughout the subsequent investigation: The crew calculated the take-off performance parameters based on runway 10 instead of runway 19, resulting in the aircraft being about 6,800 lbs (3,085 kg) over the runway limit weight and an incorrect flap setting being applied. The airline’s procedures did not assign the take-off performance data calculations to a specific crew member. The airline’s procedures did not provide for a cross-check of the take-off data calculations by another crew member. There was no provision in the airline’s procedures for verifying that the departure runway is one for which the take-off data calculations were based on.
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