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Pilot distraction

The ATSB's investigation AO-2011-151 into an incident on 8 October 2011 has once again highlighted the risks of pilots becoming distracted during the critical stages of flight preparation. It also emphasises the importance of good flight crew communication to ensure a shared understanding of an aircraft's systems status.

The incident occurred when the flight crew of an Airbus A380-800, registered VH-OQE, was preparing for departure from Los Angeles International Airport. Before takeoff, the captain changed the departure runway that was entered in the aircraft's flight management system. The procedure for completing that task was not followed exactly, resulting in the take-off speeds not being displayed on the flight instruments.

During the take-off roll, the flight crew, becoming aware that the take-off speeds were not displayed, called out the speeds from their notes instead, and proceeded with the takeoff. At all times during the takeoff, the crew were aware of how fast they were going. However, the take-off speeds that are normally displayed on the airspeed indicator were not visible for this takeoff.

The ATSB found that the captain had been distracted from updating the runway change in the aircraft's navigation systems before the aircraft taxied for the runway. Twice, before takeoff, the aircraft's systems displayed a message to check take-off data. The first officer cleared the first message on the understanding that the take-off data would be checked and in the second instance, believing that it had been checked. There were no other warnings to alert the crew that they were commencing the takeoff without the take-off speeds in the aircraft's navigation systems.

Following this incident the aircraft manufacturer has updated the aircraft's warning systems as part of a planned upgrade program. This upgrade will issue a warning if takeoff is commenced without the take-off speeds having been entered into the aircraft's systems. Qantas advised that their standard operating procedures have been updated to avoid any misinterpretation of the required actions in the case of a runway change.

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Last update 04 January 2013