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What happened

On 8 October 2011, the flight crew of an Airbus A380-800, registered VH-OQE, was preparing for departure from Los Angeles International Airport, United States of America.

Prior to 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.

What the ATSB found

The ATSB found that the captain was distracted from initially updating the runway change in the aircraft's navigation systems prior to the aircraft taxiing for the runway. Twice prior to 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 in place to alert the crew that they were commencing the takeoff without the take-off speeds in the aircraft's navigation systems.

What has been done as a result

Qantas has advised that 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. They also advised that their standard operating procedures have been updated to avoid any misinterpretation regarding the required actions in the case of a runway change.

Safety message

This incident highlights the problem of distraction during critical stages of flight preparation. It also highlights the importance of good flight crew communication to ensure a shared understanding of the aircraft's systems status.

Download Final Report
[PDF: 1.72MB]
 
 
Alternate: [DOC: 1.93MB]
 
 

General details

Date: 08 Oct 2011 Investigation status: Completed 
Time: 0712 UTC Investigation type: Occurrence Investigation 
Location   (show map):Los Angeles International Airport, USA Occurrence type:Aircraft preparation 
State: International Occurrence class: Operational 
Release date: 08 Aug 2012 Occurrence category: Incident 
Report status: Final Highest injury level: None 
 

Aircraft details

Aircraft manufacturer: Airbus Industrie 
Aircraft model: A380 
Aircraft registration: VH-OQE 
Serial number: 27 
Operator: Qantas 
Type of operation: Air Transport High Capacity 
Damage to aircraft: Nil 
Departure point:Los Angeles, USA
Destination:Melbourne, Vic.
 
 
 
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Last update 13 May 2014