Summary
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 take-off, 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 take-off.
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 take-off 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 take-off 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 take-off 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.
Occurrence summary
| Investigation number | AO-2011-151 |
|---|---|
| Occurrence date | 08/10/2011 |
| Location | Los Angeles International Airport, USA |
| State | International |
| Report release date | 08/08/2012 |
| Report status | Final |
| Investigation level | Systemic |
| Investigation type | Occurrence Investigation |
| Investigation status | Completed |
| Mode of transport | Aviation |
| Aviation occurrence category | Aircraft separation |
| Occurrence class | Incident |
| Highest injury level | None |
Aircraft details
| Manufacturer | Airbus |
|---|---|
| Model | A380 |
| Registration | VH-OQE |
| Serial number | 27 |
| Aircraft operator | Qantas |
| Sector | Jet |
| Operation type | Air Transport High Capacity |
| Departure point | Los Angeles, USA |
| Destination | Melbourne, Vic. |
| Damage | Nil |