Investigation number
AO-2011-151
Occurrence date
Location
Los Angeles International Airport, USA
State
International
Report release date
Report status
Final
Investigation level
Systemic
Investigation type
Occurrence Investigation
Investigation status
Completed
Aviation occurrence type
Aircraft Separation
Occurrence category
Incident
Highest injury level
None

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.

Aircraft Details
Departure point
Los Angeles, USA
Destination
Melbourne, Vic.
Model
A380
Serial number
27
Registration
VH-OQE
Operation type
Air Transport High Capacity
Damage
Nil
Aircraft Operator
Qantas