Aviation safety investigations & reports

Operational event - Airbus A380, VH-OQE, Los Angeles International Airport, USA, 8 October 2011

Investigation number:
AO-2011-151
Status: Completed
Investigation completed

Summary

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

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
[Download  PDF: 1.72MB]
 
 
Alternate: [Download  DOC: 1.93MB]
 
General details
Date: 08 October 2011   Investigation status: Completed  
Time: 0712 UTC   Investigation phase:  
Location   (show map): Los Angeles International Airport, USA   Investigation type: Occurrence Investigation  
State: International   Occurrence type: Aircraft Separation  
Release date: 08 August 2012   Occurrence class: Operational  
Report status: Final   Occurrence category: Incident  
  Highest injury level: None  

Aircraft details

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.  
Last update 14 November 2018