Take-off Accidents - Inadequate Performance
A review of large (above 5700 kg), turbine-powered aircraft accident and incident data has shown that there have been at least 12 major occurrences where take-off performance was significantly different from scheduled performance. Four of the aircraft involved were destroyed and there were 297 fatalities.
Underlying most of these occurrences were one or both of the following safety issues: the failure or absence of procedural defences to detect an error in the take-off performance data, and the failure of the crews to recognize abnormal performance once the take-off had commenced. These safety issues have been identified as causes and contributing factors in the TSB investigation into an accident involving MK Airlines Limited (A04H0004).
The following are some representative accidents taken from the data:
- On March 12, 2003, a Boeing 747-412 suffered a tail strike on take-off in Auckland, New Zealand, and became airborne just above the stall speed (New Zealand Investigation 03 003). The aft pressure bulkhead was severely damaged, but the crew managed to land safely. The cause of the tail strike was a result of the flight crew entering a take-off weight 100 tonnes less than the actual weight into the flight management system (FMS), resulting in low take-off speeds being generated. There was no crew cross-checking of the speeds.
- On March 11, 2003, a Boeing 747-300 in Johannesburg, South Africa, had a tail strike on take-off ( National Transportation Safety Board [NTSB] report DCA03WA031 refers). The flight engineer had entered the zero fuel weight of 203 580 kg instead of the take-off weight of 324 456 kg into the hand-held performance computer, and then transferred the incorrect computed take-off speeds onto the take-off cards.
- On June 14, 2002, an Airbus A330 had a tail strike on take-off in Frankfurt, Germany, because incorrect take-off data were entered into the FMS (TSB report A02F0069 refers). The tail strike was undetected by the flight crew, but they were notified by air traffic services during the climb-out. The aircraft sustained substantial structural damage to the underside of the tail.
- On December 28, 2001, a B747-200 cargo aircraft had a tail strike on take-off in Anchorage, Alaska, and sustained substantial damage (NTSB report ANC02LA008 refers). The crew did not account for the weight of the additional fuel (about 45 360 kg) taken on board in Anchorage, and inadvertently used the same performance cards that were used for the previous landing. The crew members were unaware that the tail had struck the runway until after arrival at their destination.
- On January 13, 1982, a Boeing 737-222 was on a scheduled flight from Washington, DC, to Fort Lauderdale, Florida. During take-off, the engine pressure ratios (EPRs) were set for 2.04, and on the take-off run, anomalous engine instrument readings were noted; the captain elected to continue the take-off. Approximately 2000 feet and 15 seconds past the normal take-off point, the aircraft became airborne. The aircraft initially climbed, but failed to accelerate. The stall warning stick shaker activated shortly after take-off and continued until the aircraft settled, hit the 14th Street Bridge and several vehicles, then plunged into the frozen Potomac River. The investigation revealed that the engine inlet pressure probes became blocked with ice, resulting in high EPR indications. Of the 79 persons on board, 74 perished, and there were four ground fatalities.
From at least as far back as 1972, there have been safety recommendations and initiatives to ensure that crews have a reliable on-board method of detecting abnormal take-off performance, particularly in situations where performance is less than required or expected. Unfortunately, there is still not a reliable in-cockpit system available for crews to detect and react to abnormal take-off performance in a timely manner.
The public report and other related documents are available on this site.
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