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REPORTS > AVIATION > 2004 > A04H0004

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  AVIATION Reports - 2004 - A04H0004

TABLE OF CONTENTS

  1. 1.0 Factual Information
    1. 1.1 History of the Flight
    2. 1.2 Injuries to Persons
    3. 1.3 Damage to the Aircraft
    4. 1.4 Other Damage
    5. 1.5 Personnel Information
    6. 1.5.1 General
    7. 1.5.2 Operating Captain
    8. 1.5.3 Operating First Officer
    9. 1.5.4 Operating Flight Engineer
    10. 1.5.5 Loadmaster
    11. 1.5.6 Non-Operating Captain
    12. 1.5.7 Non-Operating Flight Engineer
    13. 1.5.8 Ground Engineer
    14. 1.6 Aircraft Information
    15. 1.6.1 General
    16. 1.6.2 Aircraft Weight and Balance
    17. 1.6.2.1 Aircraft Empty Weight
    18. 1.6.2.2 Bradley International Airport Weight and Balance
    19. 1.6.2.3 Halifax International Airport Weight and Balance
    20. 1.6.3 Take-off Thrust
    21. 1.6.4 Aircraft Performance Data
    22. 1.6.5 Tail Strike Information
    23. 1.7 Meteorological Information
    24. 1.8 Aids to Navigation
    25. 1.9 Communications
    26. 1.10 Aerodrome Information
    27. 1.10.1 Introduction
    28. 1.10.2 Airport Electrical Power Supply
    29. 1.10.3 Runway 24 Slope
    30. 1.10.4 Earthen Berm
    31. 1.10.5 Halifax Automatic Terminal Information Service
    32. 1.11 Flight Recorders
    33. 1.11.1 Cockpit Voice Recorder
    34. 1.11.2 Flight Data Recorder
    35. 1.11.3 Flight Data Recorder Data Losses
    36. 1.11.4 Halifax Take-off - Flight Data Recorder Recorded Events
    37. 1.11.5 Halifax Take-off Compared to the Bradley Take-off
    38. 1.12 Wreckage and Impact Information
    39. 1.12.1 Impact Information
    40. 1.12.2 Wreckage Examination
    41. 1.13 Medical Information
    42. 1.14 Fire
    43. 1.14.1 General
    44. 1.14.2 Grid Map
    45. 1.14.3 Radio Communications
    46. 1.14.4 Site Command
    47. 1.14.5 Persons on Board and Dangerous Goods
    48. 1.15 Survival Aspects
    49. 1.16 Tests and Research
    50. 1.17 Organizational Information
    51. 1.17.1 MK Airlines Limited
    52. 1.17.1.1 General
    53. 1.17.1.2 Flight Operations Supervision and Oversight
    54. 1.17.1.3 Flight Operations Quality and Flight Safety Program
    55. 1.17.1.4 Company Aircraft Training and Testing
    56. 1.17.1.5 Crew Pressures
    57. 1.17.1.6 Company Maintenance Practices
    58. 1.17.2 Ghana Civil Aviation Authority
    59. 1.17.2.1 General
    60. 1.17.2.2 Ghana Civil Aviation Regulations
    61. 1.17.2.3 Ghana Civil Aviation Authority Flight Operations Oversight
    62. 1.17.2.4 Ghana Civil Aviation Authority Airworthiness Oversight
    63. 1.17.3 Transport Canada
    64. 1.17.4 United States Federal Aviation Administration
    65. 1.17.5 United Kingdom Civil Aviation Authority
    66. 1.18 Other Relevant Information
    67. 1.18.1 Boeing Laptop Tool
    68. 1.18.1.1 Introduction
    69. 1.18.1.2 MK Airlines Limited Crew Training on Boeing Laptop Tool
    70. 1.18.1.3 Performance Data from the Boeing Laptop Tool
    71. 1.18.1.4 Maximum Allowable Take-off Weight at Halifax
    72. 1.18.1.5 Boeing Laptop Tool Take-off Performance Data at Halifax
    73. 1.18.1.6 Boeing Laptop Tool Take-off Performance Data at Bradley
    74. 1.18.1.7 Boeing Laptop Tool Take-off Performance Data at Halifax Using Bradley Weight
    75. 1.18.1.8 Landing Performance Data at Halifax
    76. 1.18.1.9 Regulatory Approval of Laptop Performance Systems
    77. 1.18.2 Performance Data References
    78. 1.18.2.1 Data Cards
    79. 1.18.2.2 Instrument Bugs
    80. 1.18.2.3 Gross Error Check
    81. 1.18.2.4 Load Planning Sheets
    82. 1.18.3 MK Airlines Limited Operations Manual
    83. 1.18.4 Procedures for Completing and Verifying Performance Data
    84. 1.18.5 Rest, Duty and Flight Time Schemes
    85. 1.18.5.1 MK Airlines Limited Rest, Duty and Flight Time Schemes
    86. 1.18.5.2 Rest, Duty and Flight Time Schemes of Other Civil Aviation Authorities
    87. 1.18.5.3 MKA1602 Crew Duty Time
    88. 1.18.5.4 Physiological Effects of Fatigue
    89. 1.18.5.5 Fatigue Management
    90. 1.18.6 Previous MK Airlines Limited Accidents and Incidents
    91. 1.18.7 Managing the Risks of an Organization
    92. 1.18.8 Take-off Accidents - Inadequate Performance
  2. 2.0 Analysis
    1. 2.1 Introduction
    2. 2.2 Halifax International Airport - Accident-Related Issues
    3. 2.2.1 Electrical Power Supply
    4. 2.2.2 Grid Map
    5. 2.2.3 Persons and Dangerous Goods On-Board Information
    6. 2.2.4 Runway Slope
    7. 2.2.5 Earthen Berm
    8. 2.2.6 Radio Communications
    9. 2.3 Weight and Balance
    10. 2.4 MK Airlines Limited
    11. 2.4.1 MK Airlines Limited Expansion
    12. 2.4.2 Rest, Duty and Flight Time
    13. 2.4.3 MK Airlines Limited Company Risk Management
    14. 2.4.4 Company Oversight of Operations
    15. 2.4.5 Company Introduction of the Boeing Laptop Tool
    16. 2.5 Regulatory Oversight of MK Airlines Limited
    17. 2.6 Halifax Take-off Performance Data
    18. 2.7 Failure to Recognize Inadequate Take-off Performance
    19. 2.8 Summary
  3. 3.0 Conclusions
    1. 3.1 Findings as to Causes and Contributing Factors
    2. 3.2 Findings as to Risk
    3. 3.3 Other Findings
  4. 4.0 Safety Action
    1. 4.1 Action Taken
    2. 4.1.1 Safety Advisory A040058-1
    3. 4.1.2 Safety Advisory A040059-1
    4. 4.1.3 Ghana Civil Aviation Authority
    5. 4.1.4 MK Airlines Limited
    6. 4.1.4.1 Notices to Flight Crew
    7. 4.1.4.2 Operations
    8. 4.1.4.3 Training
    9. 4.1.4.4 European Aviation Safety Agency Certification
    10. 4.1.4.5 Airworthiness
    11. 4.1.5 Boeing
    12. 4.1.6 Halifax International Airport Authority
    13. 4.1.7 United Kingdom Civil Aviation Authority
    14. 4.1.8 United States Federal Aviation Administration
    15. 4.2 Action Required
    16. 4.2.1 Take-off Performance Monitoring System
    17. 4.3 Safety Concerns
    18. 4.3.1 Man-Made Objects in Runway Undershoot and Overshoot Areas
    19. 4.3.2 Persons and Dangerous Goods on Board
  5. Appendices
    1. Appendix A - Flight Data Recorder Engine Data Comparison Between Bradley and Halifax
    2. Appendix B - Flight Data Recorder Flight Controls Comparison Between Bradley and Halifax
    3. Appendix C - Take-off Sequence
    4. Appendix D - Sequence of Events
    5. Appendix E - Glossary
  6. Photos
    1. Photo 1 - Main Fuselage and Number 4 Engine
    2. Photo 2 - Location of Scrape Marks and Berm
    3. Photo 3 - View of Ground Scar and Initial Impact Point with the Berm
    4. Photo 4 - Minimum Aircraft Pitch Attitude at Point of Impact with Berm
    5. Photo 5 - Accident Site and Wreckage Location
    6. Photo 6 - Engine Number 4 EPR Gauge
    7. Photo 7 - Upper Deck Configuration
    8. Photo 8 - Upper Deck Crew Rest Area
  7. Figures
    1. Figure 1 - Cargo Positions
    2. Figure 2 - BLT Take-off and Landing Performance Page
    3. Figure 3 - MK Airlines Limited Take-off Data Card
    4. Figure 4 - Boeing T-card
    5. Figure 5 - Example of Bug Settings for Take-off
    6. Figure 6 - Bradley Weight at Halifax

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Date Modified: 2008-07-31
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