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Take-Off Performance Calculation and Entry Errors: a Global Perspective

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Take-Off Performance Calculation and Entry Errors: a Global Perspective Take-off performance calculation and entry errors: A global perspective Take-off ATSB TRANSPORT SAFETY REPORT Aviation Research and Analysis Report – AR-2009-052 Take-off performance calculation and entry errors: A global perspective ATSB TRANSPORT SAFETY INVESTIGATION REPORT Aviation Research and Analysis Report AR-2009-052 Final Take-off performance calculation and entry errors: A global perspective Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau Postal address: PO Box 967, Civic Square ACT 2608 Office: 62 Northbourne Avenue Canberra, Australian Capital Territory 2601 Telephone: 1800 020 616, from overseas +61 2 6257 4150 Accident and incident notification: 1800 011 034 (24 hours) Facsimile: 02 6247 3117, from overseas +61 2 6247 3117 Email: [email protected] Internet: www.atsb.gov.au © Commonwealth of Australia 2011 In the interests of enhancing the value of the information contained in this publication you may download, print, reproduce and distribute this material acknowledging the Australian Transport Safety Bureau as the source. However, copyright in the material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you want to use their material you will need to contact them directly. ISBN and formal report title: see ‘Document retrieval information’ on page vi - ii - CONTENTS DOCUMENT RETRIEVAL INFORMATION .................................................. vi THE AUSTRALIAN TRANSPORT SAFETY BUREAU ................................ vii TERMINOLOGY USED IN THIS REPORT ................................................... viii ABBREVIATIONS ................................................................................................ ix 1 INTRODUCTION ........................................................................................ 11 1.1 Objectives ........................................................................................... 12 1.2 Report outline ..................................................................................... 12 1.3 Methodology....................................................................................... 13 1.3.1 Data sources............................................................................. 13 1.3.2 Error analysis ........................................................................... 14 1.3.3 Contributing safety factor analysis .......................................... 15 1.3.4 Limitations............................................................................... 16 2 TAKE-OFF PERFORMANCE PARAMETERS ...................................... 19 2.1 The parameters ................................................................................... 19 2.1.1 Take-off reference speeds (V speeds) ...................................... 19 2.1.2 Aircraft weights ....................................................................... 20 2.1.3 FLEX or assumed temperature ................................................ 20 2.1.4 The process .............................................................................. 20 2.2 Typical errors...................................................................................... 23 2.3 Typical consequences ......................................................................... 23 3 AUSTRALIAN DATA.................................................................................. 25 3.1 Summary of occurrences .................................................................... 25 3.2 Australia in perspective ...................................................................... 29 3.2.1 Performance parameter ............................................................ 29 3.2.2 Error action .............................................................................. 29 3.2.3 Device ...................................................................................... 30 3.2.4 Consequence ............................................................................ 31 3.2.5 Change in conditions ............................................................... 31 3.2.6 Summary of Australian data .................................................... 32 4 INTERNATIONAL DATA .......................................................................... 33 4.1 Summary of occurrences .................................................................... 33 4.1.1 Boeing 727: August 1989 ........................................................ 33 4.1.2 Boeing 757: January 1990 ....................................................... 34 - iii - 4.1.3 Douglas DC-8: March 1991..................................................... 34 4.1.4 Boeing 767: August 1999 ........................................................ 35 4.1.5 Boeing 747: December 2001 ................................................... 37 4.1.6 Airbus A330: June 2002 .......................................................... 37 4.1.7 Boeing 747: March 2003 ......................................................... 38 4.1.8 Boeing 747: March 2003 ......................................................... 38 4.1.9 Airbus A321: September 2003 ................................................ 41 4.1.10 Boeing 747: October 2003 .................................................... 42 4.1.11 Airbus A340: July 2004 ........................................................ 45 4.1.12 Boeing 747: October 2004 .................................................... 46 4.1.13 Airbus A340: August 2005 ................................................... 48 4.1.14 Embraer 190: July 2006 ........................................................ 49 4.1.15 Boeing 747: December 2006 ................................................ 51 4.1.16 Airbus A340: March 2007 .................................................... 53 4.1.17 Boeing 747: June 2007 ......................................................... 53 4.1.18 McDonnell Douglas MD83: September 2007 ...................... 55 4.1.19 Airbus A330: October 2008 ................................................. 56 4.1.20 Boeing 767: December 2008 ................................................ 57 4.2 International perspective..................................................................... 59 4.2.1 Performance parameter ............................................................ 59 4.2.2 Error action .............................................................................. 59 4.2.3 Device ...................................................................................... 60 4.2.4 Consequence ............................................................................ 60 4.2.5 Change in conditions ............................................................... 61 4.2.6 Summary of international data ................................................. 62 5 SAFETY FACTOR ANALYSIS .................................................................. 63 5.1 All safety factors ................................................................................. 63 5.1.1 Individual actions..................................................................... 63 5.1.2 Local conditions ....................................................................... 64 5.1.3 Risk controls ............................................................................ 67 5.1.4 Organisational influences ........................................................ 69 5.2 Safety factor map ................................................................................ 69 6 MINIMISING THE RISKS ......................................................................... 71 6.1 Risk controls....................................................................................... 71 6.1.1 Procedures................................................................................ 71 6.1.2 Automation .............................................................................. 72 6.1.3 Tools and materials .................................................................. 74 6.2 Local conditions ................................................................................. 75 6.2.1 Task/experience recency .......................................................... 75 - iv - 6.3 Individual actions ............................................................................... 77 6.3.1 Monitoring and checking ......................................................... 77 6.3.2 Using equipment...................................................................... 78 6.4 Detecting degraded take-off performance .......................................... 79 7 CONCLUSION ............................................................................................. 81 8 REFERENCES.............................................................................................. 83 APPENDIX A: ATSB SAFETY FACTOR TAXONOMY ............................... 87 APPENDIX B: LIST OF AUSTRALIAN OCCURRENCES ........................... 91 APPENDIX C: LIST OF INTERNATIONAL OCCURRENCES ................... 93 APPENDIX D: ADDITIONAL OCCURRENCES ............................................ 95 - v - DOCUMENT RETRIEVAL INFORMATION Report No. Publication date No. of pages ISBN AR-2009-052 January 2011 97 978-1-74251-097-2 Publication title Take-off performance calculation and entry errors: A global perspective Author(s) Hughes, K.L. Godley, S.T. Prepared By Reference Number Australian Transport Safety Bureau ATSB-OCT10/ATSB128 PO Box 967, Civic Square
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