ASN Wikibase Occurrence # 247029
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Date: | Friday 29 April 2011 |
Time: | 08:30 UTC |
Type: | Airbus A321-211 |
Owner/operator: | Thomas Cook Airlines |
Registration: | G-NIKO |
MSN: | 1250 |
Year of manufacture: | 2000 |
Engine model: | CFM56-5B3/P |
Fatalities: | Fatalities: 0 / Occupants: 231 |
Aircraft damage: | None |
Category: | Serious incident |
Location: | Manchester Airport (MAN/EGCC) -
United Kingdom
|
Phase: | Take off |
Nature: | Passenger |
Departure airport: | Manchester International Airport (MAN/EGCC) |
Destination airport: | Heraklion-N. Kazantzakis Airport (HER/LGIR) |
Investigating agency: | AAIB |
Confidence Rating: | Information verified through data from accident investigation authorities |
Narrative:The flight from Manchester Airport to Heraklion, Crete was carried out using an Airbus A321 while the crew more often flew the smaller A320. The commander was designated as Pilot Flying (PF) for the flight.
The loadsheet was generated by the handling company at 08:37 hrs, 17 minutes after the scheduled departure time. The commander accepted the loadsheet from the dispatcher and checked it. While he was doing so, the co-pilot asked him for the takeoff weight so that he could begin the performance calculations. The commander read out what he thought was the Actual Take Off Mass (ATOM) but mistakenly read out the Zero Fuel Mass (ZFM) of 69,638 kg. The commander then wrote down that figure in a space provided on the navigation log for the ATOM. The Standard Operating Procedure (SOP) then required him to compare the Estimated (E)TOM, on the line above, with the ATOM.
However, he actually compared the figure he had written down as the ATOM (69,638) with the EZFM on the line beneath.
The commander next entered some data into the FMS, which included entering the ZFM from the loadsheet in the INIT B page. The ZFM is a mandatory pilot entry which allows the FMS to compute TOM, speed management and predictions. The pilot cannot enter the TOM directly. The loadsheet was passed to the co-pilot who checked it and confirmed that it matched the commander’s entry in the FMS.
The commander then used the figure which he had incorrectly written on the navigation log as the ATOM (69,638 kg) to perform his takeoff calculation. The SOPs required each pilot to carry out a takeoff performance calculation separately. In order to do this, the ATOM figure is taken from the loadsheet and each pilot uses a laptop computer on which to carry out the calculation.
The calculations are compared and the takeoff data, speeds, flex thrust, configuration and trim position, are entered into the FMS.
In this case, the laptop computer calculated the following speeds: V1 = 131 kt, VR = 134 kt and V2 = 135 kt, using Flap 2, Flex 57°C and a green dot speed of 214 kt. (The figures that would have been generated by the laptop computer for the correct ATOM of 86,527 kg were: V1 = 155 kt, VR = 155 kt and V2 = 156 kt, with Flap 2, Flex 39°C and a green dot speed of 240 kt.) The SOP required the crew to crosscheck the green dot speed generated by the laptop computer against that generated by the FMS.
However, although they crosschecked the performance figures between the two laptops, the crosscheck with the FMS green dot speed was missed.
Before the aircraft departed, a Last Minute Change (LMC) addition of one male passenger plus bag (+89 kg) was made to the loadsheet. This did not require a recalculation of the takeoff performance data.
Later, when the aircraft took off from runway 05L, the commander noticed that the side stick control felt heavier than expected at rotation and, as the aircraft lifted off, the Lowest Selectable Speed (VLS) indication moved “too far” up the speed scale. He reduced the pitch attitude and covered the thrust levers in case more power should be required. The aircraft accelerated and climbed, but at a slower than normal rate. When the aircraft was in the cruise, the crew checked the performance figures and realised that they had used the ZFM instead of the TOM for the takeoff performance calculation.
Accident investigation:
|
| |
Investigating agency: | AAIB |
Report number: | EW/G2011/04/29 |
Status: | Investigation completed |
Duration: | |
Download report: | Final report |
|
Sources:
https://assets.publishing.service.gov.uk/media/5423010740f0b613420009dd/Airbus_A321-211__G-NIKO_12-11.pdf Revision history:
Date/time | Contributor | Updates |
24-Jan-2021 17:55 |
harro |
Added |
24-Jan-2021 17:56 |
harro |
Updated [Location, Departure airport, Destination airport] |
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