Serious incident Boeing 737-8MG (WL) G-JZHL,
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ASN Wikibase Occurrence # 270863
 
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Date:Wednesday 1 December 2021
Time:15:01 UTC
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different    
Boeing 737-8MG (WL)
Owner/operator:Jet2
Registration: G-JZHL
MSN: 63568/6138
Year of manufacture:2016
Engine model:CFM CFM56-7B26E
Fatalities:Fatalities: 0 / Occupants: 6
Aircraft damage: None
Category:Serious incident
Location:Kuusamo Airport (KAO/EFKS) -   Finland
Phase: Take off
Nature:Passenger - Non-Scheduled/charter/Air Taxi
Departure airport:Kuusamo Airport (KAO/EFKS)
Destination airport:London-Stansted Airport (STN/EGSS)
Investigating agency: AAIB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
A Jet2 Boeing 737-800 took off from runway 12 at Kuusamo Airport, Finland, with the wrong power setting. The flight continued to the destination, London-Stansted Airport.

The aircraft operated on a return flight from London-Stansted Airport to Kuusamo Airport in Finland. There were no passengers for the return flight leaving just the two pilots and four cabin crew onboard.

As the wind was still across the runway, they planned to depart from Runway 12 using intersection A. The takeoff weight was 52,100 kg with 9,600 kg of fuel. The runway was covered with 3 mm of dry snow and the airfield was reporting a Runway Condition Code (RWYCC) of 4 so the crew completed a takeoff performance calculation using medium to good braking action and derated takeoff thrust. The calculation gave Flap 5, an N1 of 89.0%, a V1 of 93 kt, a VR of 122 kt and a V2 of 131 kt which was loaded into the FMC and Mode Control Panel (MCP). The crew obtained their clearance and briefed for the takeoff whilst the aircraft was de-iced. The clearance was, after departure, to route via waypoint ibevu and climb to FL400. The co-pilot was to be the pilot flying. As the ramp was contaminated with snow the crew planned to taxi with the flaps up, selecting them before lining-up on the runway. The conditions required a pre-takeoff engine run-up to clear any ice from the engines. This required the engines to be accelerated to 70% N1 on the runway for 30 seconds whilst the aircraft was held on the brakes.

The co-pilot then advanced the thrust levers to 70% N1 whilst holding the toe brakes. However, as he did this, he felt the aircraft start to slide and yaw. The crew had briefed that this might happen and had agreed that if it did, they would release the brakes and continue the takeoff. The co-pilot recalled saying something like “it’s sliding” and the commander replied with words like “let it go”. The co-pilot recalled that he was startled by how readily the aircraft had slid and yawed and by the proximity of the snowbanks to the side of the runway. He released the brakes and focused on steering the aircraft down the runway. He remembered working quite hard with the rudder pedals to keep the aircraft straight.

The crew made the normal calls at 80 kt and this was shortly followed by V1 at 93 kt. The takeoff continued and both pilots reported being aware that something was not right. The co-pilot initiated the rotation at VR but recalled the aircraft was “very heavy” in pitch. As he looked down to the Primary Flight Display (PFD), he realised there was no vertical flight director so he focused on flying a pitch attitude to maintain airspeed. He recalled the aircraft was not climbing normally and the airspeed was hovering around V2, he described that “it felt like flying an engine failure on takeoff in the simulator”. The co-pilot remembered saying “we need more power”. At this stage the commander realised they did not have takeoff power set and manually advanced the thrust levers to 89% N 1.

On reaching 2,400 ft amsl they selected N1 on the MCP to reduce to climb power then, as the aircraft passed 3,900 ft amsl, started to accelerate and retract the flaps. Once clean they selected LVL CHG which restored the vertical flight director. The remainder of the flight to Stansted continued without further incident.

AAIB Conclusion
The aircraft took off with insufficient thrust set because the TOGA button was not pressed. It was not pressed because the co-pilot was startled by the aircraft moving as he commenced the run-up against the brakes. The aircraft started to move because insufficient brake pressure was applied. Human checks designed to detect the insufficient thrust were ineffective because both pilots were attending to other tasks. The commander was responding to a radio call from the FISO during the start of the takeoff roll. Neither pilot detected the low thrust until after the aircraft was airborne.

Weather reported about the incident time (1501Z):
EFKS 011420Z 05004KT 010V090 5000 -SN SCT024 OVC031 M08/M10 Q0983
EFKS 011520Z 05004KT 010V080 5000 -SN SCT028 OVC032 M08/M10 Q0983

Takeoff distance available for runway 12 is 2500 m according to the AIP.

Accident investigation:
cover
  
Investigating agency: AAIB
Report number: AAIB-27895
Status: Investigation completed
Duration:
Download report: Final report

Sources:

1. AAIB Final Report: https://assets.publishing.service.gov.uk/media/633d3bcfe90e07440ca13208/Boeing_737-800_G-JZHL_11-22.pdf
2. https://turvallisuustutkinta.fi/en/index/currentissues/releases/2021/l2021-a1seriousincidentatthekuusamoairporton1december2021.html
3. https://www.gov.uk/government/news/aaib-report-boeing-737-800-g-jzhl-insufficient-thrust-during-takeoff
4. https://www.flightradar24.com/data/aircraft/g-jzhl#2a0b8bfe
5. https://en.wikipedia.org/wiki/Kuusamo_Airport

Media:

Revision history:

Date/timeContributorUpdates
17-Dec-2021 17:43 penu Added
17-Dec-2021 17:50 harro Updated [Time, Aircraft type, Registration, Cn, Nature, Destination airport, Source, Narrative]
17-Dec-2021 17:56 harro Updated [Narrative]
02-Oct-2022 20:47 Dr. John Smith Updated [Source, Narrative, Category]
06-Oct-2022 18:25 harro Updated [Total occupants, Narrative, Accident report]
07-Oct-2022 03:34 Dr. John Smith Updated [Source, Embed code, Narrative]
07-Oct-2022 03:35 Dr. John Smith Updated [Embed code, Narrative]
09-Oct-2022 18:49 harro Updated [[Embed code, Narrative]]
11-Nov-2022 16:15 Dr. John Smith Updated [Source]

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