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ASN Wikibase Occurrence # 208064
Last updated: 23 August 2020
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Date:03-DEC-2015
Time:19:27 LT
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different
Boeing 737-8K2 (WL)
Owner/operator:Transavia
Registration: PH-HSG
C/n / msn: 39262/4021
Fatalities:Fatalities: 0 / Occupants: 181
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:Lisboa-Humberto Delgado Airport (LIS/LPPT) -   Portugal
Phase: Take off
Nature:Passenger - Scheduled
Departure airport:Lisboa-Humberto Delgado Airport (LIS/LPPT)
Destination airport:Amsterdam-Schiphol International Airport (AMS/EHAM)
Investigating agency: Dutch Safety Board
Narrative:
On December 3, 2015, a Boeing 737-800 departed from Lisbon Airport to Amsterdam Airport Schiphol. The pilots noticed that the remaining runway length was less than expected during the take-off roll, shortly prior to rotation. The take-off was continued.
Approximately 430 metres before the end of the runway the aircraft became airborne. The take-off performance in Lisbon was calculated for an incorrect runway/take-off position combination due to an EFB input error, which was possible due to unclear naming of take-off positions at Lisbon Airport. As a consequence the available runway length was 1,120 metres less than calculated.

Direct causes
An incorrect runway and take-off position selection in the EFB performance tool by the flight crew caused the insufficient thrust setting.
The errors could propagate because there were no adequate crosschecks in place to detect the errors. A crosscheck that could detect that both pilots were making the same runway selection error was lacking.

Contributing factors of the selection error in the incident were:
the large number of data entries and transfers;
the ergonomics of the EFB performance module;
the ambiguous runway take-off position naming system at the airport.

Contributing factor in the error propagation in the incident was:
the large variation in take-off parameters due to the performance optimization of the EFB, which decreases the chance for flight crews to develop a feel for the values of take-off performance parameters.

Underlying causes
The operator did not sufficiently assess the safety barriers and risks associated with the layout and ergonomics of the EFB, because the risk assessments were carried out at a moment that the hardware and software of the EFB were not available yet (2013). After implementation of the EFB, no evaluation was carried out.
EFB processes were not evaluated and an investigation into the causes of data entry errors in EFBs has not been initiated after it became apparent that data entry errors were being made in its operation.

Sources:

OVV

Accident investigation:
cover
  
Investigating agency: Dutch Safety Board
Status: Investigation completed
Duration: 2 years and 3 months
Download report: Final report


Images:

Photo of PH-HSG courtesy AirHistory.net


Amsterdam - Schiphol (EHAM / AMS)
26 April 2018; (c) Aad van der Voet

Revision history:

Date/timeContributorUpdates
23-Mar-2018 12:09 harro Added
23-Aug-2020 11:56 harro Updated [Source, Accident report, ]

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