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ASN Wikibase Occurrence # 219804
Last updated: 6 September 2019
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Date:07-JUL-2013
Time:17:27
Type:Silhouette image of generic B77W model; specific model in this crash may look slightly different
Boeing 777-306ER
Owner/operator:KLM Royal Dutch Airlines
Registration: PH-BVG
C/n / msn:
Fatalities:Fatalities: 0 / Occupants:
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:Amsterdam-Schiphol International Airport (AMS/EHAM) -   Netherlands
Phase: Take off
Nature:International Scheduled Passenger
Departure airport:Amsterdam-Schiphol International Airport (AMS/EHAM)
Destination airport:
Investigating agency: Dutch Safety Board
Narrative:
On 7 July 2013 at 17:27, a Boeing 777-300ER took off from runway 36C at Schiphol Airport. The engine thrust selected for the take-off was lower than was required for the weight of the aircraft.

During the incident flight, the crew consisted of three pilots: a captain, a first officer and a second officer. It is not uncommon within the airline involved for the second officer to conduct the preflight duties while the captain follows the preparations from the third seat in the cockpit. Approximately 15 minutes prior to departure, the captain switched seats with the second officer. Once the loading schedule was passed on to the crew 5 minutes after the scheduled departure time, the final calculations could be made. These calculations include the required take-off thrust and the corresponding reference speeds based on the total aircraft weight provided.
The airline’s published operating procedure did not specify independent input of the aircraft weights by multiple crew members. In this case an input error had occurred.
What the procedure does enable is a comparison of the calculation results between the captain’s Electronic Flight Bag (EFB) and the first officer’s EFB. However, to arrive at a matching outcome, the input variables must be identical. A pilot mentioned an incorrect take-off weight and the other pilot used that weight, which resulted in the calculations no longer being independent, causing the failure of an important safety net.
Upon entry of the results of the take-off performance calculation into the Flight Management Computer (FMC), the computer did issue a warning that was not entirely understood by the crew and was subsequently ignored. This resulted in the failure of a second safety net.
The second officer, who had initially performed a correct calculation on the captain’s EFB, had been distracted by the need to give flight-safety instructions to the ground official who was travelling with the crew in the cockpit. As a result, the second officer restricted himself to comparing the results of the captain and first officer’s EFBs, but he did not notice the low programmed engine thrust and the corresponding low reference speeds.

For the crew, the lower than normal acceleration during takeoff from runway 36C was not sufficiently noticeable to abort the take-off. Due to the lower reference speeds, the rotation point on the runway more or less coincided with the normal rotation point. Shortly after the rotation, the aircraft did not become airborne straight away: this took a total of four seconds longer than for normal rotation. As the first officer was aware of the risk of a tailstrike and because the aircraft’s tailstrike-prevention system intervened, the aircraft’s tail did not touch the runway. The speed at which the aircraft left the runway was thus the minimum lift-off speed determined by the maximum angle off attack where tail contact with the runway was just avoided. After lift-off the first officer subsequently increased the speed to above the selected reference speed, as a result of which the aircraft’s rate of climb was unwittingly increased to the minimum safe rate. Shortly afterwards, the captain detected the input error and the flight operations proceeded as normal from that point onwards.

Sources:

OVV


Revision history:

Date/timeContributorUpdates
21-Dec-2018 13:21 harro Added

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