ASN Wikibase Occurrence # 225280
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Date: | Wednesday 24 April 2019 |
Time: | 20:34 UTC |
Type: | Airbus A320-214 |
Owner/operator: | easyJet |
Registration: | G-EZTD |
MSN: | 3909 |
Year of manufacture: | 2009 |
Engine model: | CFM56-5B4/3 |
Fatalities: | Fatalities: 0 / Occupants: 181 |
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: | London-Luton Airport (LTN/EGGW) |
Investigating agency: | AAIB |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:EasyJet scheduled flight U22374 from Lisbon (LPPT) to London-Luton (EGGW), taxied from terminal 2 to runway 21 for an intersection departure on U5.
Initial departure was planned from runway 21 using U5, which gave a Takeoff Runway Available (TORA) distance of 2410m. For reasons still to be determined, the crew then re-planned for a departure from the taxiway S1 intersection of runway 21 (TORA of 3805m), without crosschecking the new TORA against charts. Therefore, the flight departed from taxiway U5 based on the wrong parameters loaded into the FMGC (Flight Management and Guidance Computer).
The captain was new to the role and was on his second on-duty travel to Lisbon Airport, however he noticed that the take-off run was longer than he had expected but did not select TOGA at any point.
The aircraft proceeded and landed on the intended destination airport without further issues.
AAIB Conclusion:
The aircraft took off using incorrect performance data for the intersection used. A selection error was made in the EFB which led the crew to believe that they had calculated performance information for a departure from S1 when in fact they had selected the full length of the runway. The procedural barrier of cross-checking the runway distance against the aerodrome ground chart failed to prevent to error. Human performance limitations mean it is difficult for pilots to recognise and react to reduced performance (acceleration) once the takeoff has begun, so robust adherence to procedures is a key defence against such incidents occurring.
Accident investigation:
|
| |
Investigating agency: | AAIB |
Report number: | EW/C2019/04/03 |
Status: | Investigation completed |
Duration: | |
Download report: | Final report |
|
Sources:
https://www.bea.aero/en/investigation-reports/notified-events/detail/event/incident-dun-airbus-a320-exploite-par-easyjet-survenu-le-24042019-a-lisbonne-portugal-enquete-m/ http://www.gpiaa.gov.pt/wwwbase/wwwinclude/ficheiro.aspx?tipo=0&id=10684&ambiente=WebSiteMenu Images:
Revision history:
Date/time | Contributor | Updates |
20-May-2019 16:43 |
harro |
Added |
20-May-2019 16:44 |
harro |
Updated [Location, Photo] |
06-Aug-2020 18:44 |
harro |
Updated [Narrative, Accident report, ] |
09-Oct-2022 18:40 |
harro |
Updated [[Narrative, Accident report, ]] |
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