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B742, Halifax Canada, 2004
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Revision as of 07:14, 6 December 2018 by Project.Manager
|On 14 October 2004, a B742 crashed on take off from Halifax International Airport, Canada, and was destroyed by impact forces and a post-crash fire. The crew had calculated incorrect V speeds and thrust setting using an EFB.|
|Actual or Potential
|Fire Smoke and Fumes, Ground Operations, Human Factors, Loss of Control|
|Flight Conditions||On Ground - Normal Visibility|
|Type of Flight||Public Transport (Cargo)|
|Origin||Halifax Stanfield International Airport|
|Intended Destination||Zaragoza Airport|
|Take off Commenced||No|
|Flight Phase||Take Off|
|Location - Airport|
|Airport||Halifax Stanfield International Airport|
|Tag(s)||Post Crash Fire|
|Tag(s)||Data use error,|
Procedural non compliance,
|Tag(s)||Reduced Thrust Take Off|
|Damage or injury||Yes|
|Aircraft damage||Hull loss|
|Fatalities||Most or all occupants (7)|
|Causal Factor Group(s)|
USE OF INCORRECT TAKEOFF WEIGHT IN EFB PERFORMANCE CALCULATION
On 14 October 2004, a BOEING 747-200 crashed on take off from Halifax International Airport, Canada, and was destroyed by impact forces and a post-crash fire. The crew had calculated incorrect V speeds and thrust setting using an Electronic Flight Bag.
The following is taken from the official accident investigation report produced by the Canadian Transportation Safety Board (Canada):
"On 14 October 2004, an MK Airlines Limited Boeing 747-244SF (registration 9G-MKJ, serial number 22170) was being operated as a non-scheduled international cargo flight from Halifax, Nova Scotia, to Zaragoza, Spain. At about 0654 coordinated universal time, 0354 Atlantic daylight time, MK Airlines Limited Flight 1602 attempted to take off from Runway 24 at the Halifax International Airport. The aircraft overshot the end of the runway for a distance of 825 feet, became airborne for 325 feet, then struck an earthen berm. The aircraft's tail section broke away from the fuselage, and the aircraft remained in the air for another 1200 feet before it struck terrain and burst into flames. The aircraft was destroyed by impact forces and a severe post-crash fire. All seven crew members suffered fatal injuries."
- The aircraft had previously flown into Halifax from Bradley International Airport, USA.
- The crew used the Boeing Laptop Tool (BLT) to calculate the take off performance data.
The TSB determined the following causes and contributing factors:
- "The Bradley take-off weight was likely used to generate the Halifax take-off performance data, which resulted in incorrect V speeds and thrust setting being transcribed to the take-off data card.
- The incorrect V speeds and thrust setting were too low to enable the aircraft to take off safely for the actual weight of the aircraft.
- It is likely that the flight crew member who used the Boeing Laptop Tool (BLT) to generate take-off performance data did not recognize that the data were incorrect for the planned take-off weight in Halifax. It is most likely that the crew did not adhere to the operator's procedures for an independent check of the take-off data card.
- The pilots of MKA1602 did not carry out the gross error check in accordance with the company's standard operating procedures (SOPs), and the incorrect take-off performance data were not detected.
- Crew fatigue likely increased the probability of error during calculation of the take-off performance data, and degraded the flight crew's ability to detect this error.
- Crew fatigue, combined with the dark take-off environment, likely contributed to a loss of situational awareness during the take-off roll. Consequently, the crew did not recognize the inadequate take-off performance until the aircraft was beyond the point where the take-off could be safely conducted or safely abandoned.
- The aircraft's lower aft fuselage struck a berm supporting a localizer antenna, resulting in the tail separating from the aircraft, rendering the aircraft uncontrollable.
- The company did not have a formal training and testing program on the BLT, and it is likely that the user of the BLT in this occurrence was not fully conversant with the software…"
- For further information, see the full TSB Accident Investigation Report