Final
Report № AIFN/0010/2018, issued on 10 January 2022
26
A decision to take control of the Aircraft from the Copilot required the Commander to call
“I have control” and then for the Copilot to transfer control by responding “You have control” and for
the Copilot to then assume pilot monitoring functions. In addition, when the Commander mentally
decided to continue the takeoff, he was required to make his intentions known with the callout ‘Go’.
The investigation believes that these callouts were not accomplished from the statements and
interviews with the flight crew.
The Commander perceived that the remaining runway available was insufficient to reject
the takeoff as indicated by his statement to the Investigation
“I saw the end of runway coming.” The
Aircraft manufacturer's
guidance and the Operator’s policy for a rejected takeoff recognizes the
risks involved with such a decision. This is why the manufacturer divided the take-off speeds into
high-speed and low-speed regimes. The Commander applied the principle of
‘go-minded’ similar to
the decision of continuing a takeoff at or beyond 100 knots
The Commander’s decision was based on his perception of the runway available to stop
the Aircraft. His immediate reaction to his realization that the takeoff was from the wrong runway
was by advancing the thrust levers to TOGA. He misjudged that the remaining runway would have
been sufficient to reject the take-off safely.
The nonstandard action by the Commander of moving the flap lever position from 1+F to
Flap 2 position during the take-off roll would have required him to shift his attention from outside
peripheral view during the take-off roll to the cockpit flap lever and engine and warning display
(E/WD) to confirm that flaps/slats are moving to the selected position. This action could have caused
lateral disruption in control of the Aircraft during takeoff due to the shift of sight. The Investigation
believes that the Commander's efforts aimed at liftoff before reaching the end of the runway rather
than rejecting takeoff at lower than 100 knots airspeed. That judgment and consequent decision
were indications of a
‘take-off minded’ situation.
The Commander was aware of the
‘High/Low rejected take-off speed’ criteria, and was
trained on rejected takeoff. There was no provision in the Operator
’s
flight crew operating manual
(FCOM)
to provide the flight crew with information about the runway accelerate-stop distance,
aircraft take-off weight, or aircraft take-off speeds. Therefore, a decision to reject a takeoff was left
to the flight crew.
Had the Commander decided to reject the takeoff any time within the low-speed regime
below 100 knots, and should he have applied maximum reverse engine thrust, which would
automatically engage maximum autobrakes, the Aircraft would have safely stopped on runway 12.
This was confirmed by the performance calculations provided by the Aircraft manufacturer and the
simulated flight sessions.
The Investigation recommends that the Operator use this Incident to reinforce to the pilots
the importance of full pre-flight briefing, including positive runway identification, familiarization with
runway signage, markings, and distances, effective crew resource management during taxi and
takeoff, and safeguarding the aircraft and occupants when making the decision to reject a takeoff
at low and high speeds.
The Investigation recommends that the Operator improve the flight planning data by
providing relevant runway accelerate-stop distances to the flight crew.
2.3.5
Crew performance
It is most likely that the late visual perception that the Aircraft was on the wrong runway
surprised both flight crewmembers. The lack of cockpit voice recordings deprived the Investigation
from the conversation data related to cockpit conversation, which could have provided cues of the
crew's psychological condition and how it could have affected their performance. The only reference
