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Australian transport safety bureau incident report highlights risks of pilot distraction

Thursday 16 August, 2012

The Australian Transport Safety Bureau (ATSB) reports that they investigated an incident which occurred on 8th October 2011. The investigation has highlighted the risks of pilots becoming distracted during the critical stages of flight preparation. ATSB advise that the investigation report also emphasises the importance of good flight crew communication to ensure a shared understanding of an aircraft's systems status.

The ATSB report that the incident which was the subject of the investigation occurred when the flight crew was preparing for departure from Los Angeles International Airport. Before take-off, the captain changed the departure runway that was entered in the aircraft's flight management system. The procedure for completing that task was not followed exactly, resulting in the take-off speeds not being displayed on the flight instruments.

The ATSB found that the captain had been distracted from updating the runway change in the aircraft's navigation systems before the aircraft taxied for the runway. There were no other warnings to alert the crew that they were commencing the takeoff without the take-off speeds in the aircraft's navigation systems.

Following this incident the aircraft manufacturer has updated the aircraft's warning systems as part of a planned upgrade program. This upgrade will issue a warning if takeoff is commenced without the take-off speeds having been entered into the aircraft's systems. Qantas advised that their standard operating procedures have been updated to avoid any misinterpretation of the required actions in the case of a runway change.

More information and a copy of the investigation report can be found at ATSB website.