What happened
On 12 July 2006, an Air Canada Embraer 190-100, registered C-FHIU, was preparing for a scheduled flight from Edmonton, Alberta, to Toronto, Ontario. The flight was carrying 81 passengers and five crew members. During the turnaround in Edmonton, the crew had to manage several non-standard tasks, including a power-down of the aircraft to clear a maintenance fault and managing a defective power cord for an electronic flight bag (EFB) laptop.
During the pre-flight preparations, the first officer calculated take-off performance data using the captain's laptop. During this process, an error was introduced when the fuel on board was recorded as 3,700 kg instead of the planned 10,200 kg. When the departure runway was changed by air traffic control, the captain recalculated the performance data using the same incorrect fuel figure. This resulted in incorrect thrust settings and V-speeds being entered into the flight management system.
At 1011 mountain daylight time, the aircraft commenced its take-off from Runway 12. During the rotation phase, the crew noticed that the aircraft's pitch response was abnormal, feeling as though the plane was out of trim and slow to react. The crew identified the discrepancy once the aircraft reached 10,000 feet and notified company dispatch. The flight proceeded to Toronto without further incident.
The investigation
The TSB examined the sequence of events leading to the incorrect data entry and the effectiveness of the existing safety barriers. The investigation looked into the workload of the crew, which had been increased by several factors, including a defective laptop cord, an absent flight service director, and a water overflow issue in the cabin.
Investigators also reviewed the design of the operational flight plan and the company's standard operating procedures (SOPs). The investigation noted that while the crew deviated from SOPs by not having the pilot not flying verify the calculations, the physical layout of the flight plan made it difficult to spot errors. The performance data was transcribed to the top right corner of the page, while the planned weights were located in the bottom left, preventing an easy side-by-side comparison.
Findings
- The crew took off using incorrect take-off performance references.
- A combination of crew deviations from SOPs and the design of the operational flight plan prevented the identification of a significant weight discrepancy.
- An error in the fuel weight entry led to the use of lower-than-required thrust and inappropriate takeoff speeds.
- The aircraft lacked a system to provide the crew with a timely indication of inadequate take-off performance.
Safety action
Following the investigation, Air Canada engaged with manufacturers to develop gross error checking capabilities for automated data entry within the flight management system.