What happened
On 30 July 2023, an Airbus A320-214, registration G-EJCI, was performing a commercial passenger flight from Toulouse-Blagnac Airport to London Gatwick. During pre-flight preparations, the crew calculated takeoff performance for intersection N2 of Runway 32R, which provided 2,300 m of available distance.
During taxi, the crew requested to use intersection N2. While the Ground Controller approved the request and instructed the aircraft to contact the Tower upon reaching N2, the aircraft actually entered the runway via the N4 intersection. This error reduced the available takeoff distance by approximately 500 m. The Tower Controller, who was not visually monitoring the aircraft due to low traffic density and a lack of concentration at the start of the shift, issued the takeoff clearance for N2. The crew initiated the takeoff run from the N4 position, rotating with only 500 m of runway remaining. The crew realized the error during the climb phase.
The investigation
The investigation, delegated to the AAIB by the French BEA, examined the flight crew's actions, the air traffic control environment, and the technical tools used during the departure. Investigators looked into the crew's mental model of the airport layout, the workload levels of both the pilots and the controllers, and the design of the FlySmart+ application used for performance calculations. The investigation also reviewed the staffing levels in the Toulouse control tower at the time of the incident.
Findings
- The crew's mental model was inaccurate because the FlySmart+ application only displayed takeoff options for N1 and N2, omitting the N4 intersection.
- The crew failed to verify the takeoff intersection because the co-pilot was heavily focused on completing checklists during a compressed timeframe.
- High workload and an "expeditious mindset" driven by previous flight delays contributed to the error.
- The Tower Controller did not visually monitor the aircraft's progress, failing to notice the incorrect entry at N4.
- The co-pilot experienced high task saturation and did not communicate a feeling of being overwhelmed to the commander.
- The use of the airport chart was likely not active on the electronic flight bag during taxi, reducing situational awareness regarding the taxi route.