History of the Flight
The crew reported for duty at 0245 UTC on 28 October 2008 at Sangster International Airport, Jamaica, for a flight to the UK. The flight crew consisted of a commander, a co-pilot, and a supernumerary pilot (an A330 line captain and qualified A320/A321 training captain).
During pre-flight preparation, the crew could not locate the aircraft's performance manual. At about 0400 UTC, the commander contacted the operator's flight dispatch department in the UK by mobile telephone, requesting takeoff performance figures using the Flight Operations Versatile Environment (FOVE) computerised system. The dispatcher in the UK calculated the figures and read them back to the commander. The telephone was then handed to the co-pilot to repeat the process as a cross-check. Both pilots reported receiving the same takeoff performance figures, which were entered into the Flight Management Guidance System (FMGS).
The remainder of pre-flight preparation was completed without incident, and all three pilots briefed for departure from Runway 07. None of the performance figures entered into the FMGS were considered abnormal for the aircraft's planned weight.
Takeoff commenced at 0426 UTC with the commander as handling pilot. The aircraft accelerated normally, and the co-pilot made standard calls at 100 kt and V1/VR. The commander noted the calls followed closely. On hearing 'rotate', he pulled back on his sidestick, pitching to about 10° nose up, but stated the aircraft 'did not feel right' and instinctively selected TOGA (Takeoff/Go-Around) power. The aircraft then became airborne and climbed away safely.
After completing after-takeoff checks, the crew checked the takeoff performance figures using generic data in the FCOM 2 manual carried on the flight deck, revealing significant differences from the figures used for the takeoff.
Airport and Performance Calculations
Sangster International Airport has one runway designated 07/25. The Takeoff Run Available (TORA) for Runway 07 is 2,663 m, with an Accelerate/Stop Distance Available (ASDA) of 2,724 m and an upslope of 0.03%.
The operator's aircraft carried a performance manual with tabulated data for takeoff performance. Crews could also contact the dispatch office for FOVE-calculated data, which was generally used when performance was more limiting.
The FOVE system required input of aircraft data, takeoff weight, weather conditions, and runway information. Output included V1, VR, V2 speeds, and the FLEX temperature for reduced thrust. The system also calculated Green Dot speed, but that function had been disabled on the operator's FOVE system for an unknown reason, and no procedure required passing it to crews.
The FOVE performance log recorded a takeoff mass (TOM) of 120,800 kg, whereas the actual TOM from the aircraft's loadsheet was 210,183 kg. Recalculated with the correct TOM, the output conditions were: FLEX 50°, V1 136 kt, VR 140 kt, V2 147 kt, Config 2, Perf limit wt 236,893 kg. The incorrect figures used for the takeoff were: FLEX 63°, V1 114 kt, VR 114 kt, V2 125 kt, Config 2, Perf limit wt 236,893 kg.
Operator's FOVE Procedure
The operator's Flight Support Procedures Manual contained instructions for dispatchers on using the FOVE system. This manual was intended for ground staff only; flight crews were not provided with a comparable written procedure for obtaining FOVE performance figures.
The procedure required the dispatcher to obtain input figures from the crew, enter them into FOVE, read back the input figures to one crew member as a cross-check, then read back the performance figures. The dispatcher would then request to speak to the other crew member and repeat the process with a second dispatcher (or duty pilot if alone). Two independent sets of performance figures were generated, and the two pilots compared them. If consistent, the figures were entered into the FMGS.
The dispatcher logged input and output on a logsheet, but there was no standard method or requirement for flight crews to record the figures or input information as part of flight documentation. The FOVE procedure did not appear in any flight crew documentation. A flight crew air safety report raised in August 2008 had questioned the cross-check procedure, but no response had been received at the time of this incident.
The operator had no procedure requiring the FOVE-generated Green Dot speed to be passed to crews. Additionally, the procedure did not specify passing any emergency turn procedures, as that information was supposed to be in the onboard performance manual, which the crew could not find.
Post-Incident Actions
The investigation could not identify the exact source of the error. Deficiencies were revealed in the operator's procedures for calculating performance using the FOVE system. A study of previous takeoff performance events showed that the number and potential severity warranted additional safeguards to be identified by industry and required by regulators. Two Safety Recommendations were made.
During the final descent of the flight, the aircraft's performance manual was found; it had been incorrectly stowed amongst navigation charts.
The commander held an Airline Transport Pilot's Licence, was 47 years old, and had 14,500 total flying hours (3,000 on type), with 170 hours in the last 90 days and 40 in the last 28 days.