Incorrect data partly to blame for fatal Halifax plane crash - investigators


Thursday, Jun 29, 2006
Police patrol the debris field of a downed 747 cargo plane near the airport in Halifax in October, 2004.
  HALIFAX (CP) - Incorrect data entered into takeoff software was partly to blame for the fiery crash of a Boeing 747 cargo plane in Halifax that killed seven crew members, the Transportation Safety Board said Thursday when it released its final report into the accident.

The board found that crew fatigue aboard the MK Airlines Ltd. jet "increased the probability" of making such a crucial mistake.

The report says the crew failed to notice that the throttles for the engines were set too low before the crash occurred in October 2004.

"Our investigation . . . underscored the importance of well-rested, attentive and fully trained crews," said

Wendy Tadros, the board's acting chairwoman. "It also showed us that airline companies must actively ensure that their crews adhere to proper procedures."

Gatineau - The fatal crash of an MK Airlines Limited freight transport plane at Halifax International Airport, Nova Scotia, underscores the need for better systems to ensure correct take-off speed and thrust, the Transportation Safety Board of Canada (TSB) said in its final report (A04H0004) released today.
The report concluded that the speed and thrust settings selected by the crew members in preparation for their October 14, 2004 flight to Spain were incorrect for the weight of the Boeing 747-244SF, a converted jumbo jet. The aircraft did not achieve sufficient altitude, hit a berm at the end of the runway, crashed into the adjacent forest, and burned. All seven crew members died.
The investigation found that the crew did not receive adequate training on the Boeing Laptop Tool, a computer program used to calculate the take-off velocity and power necessary in light of factors such as fuel weight, payload, and environmental conditions. TSB investigators found that crew fatigue and a dark take-off environment may have compounded the likelihood of error. As a consequence, the Board called on Canadian and international regulatory authorities to ensure that crews of large aircraft will be alerted in time when there is not enough power to take off safely.
The Board recommended that: The Department of Transport, in conjunction with the International Civil Aviation Organization, the Federal Aviation Administration, the European Aviation Safety Agency, and other regulatory organizations, establish a requirement for transport category aircraft to be equipped with a take-off performance monitoring system that would provide flight crews with an accurate and timely indication of inadequate take-off performance.
"We are asking the world's regulatory agencies to ensure that crews of large aircraft will be alerted in time when there is not enough power to take off safely," said TSB Acting Chair Wendy Tadros. "Our investigation uncovered the causes and contributing factors. We now need to work to ensure that this type of accident doesn't happen again."

MK Airlines, a British-based company, has said it believes the crew received adequate rest and that it provided them with adequate training.

Investigators had earlier concluded the heavily laden aircraft simply didn't have

 enough speed or power to make it off the runway.

The board is recommending that international aviation authorities require cargo aircraft to be equipped with a device that would sound an alarm when there is not enough power to take off safely.

"This investigation has shown that the problem we are addressing today is a pervasive problem," said Tadros. "Our recommendation has the potential to make air travel safer, not only here in Canada, but around the world."

Tadros said the board found evidence of 12 similar accidents worldwide that cost 300 lives.

"This is why we believe we need an additional line of defence - a mechanism to catch the unexpected errors," she told a news conference.

The MK Airlines plane, carrying lobsters and tractor parts, failed to lift off and dragged its tail along the runway before breaking up and erupting into flames in a wooded area near Halifax International Airport.

The plane's entire crew was killed, including Capt. Michael Thornycroft, a resident of South

 Africa, as well as Capt. David Lamb and flight engineers Pete Launder and Steve Hooper, all residents of Zimbabwe.

Also killed were ground engineer Mario Zahn, a German who lived in South Africa, and loadmaster Chris Strydom and first officer Gary Keough, both of Zimbabwe.


from this link

the TSB Report