Serious incident Boeing 737-8K5 (WL) G-FDZS,
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ASN Wikibase Occurrence # 388602
 
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Date:Monday 4 March 2024
Time:11:04
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different    
Boeing 737-8K5 (WL)
Owner/operator:TUI Airways
Registration: G-FDZS
MSN: 35147/2866
Year of manufacture:2009
Fatalities:Fatalities: 0 / Occupants: 169
Aircraft damage: None
Category:Serious incident
Location:Bristol Airport (BRS/EGGD), Lulsgate, Bristol, Gloucestershire -   United Kingdom
Phase: Taxi
Nature:Passenger
Departure airport:Bristol Airport (BRS/EGGD)
Destination airport:Las Palmas-Airport de Gran Canaria (LPA/GCLP)
Investigating agency: AAIB
Confidence Rating: Information verified through data from accident investigation authorities
Narrative:
A TUI Airways Boeing 737-800, registration G-FDZS performing flight BY-6114 from Bristol,UK to Las Palmas, Canary Islands (Spain) with 163 passengers and 6 crew, was departing Bristol's runway 09, when autothrottle disengaged upon selection of TOGA at the start of the takeoff roll. The crew manually set the thrust to 84.5% N1 (rather than 92.8% N1 as needed) and continued takeoff. The aircraft rotated about 260 meters prior to the end of the runway and crossed the end of the runway at 10 feet AGL. The crew continued the flight to Las Palmas although whenever they tried to engage auto thrust, it disconnected again. The aircraft landed safely in Las Palmas. The incident was the subject of an AAIB investigation, and the following is the AAIB Special Bulletin, published on 30 May 2024 about the incident:

"AAIB Special Bulletin S1/2024: Boeing 737-8K5, G-FDZS: A Special Bulletin concerning the failure of the auto throttle on a Boeing 737-8K5 (G-FDZS), on takeoff from Bristol Airport, 4 March 2024.

The aircraft was prepared for a flight from Bristol Airport to Las Palmas, Gran Canaria with six crew and 163 passengers. The flight was a line training sector for a new captain who was sitting in the left seat, with a training captain, acting as aircraft commander, sitting in the right seat.

Having completed their pre-flight preparation, the aircraft left the stand at Bristol to taxi to Runway 09 at 10:41 hrs. The A/T arm switch on the Mode Control Panel (MCP) had been set to ARM during the before start procedures in accordance with the operator’s SOPs.

The aircraft taxied onto Runway 09 at 1104 hrs and was cleared for takeoff shortly afterwards. The left seat pilot handed control of the aircraft to the right seat pilot who was to be PF for the sector. The PF advanced the thrust levers to 40% N1 and paused for the engines to stabilise before pressing the Takeoff/Go-Around switch (TOGA) which engages both the A/T in N1 mode and the autopilot/flight director system (AFDS) in takeoff mode.

At this point, the A/T disengaged with an associated warning and the A/T arm switch on the MCP was re-engaged by the PM almost immediately afterwards. At the same moment the PF advanced the thrust levers manually towards the required takeoff setting before releasing the thrust levers for the left seat occupant to control in accordance with the SOPs.

When the A/T arm switch was re-engaged on the MCP after initial A/T disengagement, it did not control the thrust lever servos as the pilots expected and instead entered an armed mode. As a result, the thrust levers did not advance to the required thrust setting and neither pilot moved them from the position the PF had set them to. Despite the SOP requiring that the thrust is set by 60 kt and checked as correct at 80 kt, the incorrect setting was missed by both pilots.

This resulted in the aircraft takeoff being conducted with significantly less thrust than required, 84.5% N1 was used instead of 92.8% N1, with the associated reduction in aircraft performance.

The rotation point was 260 m from the end of the runway and the aircraft crossed the end of the runway at a height of approximately 10 ft. Both pilots had noted how close to the end of the runway they were. The flight to Las Palmas was uneventful apart from several attempts to re-engage the A/T and subsequent disengagements"

=Damage sustained to airframe=
Per the AAIB Report "none reported"

Accident investigation:
cover
  
Investigating agency: AAIB
Report number: 
Status: Preliminary report
Duration: 2 months
Download report: Preliminary report

Sources:

1. AAIB Special Bulletin S1/2024: https://assets.publishing.service.gov.uk/media/665092d816cf36f4d63eba8f/S1-2024__Boeing_737-8K5_G-FDZS.pdf

Location

Media:

Revision history:

Date/timeContributorUpdates
31-May-2024 05:55 Dr. John Smith Added
31-May-2024 05:56 ASN Updated [Aircraft type, Operator, Source, Embed code, Narrative, Accident report]
31-May-2024 05:58 ASN Updated [Embed code, Accident report]

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