On October 14, 2004, a Boeing 747-244SF was being operated as a non-scheduled international cargo flight from Halifax, N.S., to Zaragoza, Spain. At about 0654 coordinated universal time (UTC), 3:54 Atlantic Daylight Time (ADT), the aircraft attempted to take off from Runway 24 at the Halifax International Airport. The aircraft overshot the end of the runway for a distance of 825 ft, became airborne for 325 ft, and then struck an earthen berm. The aircraft’s tail section broke away from the fuselage and the aircraft remained in the air for another 1 200 ft before it struck terrain and burst into flames. The aircraft was destroyed by impact forces and a severe post-crash fire. All seven crew members suffered fatal injuries.

Findings as to causes and contributing factors

1.        The Bradley take-off weight was likely used to generate the Halifax take-off performance data, which resulted in incorrect V speeds and thrust setting being transcribed to the take-off data card.

2.        The incorrect V speeds and thrust setting were too low to enable the aircraft to take off safely for the actual weight of the aircraft.

3.        It is likely that the flight crew member who used the Boeing Laptop Tool (BLT) to generate take-off performance data did not recognize that the data were incorrect for the planned take-off weight in Halifax. It is most likely that the crew did not adhere to the operator’s procedures for an independent check of the take-off data card.

4.        The pilots did not carry out the gross error check in accordance with the company’s standard operating procedures (SOP), and the incorrect take-off performance data were not detected.

5.        Crew fatigue likely increased the probability of error during calculation of the take-off performance data, and degraded the flight crew’s ability to detect this error.

6.        Crew fatigue, combined with the dark take-off environment, likely contributed to a loss of situational awareness during the take-off roll. Consequently, the crew did not recognize the inadequate take-off performance until the aircraft was beyond the point where the takeoff could be safely conducted or safely abandoned.

7.        The aircraft’s lower aft fuselage struck a berm supporting a localizer antenna, resulting in the tail separating from the aircraft, rendering the aircraft uncontrollable.

8.        The company did not have a formal training and testing program on the BLT, and it is likely that the user of the BLT in this occurrence was not fully conversant with the software.

While we would have liked to publish the remainder of the TSB’s extensive conclusions on this report, space considerations prevented us to do so. Therefore our readers are encouraged to read the complete Final Report of this major investigation in the Air Reports section of the TSB Web site: www.tsb.gc.ca/en/reports/air/2004/a04h0004/a04h0004.asp.