Investigators have attributed an EasyJet Airbus A320’s wrong-intersection take-off at Toulouse to the crew’s limited attention capacity – a consequence of high workload – and confirmation bias.
The aircraft (G-EJCI) had arrived 90min late into Toulouse on 30 July 2023, putting pressure on the crew during the return service to London Gatwick.
Both pilots completed the performance calculations for a runway 32R take-off from intersection N2, which provided 2,300 distance.
While they discussed the taxiing route, which was short and simple, they did not discuss the location of the intersection – which was not visible from their parking stand.
As the aircraft taxied it was cleared to line up and depart from N2. When the first officer read back the clearance, the aircraft was approaching the N4 intersection.
The crew had used an application known as ‘FlySmart+’ for the take-off preparations which showed the location of intersection N2.
But it did not display intersection N4, because the data was drawn from EasyJet’s operation. EasyJet did not use N4 – from which a 32R take-off is prohibited for jets over 7t – and the application therefore made N4 unavailable to crews.
“It is probable that the incomplete intersection information presented to the crew on the ‘FlySmart+’ app contributed to an inaccurate mental model of the runway layout,” says the UK Air Accidents Investigation Branch.
The high workload conditions, it adds, resulted in attentional capacity limitations and “suboptimal” situational awareness.
“This manifested as an inability to process all relevant environmental information and a failure to perceive and respond to external runway intersection signage,” it states.
As a result, the crew turned towards the N4 intersection holding-point without realising the error. The tower controller did not visually monitor the aircraft and did not notice the wrong turn.
But it left the A320 with a take-off distance some 500m shorter than planned. When the aircraft departed, it rotated with around 500m of runway remaining and passed the upwind end at 180ft.
None of the 182 occupants was injured.
The inquiry says the “challenging” operating environment probably created an “expeditious mindset” with a perceived pressure to “keep the operation flowing”. It says this can lead to task saturation and incorrect priority management.
Combined with an inaccurate mental model, it adds, the pressure left the crew “vulnerable” to confirmation bias – reinforced by the early take-off clearance given just as the aircraft had reached an intersection consistent with the pilots’ shared model of N2’s location.
“It was therefore likely that the crew would focus on confirmatory information that aligned with their existing beliefs,” says the inquiry. The tower’s not monitoring the jet’s progress meant a potential safety barrier was “rendered ineffective”, it adds.
EasyJet responded to the incident with changes to procedures on taxi intentions, and highlighted the risks of intersection departures. The carrier also amended crew information for Toulouse notifying the unavailability of certain runway intersections, and planned to review its ‘FlySmart+’ module to include representation of all intersections.
