Emirates A345 Tail Strike Captain breaks his silence
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My heart goes out to the crew involved. No one makes deliberate mistakes in the cockpit. We all fly to the best of our abilities.
When the airline has a PIC with 3.5 hours sleep to their name there are more at fault than the crew (despite this being common from what I hear).
The interim report said:
98.9 hrs in last 30 days, 229 in the last 90
Thrust levers moved to the TOGA detent, aircraft passes end of runway 16.
All facts above from the independent sources. Why not wait for the ATSB report and then judge whether it was a reasonable string of errors for the crew to make, whether they spotted any of the clues to their predicament and what other factors are involved. Maybe it wasn't the big bad airline that was at fault, maybe they contributed but blind defence of the crew is equally silly particularly based on a tabloid newspaper article.
The same thread has been going on in the ME forum forever.
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"Why not wait for the ATSB report and then judge whether it was a reasonable string of errors for the crew to make, whether they spotted any of the clues to their predicament and what other factors are involved. Maybe it wasn't the big bad airline that was at fault, maybe they contributed but blind defence of the crew is equally silly particularly based on a tabloid newspaper article."
But that is just the point. The company sacked the pilots before a full investigation, and any acknowledgement that there might be underlying root causes. Contemporary safety management recognises the interelatedness of the human-machine-environment interface, the importance of culture and unavoidability of human error. There may be inmportant lessons to learn regarding the nature of this work involving multiple time-zones, inability to sleep and fatigue. So the wrong decisions regarding fitness to fly may have already stemmed from fatigue.
Clearly, the company has already made up its mind. That says to me a company with a bad safety culture. I'm very impressed with the commentary from older pilots on this forum regarding flying ability and personal responsibility, but refusal to accept the complex implications of fatigue states is antiquated, as is the notion that an organisation is never implicitly responsible for its employee's errors.
But that is just the point. The company sacked the pilots before a full investigation, and any acknowledgement that there might be underlying root causes. Contemporary safety management recognises the interelatedness of the human-machine-environment interface, the importance of culture and unavoidability of human error. There may be inmportant lessons to learn regarding the nature of this work involving multiple time-zones, inability to sleep and fatigue. So the wrong decisions regarding fitness to fly may have already stemmed from fatigue.
Clearly, the company has already made up its mind. That says to me a company with a bad safety culture. I'm very impressed with the commentary from older pilots on this forum regarding flying ability and personal responsibility, but refusal to accept the complex implications of fatigue states is antiquated, as is the notion that an organisation is never implicitly responsible for its employee's errors.
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Agree about the sleep (despite the tone of my earlier post).
I don't know much about the long haul airline industry, and I'm sure the company provides the required rest period. Mainly what I feel is that dismissing the pilots outright won't help improve the situation.
For those in the big-plane industry is dismissal the usual route for an incident like this?
I don't know much about the long haul airline industry, and I'm sure the company provides the required rest period. Mainly what I feel is that dismissing the pilots outright won't help improve the situation.
For those in the big-plane industry is dismissal the usual route for an incident like this?
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Bud,
Wouldn't disagree. Emirates safety culture has been dented but whilst accepting the principle in any other industry if you cost your employer money through reckless action you would be locked up. Look at the financial industry.
I do not know if they were reckless but by 'resigning' they retained benefits and have a chance of getting their lives back. If they were found culpably negligent and then fired, the chances of getting a job in the future would I suspect be reduced. If a decision was taken that they were legally responsible for the damage under UAE law, I shudder to think what might result.
Maybe there are other angles to the story.
Wouldn't disagree. Emirates safety culture has been dented but whilst accepting the principle in any other industry if you cost your employer money through reckless action you would be locked up. Look at the financial industry.
I do not know if they were reckless but by 'resigning' they retained benefits and have a chance of getting their lives back. If they were found culpably negligent and then fired, the chances of getting a job in the future would I suspect be reduced. If a decision was taken that they were legally responsible for the damage under UAE law, I shudder to think what might result.
Maybe there are other angles to the story.
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Apparently these guys were sacked not because they made a mistake but because they did not do the required crosschecks. The CVR was enough for the airline to immediately give them walking papers.
Also, the EK pilots are nonunion, living in a somewhat benevolent dictatorship where the govenment and the airline are both headed by Sheikh Mak. If things go south, you don't have a lot of job protection.
Also, the EK pilots are nonunion, living in a somewhat benevolent dictatorship where the govenment and the airline are both headed by Sheikh Mak. If things go south, you don't have a lot of job protection.
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Schnowzer:
Is it a crew that is waiting in Melbourne, or are they coming from Dubai?
Just to clarify.
Thanks in advance
Colocolo
The onward flight to NZ done by the augment crew is much more tiring.
Is it a crew that is waiting in Melbourne, or are they coming from Dubai?
Just to clarify.
Thanks in advance
Colocolo
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It's only too easy for some of you guys to sit in your comfy armchairs at home and pick the bones out of this.
Layovers of 18 to 30 hours should be looked at very closely. How can anyone sleep twice within that period? Having arrived in Melbourne after a long duty period; gone to bed because you're tired, and then try and get another sleep period in the bank before you go and fly again... it's impossible. Do this several times and the effects are cumulative... fatigue has set-in and you will make mistakes.
This isn't a first and it won't be the last!
Until such time as you too have experienced a batch of 24 hour layovers and the fatigue that goes with it... don't preach at this guy for making what was a simple mistake.
As for those who advocate 'going sick' and staying at the hotel... EK management will hand you your coat when you return to base. The airline is equally to blame!
TCF
Layovers of 18 to 30 hours should be looked at very closely. How can anyone sleep twice within that period? Having arrived in Melbourne after a long duty period; gone to bed because you're tired, and then try and get another sleep period in the bank before you go and fly again... it's impossible. Do this several times and the effects are cumulative... fatigue has set-in and you will make mistakes.
This isn't a first and it won't be the last!
Until such time as you too have experienced a batch of 24 hour layovers and the fatigue that goes with it... don't preach at this guy for making what was a simple mistake.
As for those who advocate 'going sick' and staying at the hotel... EK management will hand you your coat when you return to base. The airline is equally to blame!
TCF
Flaperon777
What has de-rate got to do with the basics?
On the 744 a 100T difference in T/O wt can give you V1,VR and V2 numbers that are approx 25-30kts different. Using a ZFW of 230t, fuel 120t you should get roughly 150/160/170. Take off 100t and you will get 125/130/145 ish.
That to me is not insignificant.
What has de-rate got to do with the basics?
On the 744 a 100T difference in T/O wt can give you V1,VR and V2 numbers that are approx 25-30kts different. Using a ZFW of 230t, fuel 120t you should get roughly 150/160/170. Take off 100t and you will get 125/130/145 ish.
That to me is not insignificant.
The pilot stated it was a 24 hour layover, the most common in long haul and the worst for getting rest. CAD371 reduces duty times for rest periods of 18 to 30 hours as it is recognised that the quality of rest is reduced, or quality rest hard to take.
Don't understand that? The take this example of a pattern I was very familiar with.
Departure from LHR at about 7pm UK time. Land at JFK about 10pm NY time, but 2am body clock time. By the time you get to the hotel, it's now 4am body time. Go to bed. Wake up at 3am NY time which is 8am body time because it's when you usually get up and the wake up time your circadian rhythem is programmed for. So you've just had four hours sleep.
You mooch around for most of the morning, then at about 1pm NY time you go back to bed and try to sleep. Except you can't because it's 6pm body time and you're circadian rythem says it's not time to sleep yet.
It's now 5pm NY time and the wake up call goes off which is a bit of a b#gger because you finally dropped off to sleep about 20 minutes ago. You get up, go to the airport for the 8pm NY departure time, for which you aren't feeling at your best for because it's now 1am UK and body time and you have had 4 hours and twenty minutes of low quality sleep in the last 36. You now fly for 7 hours back to LHR landing at 8am feeling like death.
Now imagine you do this 5 or 6 times a month, for 900 flying hours a year, but not always to New York. Perhaps to other time zones in the opposite direction. Now some of you (who obviously haven't flown long haul as a pilot) may begin to understand how this pilot felt at the start of his duty.
Sure, it's easy to say he should have got some rest in his 24 hours off, but that's very hard when your body is saying it's not time to sleep. And he could have called in and told crewing that he wasn't rested enough to fly. But many long haul pilots get to this level of fatigue and if this was done then the majority of long haul flights would be cancelled.
There were three pilots on this crew. All managed to let this error slip through the stated four levels of protection. There is no disputing that they
up. But rather than just blame the pilots solely, lets look at the other factors which led to this accident. Because unless these problems are addressed, it will happen again. Maybe nextime with fatal consequences.
(An almost duplicate post of Chitterne's - he posted his while I was writing mine!)
Don't understand that? The take this example of a pattern I was very familiar with.
Departure from LHR at about 7pm UK time. Land at JFK about 10pm NY time, but 2am body clock time. By the time you get to the hotel, it's now 4am body time. Go to bed. Wake up at 3am NY time which is 8am body time because it's when you usually get up and the wake up time your circadian rhythem is programmed for. So you've just had four hours sleep.
You mooch around for most of the morning, then at about 1pm NY time you go back to bed and try to sleep. Except you can't because it's 6pm body time and you're circadian rythem says it's not time to sleep yet.
It's now 5pm NY time and the wake up call goes off which is a bit of a b#gger because you finally dropped off to sleep about 20 minutes ago. You get up, go to the airport for the 8pm NY departure time, for which you aren't feeling at your best for because it's now 1am UK and body time and you have had 4 hours and twenty minutes of low quality sleep in the last 36. You now fly for 7 hours back to LHR landing at 8am feeling like death.
Now imagine you do this 5 or 6 times a month, for 900 flying hours a year, but not always to New York. Perhaps to other time zones in the opposite direction. Now some of you (who obviously haven't flown long haul as a pilot) may begin to understand how this pilot felt at the start of his duty.
Sure, it's easy to say he should have got some rest in his 24 hours off, but that's very hard when your body is saying it's not time to sleep. And he could have called in and told crewing that he wasn't rested enough to fly. But many long haul pilots get to this level of fatigue and if this was done then the majority of long haul flights would be cancelled.
There were three pilots on this crew. All managed to let this error slip through the stated four levels of protection. There is no disputing that they
up. But rather than just blame the pilots solely, lets look at the other factors which led to this accident. Because unless these problems are addressed, it will happen again. Maybe nextime with fatal consequences.(An almost duplicate post of Chitterne's - he posted his while I was writing mine!)
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Well said Dan.
Folks, those of you who don't operate as crew in the longhaul area and those of you who fly substantially less than a full 900 hour roster really shouldn't comment on the management of rest patterns on the dreaded 24-hour slips.
It frequently just isn't possible to sleep on demand for a few hours before pickup.
The example Dan gives which is quite typical, ie Europe to US Eastern Seaboard with a red eye flight home after 24 hours. In that rotation, the flight home is exactly when your body is screaming at you to go to bed and sleep.
And as for those comments/suggestions to go 'crew fatigue' - it's the job, you have to find a way to cope, often by catching a half hour of controlled rest at a quiet time in the cruise in the seat, and yes, tell your oppo that you feel like death warmed up and take things slowly.
If things go wrong then the adrenalin rush will kick in and your alertness will increase immediately.
In the MEL case, it seems to me that a lack of rigour in the checking process possibly due to defficient SOP's and a possible lack of mental modelling for the take off let them down.
Bad show on the airline management though, nonetheless.
[Edited to add: 2008 = 870 flying hours, 520 time zone changes, 57 nights out of bed = lost sleep]
Folks, those of you who don't operate as crew in the longhaul area and those of you who fly substantially less than a full 900 hour roster really shouldn't comment on the management of rest patterns on the dreaded 24-hour slips.
It frequently just isn't possible to sleep on demand for a few hours before pickup.
The example Dan gives which is quite typical, ie Europe to US Eastern Seaboard with a red eye flight home after 24 hours. In that rotation, the flight home is exactly when your body is screaming at you to go to bed and sleep.
And as for those comments/suggestions to go 'crew fatigue' - it's the job, you have to find a way to cope, often by catching a half hour of controlled rest at a quiet time in the cruise in the seat, and yes, tell your oppo that you feel like death warmed up and take things slowly.
If things go wrong then the adrenalin rush will kick in and your alertness will increase immediately.
In the MEL case, it seems to me that a lack of rigour in the checking process possibly due to defficient SOP's and a possible lack of mental modelling for the take off let them down.
Bad show on the airline management though, nonetheless.
[Edited to add: 2008 = 870 flying hours, 520 time zone changes, 57 nights out of bed = lost sleep]
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Dan Winterland,
A frighteningly accurate post.
As I read it, I found myself chuckling, particularly at the "wake-up call going off 20 min after you have fallen asleep" bit. Last time in New York, your timeline is almost exactly what happened to me. I am about to go eastbound now with an 8hr time change, though thankfully with a longer slip which helps with the sleep.
The cumulative effects of duties like this should not be underestimated when it comes to functioning well on the flight deck. However, the more enlightened airlines recognise this to some extent and put in place SOPs to prevent the kind of error that appears to have been made here. If those SOPs are not adhered to, then the crew are on thin ice when it comes to any subsequent incident.
FF
A frighteningly accurate post.
As I read it, I found myself chuckling, particularly at the "wake-up call going off 20 min after you have fallen asleep" bit. Last time in New York, your timeline is almost exactly what happened to me. I am about to go eastbound now with an 8hr time change, though thankfully with a longer slip which helps with the sleep.
The cumulative effects of duties like this should not be underestimated when it comes to functioning well on the flight deck. However, the more enlightened airlines recognise this to some extent and put in place SOPs to prevent the kind of error that appears to have been made here. If those SOPs are not adhered to, then the crew are on thin ice when it comes to any subsequent incident.
FF
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What's wrong with this forum?
Top Bunk
Agree with everything you said.
What's up with this forum? That's two accurate and informative posts in a row that appear to have been made by people who have actually done the job.
People will start talking!
Agree with everything you said.
What's up with this forum? That's two accurate and informative posts in a row that appear to have been made by people who have actually done the job.
People will start talking!
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Dan W, great post, and very accurate. What's the old saying about long haul pilots? "The best two hours sleep you'll ever get on an oversight usually starts 20 minutes before your wakeup call."
In the case of Emirates pilots doing DXB-JFKs (or DXB-MELs), with Dubai being UTC+4, you can add another four hours to the "out of circadian synch" they suffer than a pilot operating LHR-JFK - and that's not taking into account the absolutely bloody awful unique-to-EK "aft torpedo tube" crew rest with no sit up capability that the EK777s have. (The 354's crew rest is somewhat better, but not a lot.)
-------
Airbubba you are correct in what you say, ("Apparently these guys were sacked not because they made a mistake but because they did not do the required crosschecks.) However, as I understand it, you are incorrect in saying
As I understand it - and I heard this straight from the horse's mouth, (i.e., Mr Ed himself), so it must be 100% true - 
after the sorry experience of the police and the lawyers getting involved and laying criminal crarges against a Kiwi Dash 8 crew some years ago, the Oz investigators have not made the CVR available to anyone, including EK management.
However, at the time of this accident (and perhaps even moreso after it), I think it would be pretty safe to assume that with four EK pilots (just about any four EK pilots!!) gathered in one small cockpit, something politically incorrect regarding EK senior management would likely to be said by at least one of them.
I too (along with about 30 other captains at that particular meeting) heard directly from Mr Ed a very different version of events about the way the operating crew volunteered their resignations than what the captain has told the Sunday Herald. As stated above in my first paragraph, of course I am certain - 100% - that the reporter must have got it wrong, because, like every other EK pilot, I know Mr Ed would never lie to me.
In the case of Emirates pilots doing DXB-JFKs (or DXB-MELs), with Dubai being UTC+4, you can add another four hours to the "out of circadian synch" they suffer than a pilot operating LHR-JFK - and that's not taking into account the absolutely bloody awful unique-to-EK "aft torpedo tube" crew rest with no sit up capability that the EK777s have. (The 354's crew rest is somewhat better, but not a lot.)
-------
Airbubba you are correct in what you say, ("Apparently these guys were sacked not because they made a mistake but because they did not do the required crosschecks.) However, as I understand it, you are incorrect in saying
The CVR was enough for the airline to immediately give them walking papers.
after the sorry experience of the police and the lawyers getting involved and laying criminal crarges against a Kiwi Dash 8 crew some years ago, the Oz investigators have not made the CVR available to anyone, including EK management.However, at the time of this accident (and perhaps even moreso after it), I think it would be pretty safe to assume that with four EK pilots (just about any four EK pilots!!) gathered in one small cockpit, something politically incorrect regarding EK senior management would likely to be said by at least one of them.
I too (along with about 30 other captains at that particular meeting) heard directly from Mr Ed a very different version of events about the way the operating crew volunteered their resignations than what the captain has told the Sunday Herald. As stated above in my first paragraph, of course I am certain - 100% - that the reporter must have got it wrong, because, like every other EK pilot, I know Mr Ed would never lie to me.
Last edited by Wiley; 17th Jul 2009 at 07:20.
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Dan/Topbunk,
Excellent posts and the main points very well made. However, to keep the thread accurate. This was a 4 man crew, the operating crew having just had 38 hours in MEL.
I do not know the crews previous rosters but having done 90+ hours in 28 days then the Captain was probably fairly fatigued. Like it or not, given the present climate and rules, this is part of ULR flying. As a professional one is in a position (obliged) to mitigate this fatigue risk. How that is done is up to the individual. As a starter for 10 though I would suggest that recognising that you are not always at your peak and therefore a more pedantic approach to SOPs may not be a bad idea.
Excellent posts and the main points very well made. However, to keep the thread accurate. This was a 4 man crew, the operating crew having just had 38 hours in MEL.
I do not know the crews previous rosters but having done 90+ hours in 28 days then the Captain was probably fairly fatigued. Like it or not, given the present climate and rules, this is part of ULR flying. As a professional one is in a position (obliged) to mitigate this fatigue risk. How that is done is up to the individual. As a starter for 10 though I would suggest that recognising that you are not always at your peak and therefore a more pedantic approach to SOPs may not be a bad idea.
Sure, it's easy to say he should have got some rest in his 24 hours off, but that's very hard when your body is saying it's not time to sleep. And he could have called in and told crewing that he wasn't rested enough to fly. But many long haul pilots get to this level of fatigue and if this was done then the majority of long haul flights would be cancelled.
I think you get used to running at 80% and make allowances in the way you operate. I get asked a lot, as I'm a LH pilot, 'What's the secret of overcoming tiredness and jet lag?' and I say, 'There isn't one: you just know how you'll be feeling in advance and make allowances for it.' A bit like a hangover isn't a great surprise after you've been drunk more than a few times. Of course this includes all the things like exercise, good diet and (attempted) rest but as diurnal mammals we are just not built to function well during our personal 'night'.
I remember when I flew SH, reading the company incidents digest and being amazed at some of the things that went on in LH. Now, having got the t-shirt, I'm amazed that there are so few...
And as for those comments/suggestions to go 'crew fatigue' - it's the job, you have to find a way to cope, often by catching a half hour of controlled rest at a quiet time in the cruise in the seat, and yes, tell your oppo that you feel like death warmed up and take things slowly.
If things go wrong then the adrenalin rush will kick in and your alertness will increase immediately.
In the MEL case, it seems to me that a lack of rigour in the checking process possibly due to defficient SOP's and a possible lack of mental modelling for the take off let them down.
If things go wrong then the adrenalin rush will kick in and your alertness will increase immediately.
In the MEL case, it seems to me that a lack of rigour in the checking process possibly due to defficient SOP's and a possible lack of mental modelling for the take off let them down.
The cumulative effects of duties like this should not be underestimated when it comes to functioning well on the flight deck. However, the more enlightened airlines recognise this to some extent and put in place SOPs to prevent the kind of error that appears to have been made here. If those SOPs are not adhered to, then the crew are on thin ice when it comes to any subsequent incident.
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Dan W and Chitterne - great posts. I have several mates currently flying the route concerned and all echo what you have posted. Anyone suggesting going crew fatigue is either not in possession of the full facts or is being overly simplistic about the problem, IMO.
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Chitterne - it was a 38 hour layover! And as ULR goes I think one of the more 'restful' patterns that we do at EK..
And it was not a 'mistake' but a major violation of SOP
And it was not a 'mistake' but a major violation of SOP
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I don't know abut the A340 but the A320 series has gross weight calculated by the FACs. I generally see a 2 to 4000 pound difference in the "paper" weights the load controllers calculate for flight.
The Captain evidently called for rotation at the predetermined (wrong) weight. They should have gone from Flex to Toga at that point, if the jet won't fly off at the normal rotation rate.
I've had an experience in the Airbus where the FAC weight was later found to be considerably greater than the load sheet (Specific Airport where an error in loading process was ultimately discovered)
But, during the take-off, we (Both crew) noticed what appeared as "Lesser" performance than expected at an early stage of the take-off (100 knot call-out) and reacted at that time. Take-off, flight and landing were uneventful. Similarly, this was an airport that we both operated from regularly, and the load sheet weight was "Typical" for that station, although the actual weight was much greater.
I only reflect on this because I'm a bit surprised that a crew with this experience level didn't see it coming sooner.
That said, I completely agree that this could happen to anyone. Thankfully, the only damage was to aircraft and pride.
Just my 2 cents worth....
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TopBunk and Dan - Spot on
WhiteKnight - Why so judgemental and protective of EK
I would hope we as an industry have moved on from "Pilot Error -> Case Closed" - We are in the era of the organizational responsibility now
WhiteKnight - Why so judgemental and protective of EK
I would hope we as an industry have moved on from "Pilot Error -> Case Closed" - We are in the era of the organizational responsibility now