EK407 Tailstrike @ ML

[strobes_on]

Loose liver - lets have your in depth analysis then.

Mr. Ed - Some significant thread drift with your "off beat" comments.

To me, a likely scenario with this event is:

1. The crew at some stage may have extracted laptop speeds and FLEX using ZFW as TOW.
2. The FMGC may well have contained the correct weight data (from the flight plan).
3. The PERF T/O page had the incorrect V speeds from the laptop.
4. The crew rotated at the incorrect (low) Vr to a normal pitch attiude.
5. The aircraft flap configuration and speed was inappropriate for flight.
6. When the aircraft wouldn't become airborne, the pitch attitude was increased and the aircraft had a severe tail stirke with possible multiple contacts.
7. The higher FLEX temperature combined with tailstrike drag contributed to the long ground roll.
8. TOGA thrust was probably selected at some stage.

The crew did a remarkable job in a very dynamic situation. After all, they were expecting the aircraft to fly off after rotating at the Vr speed in the PERF T/O page. They were confronted with a situation about which they had no experience. What would we all do ? I wouldn't like to be there.

There probably is an error component on the part of the crew with respect to cross checking (no idea what the EK checking procedure REALLY is) . But I bet there are much greater systemic issues for which management and the company must take responsibility.

I hope the Australian ATSB is able to overcome Dubai Inc. in arriving at a final report that tackles the difficult and overriding issues of corporate errors and cover ups.

As a final comment, it's probably now worth including SIM sessions that look at this type of event, and also maybe having an idea of what the V speeds should roughly be at heavy weights.

Discussion about V1 > Vr has no place here.

[Looseliver]

Strobes, no in-depth analysis from me sorry; I don't claim to have superior knowlege on the topic. But I do have a question:

Why isn't there an error message generated when ZFW is used in place of TOW?

[strobes_on]

The laptop will quite happliy generate (albeit much lower) speeds if the ZFW is entered. The FLEX temperature and configuration may also be very different.

[CONF iture]

If Vr is reach as no V1 has yet been encountered, then V1=Vr.
Happens many times ... For you on that day too much asphalt for nothing.

The crew did a remarkable job in a very dynamic situation. After all, they were expecting the aircraft to fly off after rotating at the Vr speed in the PERF T/O page. They were confronted with a situation about which they had no expereince. What would we all do ? I wouldn't like to be there.
I believe both guys were as full back stick they could ...

[crazyaviator]

It all sounds like russian roulette for the PASSENGERS ,,, management telling the pilots how to suck every joule of energy out of every gram of fuel , saving pennies here and dimes there and creating a condition wherin factors lead to increased holes in the cheese model of accident investigation !!!
Put the friggen throttles to MAX take-off power, get off the ground and get climbing early THEN think of saving pennies here and dimes there,,,looks like the cart is ruling the horse NOW !!!

[The Stooge]

Why was my earlier post deleted? How does some tool think that V1 comes after Vr?, so perhaps the given name was quite appropriate.

[KABOY]

I think that your V1 exceeding VR calculation is coming out of performance charts for a certain environmental envelope and maximum certified weights.

If you don't meet these conditions and VR is lower, your V1 is decreased to meet VR.You abort at VR all performance calculations are VOID regardless of V1.

I have seen these charts where our V1 speed would have us airborne and flying almost at V2!

[Sir Richard]

blueloo

Minimum thrust/Maximum reduction depends on several factors including aircraft and engine combination, company preference and regulating authority.

Using one operator's B747-400 for example:-

Fixed Derates of 10% and 20% are available which may then be subject to Assumed Temperature Derates of up to 25%. This gives a maximum reduction of up to 40% from Rated Thrust.

Using 100,000 lb as Rated Thrust makes the sums simple for this example:-

Max Thrust. 100,000 - up to 25% Assumed Temp Reduction = 75,000

10% Derate . 90,000 - up to 25% Assumed Temp Reduction = 67,500

20% Derate . 80,000 - up to 25% Assumed Temp Reduction = 60,000

Oh for a B747-400 with 4 x 100,000 lbs of thrust ! like :mad: off a shovel

You will understand that even on a 4km runway, any significant thrust reduction from that required will fail to accelerate the aircraft sufficiently for normal flight.

[blueloo]

It all sounds like russian roulette for the PASSENGERS ,,, management telling the pilots how to suck every joule of energy out of every gram of fuel , saving pennies here and dimes there and creating a condition wherin factors lead to increased holes in the cheese model of accident investigation !!!
Put the friggen throttles to MAX take-off power, get off the ground and get climbing early THEN think of saving pennies here and dimes there,,,looks like the cart is ruling the horse NOW !!!


Its not just about saving pennies - its about longer engine life, and less exposure to max temps/high egts etc, will hopefully mean less chance of the engine exploding/catastrophic failure on some dark and stormy night at MTOW.

[FrequentSLF]

Its not just about saving pennies - its about longer engine life, and less exposure to max temps/high egts etc, MTOW.

Longer life = pennies

will hopefully mean less chance of the engine exploding/catastrophic failure on some dark and stormy night at

I respectfully disagree, it also pennies here. It means that more parts have to be changed more often to avoid the possibility of exploding/catastrophic failure. The end sum is the number of hours that the engine operates at max trust and take off power

[blueloo]

Longer life = pennies

Absolutely - Yes I don't disagree with this. My comment was not meant to discount this.

it also pennies here. It means that more parts have to be changed more often to avoid the possibility of exploding/catastrophic failure. The end sum is the number of hours that the engine operates at max trust and take off power

Don't disagree with this either.

Both points have been mentioned before.

I still however maintain that less exposure to higher egts and more frequent max thrust means less chance (not no chance) of catastrophic (or even partial) engine failure. Yes, it means more frequent part changes and more cost - but in the intervening periods the engine is still exposed to more extremes.

[CDRW]

Better not let FrequentSLF see the airlines fuel policy ! That we actually take off with less than full tanks - sometimes half tanks, sometimes quarter tanks!!

[FrequentSLF]

Better not let FrequentSLF see the airlines fuel policy ! That we actually take off with less than full tanks - sometimes half tanks, sometimes quarter tanks!!

Funny:D

This post added a lot to the discussion.
Make sure that you do not confuse pounds with kilos when you refuel and you have installed the right fuel gauge. :(

back to the thread

blueloo

but in the intervening periods the engine is still exposed to more extremes

I agree. The fact is that EK will need quite a number of take-offs to recover the money lost to repair the airframe (if will be repaired). Would be interesting to sum up the cost of all tail strikes...I also add that I do not consider myself in danger because of this practice. I am very well aware that anything in the business is driven by the pennies.
The guys in front know what they are doing. However I have a very simple question. If not driven by company policy, would you or not use always max trust?

[judge.oversteer]

All very well with the figures but it might be a bit more helpful if you stated what engine type you are referring to ie. RR, GE. or PW, as they are different figures (de-rate percentages) without getting into pedantics.

Cheers

JO

[suninmyeyes]

Some people on this thread seem to be implying that an intersection takeoff is akin to negligence or poor airmanship.

There are many reasons for intersection takeoffs. Some airports like Chicago and Newark sometimes promulgate on the ATIS that the takeoff will be from an intersection. At other airports like in the Caribbean full length may result in a tricky 180 degree turn at night on a limiting runway, get that wrong and you may close the airport and isolate the island for 24 hours. The 180 degree turns can scuff the main gear badly and if only for a gain of 300 meters it is not worth it. I find those 180 degree turns in a wide bodied Boeing more stressful than any takeoff.

On rare occasions I have used intersection takeoffs to jump a queue, to avoid an aircraft that has stopped on a taxiway with a problem, to make a tight slot, to reduce taxy time or to avoid a tight wingtip clearance situation with a remotely parked aircraft. This is commercial operation. I would not do an intersection takeoff if there was no justification behind it. For those who expound the "runway behind you is useless" mantra if it is perfectly safe to takeoff from the full length of a 2500 meter runway it therefore must be equally safe to take off under the the same conditions 500 meters along a 3000 meter runway. The takeoff is either legal or not legal. Full length with the wrong takeoff data as in the EK case is not safe. An intersection takeoff with the correct figures is safe and legal.

[NO LAND 3]

Better not let FrequentSLF see the airlines fuel policy ! That we actually take off with less than full tanks - sometimes half tanks, sometimes quarter tanks!!

Actually CDRW makes a perfect point about the logic you are using SLF. It's directly analogous, albeit taken to its logical extreme.

Economics are part of life, and in aviation we balance risk vs reward.

[NO LAND 3]

Some people on this thread seem to be implying that an intersection takeoff is akin to negligence or poor airmanship.
I get tired of this old chestnut as well. All very true if you are in your 185 trying to get out of a jungle strip but hardly applicable to airline ops.
To use an extreme example: imagine the runway is fifty miles long. Is it safe to use the intersection halfway down? That would leave twenty five miles. But what about using the runway behind you? Obviously that would be a stupid waste of time and fuel. So in this case all of sane disposition would agree that an intersection departure is appropriate. Now that I have you all in my net, lets start reducing the size of the runway. At some length it will become inappropriate to do an intersection departure. This point will be subjective but for those of us who fly commercially it will be at least a length calculated to provide an adequate margin of safety.
This has nothing to do with the original thread by the way.

[blueloo]

f not driven by company policy, would you or not use always max trust?

I guess would depend on current type..... but no I wouldnt always use max thrust because current aircraft type performs so well, that it would be quite a handful at low weights and max thrust - probably 25+ degrees nose up on takeoff to prevent speed from running away - we operate from low domestic weights ( approx 1hr flights) up to max t/o international flights (10hrs +)

Also a low altitude level of would be fairly uncomfortable for pax from a max thrust takeoff at low weights.

Even with a fairly decent pad/buffer we can get a derated takeoff near the MTOW at times.

[Smilin_Ed]

have I got your message right, Ed? You're suggesting there's someone out there (you?) who'd sit there and conduct a pre-takeoff brief that included the gem that he would abort AFTER the nose wheel was off the ground?

No, Wiley you do not have the message right. V1, by definition, is the speed where, if you have a problem you can still stop in the remaining runway available. If you have a long enough runway you will get to Vr before you reach the point beyond which you don't have room to stop. That means that V1 is beyond Vr, but you have already rotated so it doesn't matter. You never really get to V1, except in the air.

I seem to remember this all started when I suggested that intersection takeoffs are not smart because you have discarded some of your safety factor. SOP won't save you in court.

[Flap62]

Would you,or not use max thrust -


No. Not if I had the choice. In a lightish weight large jet (certainly with 4 engines), and you were to use max thrust and an outboard engine let go at say 50kts - you would not be able to keep it on the runway - you would go off the side - fact! Full power can increase the risk if it is not required.

[John R]

Ed - can you name a major airport with a sufficiently long runway where your V1 theory would be practical.

[Smilin_Ed]

Ed - can you name a major airport with a sufficiently long runway where your V1 theory would be practical.

John, it's not a theory, it's just physics. Someone mentioned earlier V1 = Vr. OK, say it that way. If you're light and have a long runway, you can get to Vr before you reach the point of no return (V1). When you reach Vr then you go.

[Ex Cargo Clown]

Can we please just draw a line under this ridiculous notion that Flex/Assumed Temp thrust reduction is in some way unsafe.

Facts.

It reduces engine wear through lower EGT

It reduces the chances of VMCG problems

It allows far smoother climb out, imagine using full rated thrust in a very lightly loaded 757 with a 400oft level off SID, not fun for anyone

Oddly reduced thrust actually can help in an engine out situation, things happen slower and there is less chance of having control difficulties, plus you still have the protection by virtue of perf calcs that you will make all necessary performance criteria.

So can the idiot SLF who are prattling on about this please stop it.

If you put incorrect performance figures into the FMC and have incorrect speeds then yes, you are in a bit of trouble, but you could just as easily use full rated thrust and have some lunatic pop the speedbrake, retract flaps etc. That will kill you as well.......

As for the V1 > Vr argument, well words fail me. By definition it cannot be, fact.

[ferris]

Clown (how apt)
Can we please just draw a line under this ridiculous notion that Flex/Assumed Temp thrust reduction is in some way unsafe.
I think you are confusing "unsafe" and "increased risk". If you cannot see that there is an increased risk in using reduced thrust that delays rotation until near the end of the available runway for every take off, then I would ask YOU to kindly desist posting.
No one has answered this: Is the increase in risk associated with reducing the thrust for take-off balanced against the decrease in risk (as outlined in the Clown's post) AND the commercial benefit?

If it is, surely as PIC (and the acceptor of the risk), you are aware of the numbers involved, or your employer has told you not to worry, as THEY accept the risk on your behalf?

[Sir Richard]

judge.oversteer

As I said, it was just an example to show that selected thrust may be as low as 60% of maximum thrust. I believe the fixed de-rates may be operator selected depending on the engine type. Even the sub-types may have a different "fixed" de-rate. (T/O 1, T/O 2)

Those percentages were for the RR with the Trent core, G and H cores may be different, as will GE and PW.

Climb de-rates (CLB 1, CLB 2) also washout at different rates.

I am sure an engine specialist can give you more information. :8

[Sir Richard]

FrequentSLF (and others)

I am happy to use reduced thrust whenever it is available. Treat the engines with a little TLC and they will serve you well.:ok:

As many have said, the CORRECT reduced thrust does not reduce safety. :ugh:

We are assuming that some sort of Flex Thrust error caused EK's problem and that the repairs will be expensive individually for EK. You have to compare this with the global savings made by using Flex/De-rate on a daily basis.

[ Compare the useful life of an F1 engine (maybe 1000 miles/6 hours) with that of a well driven taxi (maybe 250,000miles/10,000 hours) and you may see my point of view. :rolleyes: ]

[ferris]

You have to compare this with the global savings made by using Flex/De-rate on a daily basis. Ok then, let's compare. What, exactly, is the saving by using reduced thrust? Your F1 analogy is invalid, because the F1 engine performs at max for it's entire life. Max thrust used for take off would be in a burst of about 1 minute for an entire flight (of potentially 13 hours or so, as in the EK407 case).
Can you see what I am getting at? I'd just like someone to come out and declare that the risk numbers have been done, and that crews are aware of exactly what risk they are accepting. I'd expect that as airlines are big businesses with large sums of money at stake, someone, somewhere has done this.

[Sir Richard]

ferris

Sorry you did not like my analogy.

Try this one:

Most engines are rated for 5 minutes (10 minutes in case of an engine failure) at max thrust. Try this for every takeoff and the engines will run out of useful life at a much faster rate than a similar engine treated with TLC. Thermal and physical stresses are so much greater at max thrust compared with max continuous or Flex/De-rate. That is why there is the time limit.

I think your 1 minute is a little mean for a 13 hour sector at close to max takeoff weight. I am just guessing (and from experience) that the average sector length probably is less than 7 hours for a 744/340 so twice the number of applications of high thrust per day/year.

Returning to the humble motor car for a moment. Do you ALWAYS use full throttle when moving off, or would you normally use sufficient power for a slightly more sedate departure? :}

Recommended reading:-

http://www.smartcockpit.com/data/pdfs/flightops/aerodynamics/Flex_and_Derate_Takeoff_and_Climb.pdf

and more discussions

Why Derate? — Tech Ops Forum | Airliners.net (http://www.airliners.net/aviation-forums/tech_ops/read.main/138740/)

[V1... Ooops]

Ed - can you name a major airport with a sufficiently long runway where your V1 theory would be practical.

Well, with my Twin Otter, I would say anything longer than about 2,400 feet at gross weight and ISA would be long enough... :E

[Super VC-10]

As the person who originally brought this subject up, I'd like to say that I was not implying it was poor airmanship not to use the full length of the runway. As has been shown above, there are sometimes valid reasons for not using the full length.

That said, not using the full length available is fine if everything goes OK, but it does seem that there are those very rare occasions when the runway behind you at the start of the take off run may have been just enough extra to get out of serious trouble.

[FrequentSLF]

Ex Cargo Clown

This idiot SLF has still something to say (nice to know that professionals have to resort to name calling when have nothing else to say)

Can we please just draw a line under this ridiculous notion that Flex/Assumed Temp thrust reduction is in some way unsafe

as correctly said by No Land 3

Actually CDRW makes a perfect point about the logic you are using SLF. It's directly analogous, albeit taken to its logical extreme.

Economics are part of life, and in aviation we balance risk vs reward.

Is exactly my logic. Now Ex Cargo Clown would you explain me why am I an idiot?

Thanks to all that have express their opinion about taking off at max trust.
The next logic question will be, why don't you set the trust that you want/need instead of flex/temp? Would not be easier to spot an error on the input of all the data?

[Sir Richard]

Big Surprise !

That's exactly what is done........

Input the Flex/De-rate and /or Assumed Temperature,
N1 or EPR is calculated and displayed,
Thrust levers or Autothrottle moved to achieve that N1 or EPR

Even in the good old days of steam driven clockwork aeroplanes, (Super VC10 and B747-100/200 spring to mind) these calculations were done from the books, the N1/EPR was bugged and the trusty F/E set the appropriate thrust.

Not too difficult.....:}

[Sir Richard]

Because you do not have direct access to the FADEC.

Access is via the FMC which "talks" to the FADEC.

There are many levels of redundancy for all these calculations,
ACARS RTOW calculations are rejected if rubbish is input.
Similarly, the FMC will reject many inappropriate inputs.

The old fashioned paper calculations mentioned above seemed to work without FADEC and other modern electronic gizmos.:8

When the various electronic calculators are unavailable, there is usually a paper backup method available with tables for weights/temperatures/pressures and wind components for the available runways.

[This was in reply to another question posted by SLF...which seems to have disappeared ! :hmm:]

[ray cosmic]

SLF; what you propose would be reasonable if every take-off would be field limited; i.e. dependent on the length of pavement available. In practice, other limits apply as well, like obstacle and climb limits being independent limitations of the pavement length.
Since it is basically impossible to have all this data -up to date and everything; think of construction sites with cranes in a departure area- of every airport available in the aircraft, tables are mostly provided from an operations department which are guaranteed correct and up to date.

[AutoAbort]

SLF,

Next takeoff go for TOGA and leave them there:ugh:

Wonder how long the engines will last? Or how safe that might be?

AA

[One Outsider]

This will continue to go in circles as people, who obviously have no basic knowledge or understanding of the subject, continues to insist that something is wrong and should be changed. Arguing for the sake of it, it seems.

[bantios]

Probably shown before but here is an Emirates A340-500 where a pilot selected TOGA 1/2 way during the take off roll. Interesting to see how close V1 and VR are. This flight was a light 3 hour flight.

YouTube - Take off from Sydney (http://www.youtube.com/watch?v=ZQLeBNhsyj8)

[Ex Cargo Clown]

So the anti-Flex/derate brigade's argument is, always full-rated unless an error has been introduced due to manual errors in calculating.

So by that rationale what about RVSM ? Maybe we should have min vertical separation of 2000 ft, maybe more, just in case someone mishears a clearance/put the altitude into the MCP incorrectly and it isn't cross-checked. Actually best make that 4000ft just to be safe.

What about departures at MAUW or MZFW. Surely they have to carry a greater level of "risk" as they are at the very edge of performance. Let's offload 2 tonnes of freight, actually make that 5 tonnes, just to be sure.

The fact are that there is no greater risk of Flex/Assumed Temp departures when done correctly. All figures are calculated that even the worst case scenario (engine failure at V1) is catered for as far as runway length goes, with the necessary safety margins.

If your argument is to use full-rated thrust to remove a possible error being introduced (incorrect V speeds or thrust set) then think about it this way, maybe gear shouldn't be retracted after takeoff, this will reduce the risk of the crew forgetting to lower it before landing.

How does that meerkat put it, oh yes, "Simples"

[Belgianboy]

Dear All,

I feel that is time to stop the discussion on the pro and cons of reduced power setting on take-off.

Various professionnals explained in great details the setting actually used and the in-built safety margin.

Shouldn't we wait for the preliminary report instead of wasting bandwith?

Regards

Willy

[White Knight]

This performance is all very simple really as long as you input the correct data. This nonsensical discussion of flex (used by EK)/derate (not used by EK) and TOGA shows that many here don't have any grasp of 'Performance A' and associated requirements.. And yes, a heavy 345 taking off with flex will often be rotating in the reds after a 4000m take-off roll, but as long as it clears the 'screen height' by 35' after an engine fails at V1 that's all that matters!!

As for the video on youtube a few posts back - if you listen they're just seeing 'how it goes' at TOGA when the aircraft is light.. Trust me, it's off like a scalded cat at light weight and TOGA...

[FrequentSLF]

SLF,

Next takeoff go for TOGA and leave them there

Wonder how long the engines will last? Or how safe that might be?

I never advocated that, maybe if you read my posts you will notice that.

[HAMISH MccALLUM]

Hi to all,i have been silent to date about the incident,iwas on the flight along with my wife,down the back as usual very frightening and thanks to the people up front we got to ground safely,it doesnt matter so much to me who was and what was it happened,reading your posts i feel very lucky however no one has mentioned the after care once we had saftely disembarked.
It was appaling they burried their heads in the sand,we were allowed one three minute phone call one Emirates lady was on duty at check into hotel we got a free Hilton breakfast wow, then they put on a meal for lunch in one of the conference rooms ,they catered ,terrible,one lady still organising baggage and itinery,to say the least they were very very poor.
I have flown up the front with them excellent ,done it once BAH AUK return but it wouldnt have mattered where you were you still would only be allowed one 3 minute phone call .
So needless to say i will not fly with them again.
Interested to see anitial report any idea when its due.
Happy to be alive

[west atc]

Found this interesting, seems like a very similar incident to the one in Melbourne.

ASN Aircraft accident Airbus A340-313X A6-ERN Johannesburg International Airport (JNB) (http://aviation-safety.net/database/record.php?id=20040409-0)

[HundredPercentPlease]

West atc, http://www.pprune.org/rumours-news/126248-emirates-emergency-landing-jnb.html

[White Knight]

West atc - completely different scenario....

[crazyaviator]

When i had previously mentioned Max take-off power for all take-offs , i didnt imply ALL available power, balls to the wall, EGT past the max etc. I meant a thrust level which is used to deliver rated engine performance while not exceeding any parameters AND delivering full engine life ! Dont let the bean counters tell you that 1-2 minutes at high thrust ( within limitations) on a good engine will sacrifice reliability and improve overall safety !!! Comprehensive engine inspections and care, proper care and feeding of the engine, High quality maintenance, NO previous overtemps etc and a GOOD engine to start with leads to longevity much more than minimal usage at near max temps etc.

[CONF iture]

west atc,
JNB and MEL have similarities but are actually very different.
In JNB there was low risk of tailstrike as the captain finally positively rotated 20 knots above Vr.

[Ex Cargo Clown]

Please, can we have a forum for those who actually understand anything about aviation. I refer to the following, clearly written by a 12 year old.

When i had previously mentioned Max take-off power for all take-offs , i didnt imply ALL available power, balls to the wall, EGT past the max etc. I meant a thrust level which is used to deliver rated engine performance while not exceeding any parameters AND delivering full engine life ! Dont let the bean counters tell you that 1-2 minutes at high thrust ( within limitations) on a good engine will sacrifice reliability and improve overall safety !!! Comprehensive engine inspections and care, proper care and feeding of the engine, High quality maintenance, NO previous overtemps etc and a GOOD engine to start with leads to longevity much more than minimal usage at near max temps etc.

This site was once a fantastic site, with insight from seasoned, and intelligent professionals.

Now it is infested with semi-literate idiots, who wouldn't know one end of an aircraft from another !

<Rant mode off>

Come on Rainboe, help me here !!!

[ferris]

Thanks for the reasoned replies. However, there seem to be a lot of people missing the point, not the least of whom is the Clown The fact are that there is no greater risk of Flex/Assumed Temp departures when done correctly. You really cannot see what is wrong with that statement? "Things are perfectly safe unless they go wrong". Abusing people because you cant actually put up facts as counter argument might show a certain party as being the idiot.

What about departures at MAUW or MZFW. Surely they have to carry a greater level of "risk" as they are at the very edge of performance. Let's offload 2 tonnes of freight, actually make that 5 tonnes, just to be sure. It is very easy to see the cost v. risk posed by offloading freight. It would also be easy to look at the number of events that could've been prevented by operating at less than MAUW (I'd venture to say none, without thinking too much about it, but you never know). The point is that there is a transparent, direct cost in offloading freight, but it appears that flex/derating and any benefits are purely theoretical.

If you are embarrassed because you do NOT ACTUALLY KNOW how much money (read engine wear/maintenance) is saved by using flex, that's fine. I didnt realise it was such a touchy subject. If your company knows, and just doesnt care to tell you and directs you to use flex etc. then the vicarious liability is theirs. In view of the treatment of the crew in this case, the company doesnt appear too keen on wearing that liability. I'm damn sure the insurer in the case of EK407 will be looking at it.

[woodja51]

Cool!!!... didn't know my take off had been put on You tube.... W

[positivegee]

Ferris says:

If your company knows, and just doesnt care to tell you and directs you to use flex etc. then the vicarious liability is theirs.
Ferris is correct here, but

Smilin Ed says:

SOP won't save you in court.
Smilin Ed is incorrect here.

If you follow company SOP's and use reduced power take-off's and/or intersection departures (or any other company SOP's for that matter), a tech crew is protected by the law of vicarious liability. If a tech crew ignores company SOP's and are involved in any incident that results in any liability, a crew may be found negligent and a court may then find them liable. This is not to say a crew must used reduced power or intersection departures, that decision is always left to the PIC.

+G

[megan]

From ‘The Naked Pilot’ by David Beaty
Firstly, there should be an acknowledgment that if and when the pilot makes a mistake, his will probably be the final enabling one at the apex of a whole pyramid of errors down below. This will, in turn, take the heat off investigations – the ‘we intend to find and punish the culprit’ syndrome. Only then can the pilots come forward and admit to mistakes they made or nearly made, and the reasons why can be coolly analysed and lessons learned. [Page 285]

Professor Reason in Human Error (1990) distinguishes between active error, the effects of which are felt almost immediately, and latent error, the adverse consequences of which may lie dormant within the system for a long time. This can clearly be seen in aviation, where pilots at the sharp end make an active error, while latent error lies behind the lines within the management support system. Many of these are already there awaiting a trigger, usually supplied by the pilot. ‘There is a growing awareness within the human reliability community that attempts to discover and neutralise those latent failures will have a greater beneficial effect upon system safety than will localised efforts to minimise active errors.’

As long ago as 1980, Stanley Roscoe wrote that:

The tenacious retention of ‘pilot error’ as an accident ‘cause factor’ by governmental agencies, equipment manufacturers and airline management, and even by pilot unions indirectly, is a subtle manifestation of the apparently natural human inclination to narrow the responsibility for tragic events that receive wide public attention. If the responsibility can be isolated to the momentary defection of a single individual, the captain in command, then other members of the aviation community remain untarnished. The unions briefly acknowledge the inescapable conclusion that pilots can make errors and thereby gain a few bargaining points with management for the future.

Everyone else, including other crewmembers, remains clean. The airline accepts the inevitable financial liability for losses but escapes blame for inadequate training programs or procedural indoctrination. Equipment manufacturers avoid product liability for faulty design,. Regulatory agencies are not criticised for approving an unsafe operation, failing to invoke obviously needed precautionary restrictions, or, worse yet, contributing directly by injudicious control or unsafe clearance authorisations. Only the pilot who made the ‘error’ and his family suffer, and their suffering may be assuaged by a liberal pension in exchange for his quiet early retirement – in the event that he was fortunate enough to survive the accident

Yet it is only recently that very dubious management malpractices are being identified and their contribution to accidents given sufficient weight. For though the pilot’s actions are at the tip of the iceberg of responsibility, many other people have had a hand in it – faceless people in aircraft design and manufacture, in computer technology and software, in maintenance, in flying control, in accounts departments and in the corridors of power. But the pilot is available and identifiable. [Page 221/222]

An incident/accident is generally the result of active failures (pull the trigger) on the part of the cockpit crew, but the stage may have been set by the latent failures (load the gun and put the safety catch to ‘fire’) introduced by others (management practices, certification standards, aircraft design, software, ergonomics etc etc). Put another way, the cockpit crew is the last line of defence for every ones mistakes. As good as you may think yourself, none of us are all knowing.

Capt. Fenwick of ALPA has cautioned. "Pilots will be judged against the perfect pilot flying the perfect airplane on the perfect flight. We all know that no such thing exists.”

What would EK's response be to the above?

[Sunfish]

I have not seen any post here about the matter I wish to raise, hence I will risk a post.

People on this thread talk about one of the reasons for reduced thrust takeoffs as "reduced engine wear".

I respectfully advice that it's not "reduced wear" as in the wear of the bearings in a car engine, it's actually reduced engine life which is somewhat different. Turbine blades and guide vanes are generally operating at maximum takeoff power in gas streams some Two to Three hundred degrees above the melting point of the alloys from which they are made. What keeps them from melting is the flow of cooling air through their bodies.

Despite the internal cooling, the gas stream gradually erodes the blades and vanes, and the rate of erosion is a direct function of temperature and time. The hotter they are, the longer they are, the shorter their life before they degrade to the point where they must be exchanged. I can't find images on the net of what they look like before they are replaced, but I can say they look something like a sort of melted turbine blade shaped icecream.

The motive for reducing takeoff thrust is thus to maximise the life of the blades and vanes which are effectively consumables, even though every airline I'm aware of keeps those that cannot be repaired in the (vain) hope that one day new repair schemes will one day allow these super expensive items to be returned to service.

To put it another way, the time X temperature product of the blades is finite, and each take off consumes a little of that finite life. That's why it is desirable to use the minimum thrust consistent with safety.

[jungle drums]

Flex is not really the issue here.

It is recognising and catching invalid numbers for a particular aircraft weight and takeoff condition (thrust and performance) when distracted, tired, rushed and/or constrained to complex SOPs and patter.

It is how to catch these numbers before using them kills you and your passengers.

On Flex - a technique that I was taught and like was to 'Flex' only to no less than 2000' of the available runway length, intersection or full - an extra safety margin adopted by many operators of my type.

A takeoff in conditions that required any greater amount of the runway than that required full takeoff thrust.

On top of normal V speeds, knowing that you should be at 35' by 2000' to run and seeing that point approaching quickly is a recognisable point at which to apply TOGA if less was leaving you under-performing.

It would seem reasonable to me to only flex in a heavy to within 4000' of runway available.

[herkman]

And the fate of the airplane?

Pilots seem to have been dealt with and put out to pasture, but expect that some one will see the total story, and maybe they will be back on the job, perhaps with a more understanding view by new management.

But the airplane, is it to be fixed, surely with all the skills here and with the help of Airbus it should be put back in the air.

Regards

Col

[west atc]

west atc,
JNB and MEL have similarities but are actually very different.
In JNB there was low risk of tailstrike as the captain finally positively rotated 20 knots above Vr.

No worries, happy to be corrected. :ok:

[bsieker]

Sunfish, thanks a lot for the insightful reply.

Yes, the effects of high turbine inlet temperature are very real, measurable and computable, not only increasing cost, but also statistically reducing reliability. Big carriers dealing with tens of thousands of flights every year have to take that into account.

Despite the internal cooling, the gas stream gradually erodes the blades and vanes, and the rate of erosion is a direct function of temperature and time. The hotter they are, the longer they are, the shorter their life before they degrade to the point where they must be exchanged. I can't find images on the net of what they look like before they are replaced, but I can say they look something like a sort of melted turbine blade shaped icecream.

Here's an interesting article (http://www.msm.cam.ac.uk/phase-trans/2003/Superalloys/coatings/index.html) about turbine blade coating, that contains some photos that dramatically show the erosion (and also, how advanced coatings reduce that erosion).

In some of the blades you can see little holes, which are the outlets for the cooling air mentioned. It is pumped into the blades from the root, and blown over their surface to keep them from melting.


Bernd

[Joetom]

http://www.pprune.org/2302593-post81.html
.
Excuse the drift, but this pic shows more detail of those little bits at the back of the Engines, these are in poor condition however !!!

[PJ2]

megan;
What would EK's response be to the above?
Well, clearly we have the answer to that question. The crew is apparently history and it doesn't appear as though a report will be issued as to what happened. Even though there are some reasonable scenarios posited, not discussing what happened, even informally, means that the error, whatever it was, has opportunity to re-occur. It has occurred before and the opportunity to learn from what happened here has, it seems, been lost in favour of firing the crew.

It seems that this is the sum total of EK's desired contribution to flight safety, particularly in reference to the knowledge base of this kind of incident.

[kanuck33]

Megan,I must say I agree with you 100%. Very well said. I am sure that the "blame culture" of the middle east has alot to do with the way this crew has been treated. It saddens me to think that I came from a place where these people would have retained there jobs and management would have looked at ways to close these gaps in the operational safety. Not here. As this puts the blame on management which puts there jobs in jeopardy.. Sh1t flows downhill and management won't admit there shortcomings because of it. My condolenses to the crew for being the sacrificial lamb. Now we will place another bum in the seat who in this environment could do the same mistake. Truly Sad

[757_Driver]

Flex / derate / assumed temp - call it what you will, but it DOES increase engine life and it DOES save real hard money. We had a memo in our airline reminding us to use the correct assumed temp reduction for every take off and the savings quoted were staggering.

Anyhoo - all those advocating full thrust for take off, you still have to do the performance calcs and if you make the same mistake made here and in Halifax with the 747 you are still going to rotate underspeed, still going to drag along the runway with the tail, but with alot more thrust. You will probably get airborne, but then again who knows.
Besides full thrust take offs can also have their own risk. Especially in a light aircraft, so maybe you are just swapping one risk for another, not reducing the overall risk level.

[Joetom]

Appears yet another great lesson in safety lost.

EK should begg the crew to remain employed.

Fully understand and never forget the causes of this event.

Fully understand and never forget how the crew handled the aircraft after aware of problem.

My best wishes to all the crew involved, am sure your intentions were all good.

[Capn Bloggs]

Flex / derate / assumed temp - call it what you will, but it DOES increase engine life and it DOES save real hard money.
My bloody oath it saves money. Just ask Boeing how much they are charging us for using our uprated 717 engines. Gouging is not the word.

[rmm]

And the fate of the airplane?

I drove by the front of the hangar that it's parked in yesterday. It still has the plastic sheet covering the damaged area and there were no signs of any repair work being carried out. No people and no GSE in sight.

[donal barber]

KANUCK 33 what are you taking about? "condolenses for sacrifical lambs" These pilots are profeessional and well trained people. They made a mistake and nearly killed all the passengers and crew. I will not mension anything about how much it will cost to fix because I don't see it as an issue. Peoples lifes are what we deal with, however as a ground engineer and I am the of person who will have to fix this very damaged aircraft. I take full resposabilty for my work and I expect others in this industry to do the same.

[Capn Bloggs]

Donal,

If you think it is as simple as that, you have a lot to learn about flight safety.

[pool]

I take full resposabilty for my work and I expect others in this industry to do the same.

If pilots err, they assume responsibility and have their bums at risk.

If mechanics err, training is inadequate, managers impose stupid sops, manufacturors mess up, they assume responsibility (some hardly ever though ) and pilots have their bums at risk.

Don't go down that road ...

[tbaylx]

@ Donal Barber

If you fired every professional in this industry that made a mistake you would soon not have anybody left. We are human and there for make errors. The trick is to have a system in place that traps errors before they become accidents. thta is why you engineers have dual inspections and the MM, and why there are two cockpit crew and SOP's. Firing the crew solves nothing and allows this error to happen again. The question should be what is wrong with the system and procedures in place that allowed a highly experienced and professional crew to make an error that did not get caught.

If you fail to address that then its just a matter of time before it happens again to someone else.

[ferris]

757 driver
We had a memo in our airline reminding us to use the correct assumed temp reduction for every take off and the savings quoted were staggering. Thanks, I'm happy to accept your word (rather than the motherhood statements such as "flex saves money" hitherto offered). If running the engines for a minute or so at the upper end if their performence capability does have such a dramatic affect on their life, then so be it. I wondered if/how many here actually had access to any numbers, and were just doing it because they were told to.

TBALYX et al, well said. (spoken as someone who has experienced/been the victim of the preferred ME management style).

[Bandit FO]

"Tbaylx" said what I wanted to say, only more eloquently. If there is a systemic problem with the bus departure process then it needs to be addressed. I'm an EK Boeing FO and I can tell you that the captains I fly with double check my work before departure, and then I check it again. Even so, anyone can make a mistake.

I'm sorry that these chaps got the sack.

[paulg]

tbaylx
As SLF having read this thread I would not wish to fly on EK in the future unless I felt assured that the airline had seriously acknowledged and addressed the many safety issues whch have been raised by concerned professionals in some 585 posts. I am referring to not just pre-flight data compilation cross checking and entry, but also to the apparent lack of opportunity to access online flight planning data in a timely manner, eg prior to leaving the hotel. I am also concerned to read about the poor T&C's for crew, including crew rest issues, and layover times.
Paul

[tbaylx]

Paul,

I can assure you that some of the issues that you bring up are problems at all airlines and not just EK. Often proper rest and days off are lost at the whims of management that really don't understand the effects of long haul flying on rest/sleep cycles.

Since EK has been very quiet on the whole MEL incident i can only hope that they are in the process of completing an internal investigation in coordination with the australians and the results of which will be taken into account and our procedures modified to prevent that sort of thing from happening again.

Should the investigation show that it was a crew input error it will not be the first and certainly not the last time that has occured in transport catagory aircraft operations. It may be time the the industry as a whole come up with a better mousetrap with regards to performance data entry.

[Saltaire]

This just another opinion, but I believe the following,

The flex/assumed temp on engines does save money, and is a safe operating program. It is not the issue that needs changing.

These airplanes are operating safely around the world every single minute using this function and have been doing so for decades.

This incident seems to be just a very unfortunate and isolated mistake by two very capable crew. The laptop SOP calculation when done correctly should and do trap errors. This is not to say that a revised system is not forthcoming but I find the system and SOP's to be reasonable. The process to input, SOP's and adherence to SOP's is the issue. Distraction and interruption in the flight deck pre departure also needs addressing.

I'm sure every pilot will now pay closer attention to the TO calculation and reduced thrust/flex numbers. This is a positive net result. I wish the crew a better future ahead.

[bsieker]

Well, clearly we have the answer to that question. The crew is apparently history and it doesn't appear as though a report will be issued as to what happened.

Interesting.

Since this would be classified as an accident, and not an incident (significant damage occurred to the aircraft structure) wouldn't there automatically be an official investigation by the ATSB? Complete with preliminary (possibly interim) and final report?

One of the criteria for an occurrence to be classified as an accident is:


[...] the aircraft sustains damage or structural failure which:
- adversely affects the structural strength, performance or flight characteristics of the aircraft [...]



Bernd

[star gold]

Since this would be classified as an accident, and not an incident (significant damage occurred to the aircraft structure) wouldn't there automatically be an official investigation by the ATSB? Complete with preliminary (possibly interim) and final report?

ATSB link here; 200901310 (http://www.atsb.gov.au/publications/investigation_reports/2009/AAIR/aair200901310.aspx)

[kanuck33]

Donal you said it yourself "These pilots are profeessional and well trained people."
I am sure they maliciously did not try to bend the aircraft and put lives in jeopardy.
I believe there maybe other contributing factors (I am speculating).

We are human ("to err IS human" remember). We are not perfect.

[TyroPicard]

"To err is human, to forgive is not company policy".

(Graffiti in the gents near the Dan-Air crewroom at MAN, circa 1978)

[PJ2]

Bernd;
Since this would be classified as an accident, and not an incident (significant damage occurred to the aircraft structure) wouldn't there automatically be an official investigation by the ATSB? Complete with preliminary (possibly interim) and final report?I hope so, Bernd. So far, nothing has been published regarding the details of the accident. I can't recall if it is ICAO or merely NTSB policy that a preliminary report must be published within 30 days of an accident. What is of course disturbing is the way the crew has, apparently, been handled. There is nothing here nor elsewhere to refute the rumour that the crew has been fired. In fact the entire incident has gone silent, which is not how flight safety work is done, as we know.

[Dale Hardale]

This definitely falls within the definition of an accident.

As said earlier, while the ATSB have access to the CVR and QAR/FDR, that's not the whole story. All that tells is the mechanics of what happened on the night. And yes - I'm sure the crew did make errors.

The ATSB will be hamstrung in getting to the root cause, because our beloved employer (Emirates aka Dubai Inc.) will never release any data on systemic, training or management issues that actually led to the final "piece" in the chain of events.:mad:

The crew have been made the scapegoats yet again. Crew retraining, and acceptance by Emirates of corporate responsibility would have been a far more mature approach here.

AAR, TCAS and ED should fall on their swords.

[herkman]

As a layman, was aircrew but not a driver, the situation with engine life, and operating with maximum power can be clearly seen in the situation of commercial flying and military flying.

In the military, where often it is performance that is sought, the engine life even of the same type and brand of engine, is greatly different between an engine which is operated commercially than one used by the military. However even in a military situation the use of maximum power is restricted to situations where it is absolutely required. In spite of that situation, engines on service aircraft never get to the time hung on the wing with a civilian one and are often changed long before the normal operating limits.

Again to the layman, it is not a requirement to run at maximum power, I mean after all when looks at different models of the same airframe, but one running a different brand of engine to another, there also a different level of power level for take off, does this mean that the available power on the lower powered airplane makes it unsafe. The answer must be that the the airplane if operated within its envelope is quite safe.

My experience with accidents, is that they are seldom caused by one factor.

An example.

Aircraft overloaded for what ever reason, but unknown to the crew.

The crew perhaps tired because of turn around times and or poor sleeping arrangements.

A miscalculation on the take off requirements either as an combination or part of the above.

A lack of understanding about what was going on, my understanding is that the tail on this flight contacted the runway three times, and the associated problems that caused, including the lack of acceleration.

The lack of understanding by management of their directions.

Yes it is easy to blame the crew, but some of the factors I am sure in this case where either beyond their control or not in their knowledge sector.

The operator has "sacked" the crew, but has it fixed the problem, the answer I suspect is NO.

The crew who have departed, will now be better pilots because of this incident, and I would have been using them to improve and bring about better standards than showing them the door. Perhaps the answer is that the wrong people were sacked.

Hope they turn up with a better job with a better airline.

Regards

Col

[ironbutt57]

Again good to see the "blame policy" alive and well:ugh:

Glad my airline out grew that...:ok:

[kiwi grey]

Flight's "Unusual attitude" blog reports (at So what did happen to the Emirates A340-500 at Melbourne - Unusual Attitude (http://www.flightglobal.com/blogs/unusual-attitude/2009/04/so-what-did-happen-to-the-emir.html)) that

"What I'm told is that the first officer entered a digit 2 instead of a 3 when entering the take-off weight in the laptop that the crew uses - resulting in a selection of a weight 100t less than the actual. "

:uhoh:

[Capn Bloggs]

Contact, Flight Global confirmed they've gone.

[canadansk]

If you ask them, they are gone!

[bsieker]

I can't recall if it is ICAO or merely NTSB policy that a preliminary report must be published within 30 days of an accident.

It's ICAO:


The Preliminary Report shall be sent [...] within thirty days of the date of the accident.


Cheers,

Bernd

[sanddude]

Contacted

Guess you haven,t been too long in DXB, or maybe you don,t leave the house that much!

Its quite a small community over here. The operating crew could be your neighbour:ugh:

[John R]

Positivegee:

"If you follow company SOP's and use reduced power take-off's and/or intersection departures (or any other company SOP's for that matter), a tech crew is protected by the law of vicarious liability. If a tech crew ignores company SOP's and are involved in any incident that results in any liability, a crew may be found negligent and a court may then find them liable. This is not to say a crew must used reduced power or intersection departures, that decision is always left to the PIC."

The first comment is not correct under English law. Vicarious liability is purely a mechanism by which an employer is held accountable for an employee's negligent actions. If you follow the SOP and it leads to an accident, the airline is vicariously liable for your actions. It does not "protect" the employee in any way! Indeed, if you follow erroneous SOPs blindly and they cause an accident, the "I was just doing what I was told to do" argument will not stand up in court. I think this is worth clarifying.

[Q-Ball]

Emirates jet 'close to crashing' in Melbourne

Sunday Herald Sun / April 12, 2009 12:01am

A FULLY-LADEN jet came only centimetres from crashing at Melbourne Airport last month, it has been revealed.

The Australian Transport Safety Bureau has placed it in the most serious category of aircraft mishap available to it - an accident, rather than an incident.

An ATSB investigation update shows the accident was labelled a "significant event" by investigators, who also listed damage to the aircraft as "substantial".

"During the take-off the aircraft's tail scraped the runway surface. Subsequently smoke was observed in the cabin," the report says.

A Sunday Herald Sun investigation has confirmed that the flight - EK407 to Dubai - almost failed to become airborne and barely made it over the airport perimeter fence, half a kilometre away.

Damage to the $220 million plane is so severe that the airline is considering writing it off rather than repairing it.

The fully-laden Airbus A340-500 was believed to have been travelling about 280km/h when it reached the end of the runway without becoming airborne.
At the last minute, the two pilots "rotated" the plane - or pulled its nose up into a steep ascent - causing its tail to crash into the end of the runway.

Despite its steep climb, the plane was still so low that it wiped out strobe lights that were only 70cm high and positioned 170m from the end of the runway.

It then took out an antenna, believed to be near a small building, before barely making it over the 2.44m wire perimeter fence.
Aviation expert Dick Smith said something had gone badly wrong.

"It's the closest thing to a major aviation accident in Australia for years," he said.

"The people (passengers) are incredibly lucky, it was an overrun where the plane didn't get airborne."

Mr Smith said Emirates was a "very good airline" and it was strange the pilots had resigned immediately after the accident.

"Emirates' standards are very high and they have a lot of Australian pilots," he said.

"What I'm startled by is that there hasn't been a more immediate announcement. We should get some urgent advice from the ATSB. This is one of the most serious accidents you can imagine."

A Melbourne Airport spokeswoman confirmed the size of the strobe lights, which are on a grassed area between the end of the runway and the perimeter fence, which runs alongside Operations Rd.

"The height of the runway strobe lights is 0.7m above ground level," she said.

[Nicolaus Silver]

Assume all checks are carried out on board before take off.

Suggestion

For weight and other critical input data could this be input and checked by ground staff with pilots giving last check, thus reducing risk of input error.

Reality

Accidents happen and we should learn from them.

Emirate Business Rationale

Managers in Commerce use blame as a strategy, advising the market place that it was not us, but like in Baring Brothers, someone messed up and we have solved the problem by getting rid of them. Thus it is safe to fly with us.

Speculation

Commerce has always had govt depts by the Sphericals. Look at a merchant bank's luck with competing ABC2 radio station closure, short selling extensions, negative analyst sacked, infrastructure contracts.

If an input error was the cause, I am very sure the authority advised Emirates immediately, hence the "resignations".

Commercial Reality

Regardless of Emirates playing that game, they can be counted on to fix those procedures.

Consumer Reality

If there is a next time the collective consumer body, those that can, may well decide to walk away whilst others, sadly, may not have that choice.

For those who do walk, they will still be vulnerable to human and mechanical failure, which is endemic with other carriers.

What Emirates should do is own up, detail their solution so we all can be reassured and learn from it.

[Obie]

Now look, I know this is your first post, but for an experienced airline pilot like me, who obviously knows b*gger all, compared to a super hero like you...

could you please decipher that psycho babble you've just posted?? :ok::ok:

[High Nr]

Searched through the pages of posts, but have not seen the nationality of the operating crew.

Can someone please enlighten me...?

[Nicolaus Silver]

Sorry Obie, here's the translation,

1. Should airport admin calculate settings for pilots to check and input when they come on board. These settings are then reconciled with airport admin by wireless computer link.

2. Corporations will cover up for errors if exposure affects their market. Govt and carriers should be made to publicise errors and solutions. Then we all could learn.

Yes I crap on a lot.

Cheers NS

[Obie]

Thanks Nic. Now I understand! :ok:

You don't crap on...I agree with you.

[Nicolaus Silver]

Note discussion concerning cabin disruption when pilots are calculating and inputting data.

Is it not possible for pilots to do all this in airport before boarding. Create a quiet pilots pre flight admin room with computers linked to their craft loaded with data from oil, baggage, cargo, weather, runway, flight details etc as soon as it is to hand.

This way data input can be checked by an airport administrator as being consistent for plane and admin before pilots board.

Computer self checks would also screen 3rd party input as being within normal range for this craft, cargo, fuel, destination and passengers.

If any data subsequently changes prior to take off the revised data is advised and input agreed by pilots and airport administrator, cross checking that the crafts settings have been updated and are consistent.

[derab]

High Nr

I heard one of the flight deck crew that night, he sounded North American to me.

[iceman50]

Nicolaus silver

No it is not possible nor practical and under what "regulatory" system would your "administrator" work.
You may think your ideas are workable but unfortunately you obviously have never worked in an airline / aircraft environment, details are never finalised until well after the aircrew have boarded!

[CONF iture]

This way data input can be checked by an airport administrator as being consistent for plane and admin before pilots board.
Sorry Nicolaus, but I have to disagree on that.
Far too much administration already, far too many signatures before we can go.

I believe the key is in some other place :

Probably 90% of the operation nowadays is done for a crew of only two members. These two guys must always check each other, and never ever take for granted anything. To look over your partner's shoulder is one of the main part of your job. You have to pick up any of its possible mistakes as much as you need him to do exactly the same for you, and you never miss thanking him anytime he does so.

If one the crew made a mistake in the numbers, that's ok.
But if the other crew didn't pick up the mistake because he relied on his partner and didn't take the time or didn't have the energy to check by himself the entries ... that's where is the bobo !

Also the job is exhausting at times ... Fatigue is a major intruder ...
15 days off a month should be the rule ... everywhere !

[VH-RMV]

Local reporting:

Pilot error blamed for Emirates runway mishap in Melbourne (http://www.theage.com.au/travel/travel-news/pilot-error-blamed-for-runway-mishap-20090412-a418.html)

[JohnMcGhie]

Iceman:

No it is not possible nor practical and under what "regulatory" system would your "administrator" work.
You may think your ideas are workable but unfortunately you obviously have never worked in an airline / aircraft environment, details are never finalised until well after the aircrew have boarded!

OK, so what "can" we do? If we believe the rumor, one of the pilots typed a "2" instead of a "3" and nearly spread a 300-tonne mixture of passengers and kerosine all over the end of the runway.

The aircraft's computer could have spotted that one with its in-built sanity-checking algorithm, and issued a beep and a question such as "Is this aircraft empty? Then why so much fuel?"

Expecting the other pilot, apparently bleary-eyed from fatigue, to not suffer from dyslexia, was not so successful.

How about we get the ARRIVING crew to enter the estimated settings for the next flight before they leave the aircraft? The computer could then compare each of them with the real settings entered by the operating crew, and query any that seem so different as to be unlikely?

Just a thought...

[framer]

OK, so what "can" we do? If we believe the rumor, one of the pilots typed a "2" instead of a "3" and nearly spread a 300-tonne mixture of passengers and kerosine all over the end of the runway.Thats flying man, thats flying. There are hundreds of other opportunities to make tiny errors that can have catastrophic results as well. Entering in the weight on he FMC is just one. Many are shocked to find out that a simple mistake like that can result in a major crash, mind you, often they're the same people that think pilots are just bus drivers.
How about we get the ARRIVING crew to enter the estimated settings for the next flight before they leave the aircraft?
The next crew haven't planned the next flight, they don't know the weight of the aircraft for the next sector. They don't care too much about it either as it isn't heir flight. The fuel loads and pax numbers change quite a lot sometimes.

The best way to reduce this kind of thing is having excellent crew layover conditions, good HF training, fatigue management teams/systems, and if it's a turn around then make it long enough so that the crew aren't under pressure.

[pool]

Too many cooks!

It is a two man cockpit, for heavens sake. Let them work accordingly. If you bring in the incoming crew (you barely ever meet them), the augmenting crew (their in everyone's way, having no place to go), any administrator (that couldn't be bothered by anything else but the next cricket match) or any kind of remote computer/laptop/calculator/adminstrators handheld prodigy, with programming that defies Windows 95 with a 386 processor, then you're heading the wrong way.
Too many cooks simply spoil the meal, especially those who know little about real cooking, if you get my drift.

It should be entrirely left up to the two operating pilots with the final loadsheet, provided mostly 10-15 minutes before ETD. The TO calculation should be done together and only then, with the actual loadsheet and the actual numbers and (most probably) actual runway and its conditions. That may sound late, but having done all the preflight preparations, the last 10 minutes should be calm and reserved for these crucial calculations and inputs, and subsequently adequate and specific briefing. The operating pilots should throw out ANYBODY during this phase, even including the augmenting Captain who has 30000 hours more on his cap, is TRE and comes from the land that invented better North Atlantic crossings than Lufthansa.
Any calculations and endless briefing-blahblahs done before are useless and dangerously mind pre-setting, as we subconsciously tend to thinks "it's already done".

I tend to go for fighting distractions, as a main ennemy before take-off.

As it appears in this incident, some distraction was "self induced and augmented" and might have accelerated resignation. We will see ....

[framer]

Good point.
Has anyone ever actually done a study on that?
What % of Part 121 flights have more than the normal crew compliment v's what % of Part 121 aircraft involved in a major incident have more than a normal compliment.
I would guess about 10% of flights I do have someone extra on the Flight deck yet it seems that about 30% - 50% of accidents I hear about have someone extra on.
Anyone know the stats?

[Hi_Tech]

I was waiting for some sort of reliable data from investigation to emerge before posting this story. Though the enquiry report is not published yet, the scenario of a mix up of a "2" and "3" looks most realistic.
I am with aviation for nearly 4 decades. I relate an incident that I recall very vividly which can high-light the perils of finger trouble on a modern aircraft and how pilots of yesteryears had a better knack of spotting gross errors.
It was a 747-200, 3 man crew, and I was in the cockpit (I am not a pilot). During take off preparation the 3rd crew, Flight Engineer prepared a Take off card with speeds V1, Vr, etc and kept on the pedestal. This was the norm in the airline I was working at that time. The pilot in command while setting the white bugs on his airspeed indicator, paused, gave back the card to the FE and said "Re-check, these are wrong". The First officer had already set the bugs on his side and did not see the error. The FE , re-checked the speeds, and corrected the error. There was an 11 knots error and by this time he was sweating profusely, which I remember very well. He told me later in the flight, "if the Captain reports the matter he will be fu****". A few weeks later I found out that the incident was indeed reported by the Captain, the FE was grounded and send for retraining.
A question will arise for many present day pilots, "How did the captain spot the error"? Well the year was 1982, when computers were not available and crew had a fair idea of these important figures for a particular flight. They flew one type of aircraft.
In today's scenario, everything in the cockpit is automated. The Laptop calculated figures are entered in FMC CDU, are automatically set on the PFD for V1 speeds etc for both pilots. Pilots have less chance of detecting the error, as they fly A330 one day and A345 the very next. One flight can be on a short 2 hour sector and the next can be a 14 hr one on A340. The errors from finger trouble are rarely reported and highlighted only when disasters occur.
I feel sorry for the crew. One single mistake can ruin an impeccable career. In EK407 case the error nearly killed them and the paxs. Probably could have killed off the airline as well. Any airline would have punished them unfortunately the same way (Except the highly unionized ones)
Human factors could be the main cause, but for such gross errors, you pay with your job. That is life for a pilot, I suppose. Hope the crew had no mortgage on Dubai property as well, in whcih case their next shock will be when they go to close their Bank accounts!!

[NO LAND 3]

But sources at Melbourne Airport said

That would be the baggage handlers then. Or maybe PPRUNE. Funnily nobody mentioned flaps yet...

[Teal]

"How did the captain spot the error"? Well the year was 1982, when computers were not available and crew had a fair idea of these important figures for a particular flight.There was still enough automation in those days to make errors. Consider KAL007 in 1983 when a simple mistake concerning the autopilot and INS inputs had catastrophic implications.

[ZEEBEE]

There was still enough automation in those days to make errors. Consider KAL007 in 1983 when a simple mistake concerning the autopilot and INS inputs had catastrophic implications.

As I understood it (correct me if I'm wrong) KAL007 deliberately cut the corner as KAL had done for some time in order to save fuel.
On that fateful day, the Russians were conducting tests at Kamchatka Base and were on high alert, hence the response.

In other words there was no entry error. The INS story was a cover-up

[CONF iture]

Funnily nobody mentioned flaps yet...
Mentioned earlier.
Excellent safeguards on the BUS in that matter.

[Capt Groper]

Correct me if I'm wrong but wasn't there a pay insentive at that airline, if you saved fuel you received a bonus?

[donal barber]

tbaylx, what you say is right and that this should be a leaning experience for the industry as a whole. Sacking people is not a means to an end. All that i am saying is that this thread is full of strange and imaginative reasons why the aircraft left a lot of aluminium on the runway at melbourne. As the investigation is pointing towards the wrong infromation being put into the computer ( to suggest any sort of cover up or conspiracy only insults the professionals working in this industry). I have been in engineering for 35 years and have never sacked anyone for putting there hand up for making a mistake. We are all in this industry together lets keep it professional and safe for our customers. thanks guys.

[Joetom]

Sounds like the old saying, The only silly mistake or silly question is the one thats has not been answered or learned. !!!

It can prove to be a very good/cheap way of learning and saving lots of money and face. !!!

Anyone that withholds said information should think of the next event and how they will feel. ????

But for the above to work, all operators should be on a learning curve full time.......

[Tyres O'Flaherty]

A simple mistake concerning the figures into an Ins, although not in the cockpit, resulted in Erebus.

[expat400]

Pool! Spot on.

In an earlier post I mentioned the 767 that had ZFW instead of TOW in the TODC.
After that they introduced a feature that compared the TOW with the flight number. If the numbers were not in accordance with a set parameter you had to recheck and confirm the numbers.
When the A340 entered service they opted not to have this. Ended with an "EK407" in PVG 2005.

Until I have a better system I do my own check. I check the TOW at the briefing and calculate the expected V2. If the FMC calculated one differs I investigate. Many pilots use this but it is not learned during training. Wonder why? Would be very useful for new crewmembers.

[framer]

A simple mistake concerning the figures into an Ins, although not in the cockpit, resulted in Erebus.

No it didn't.
That was one factor in the accident.
Like most accidents there were several factors that, if any one of them had been removed, the accident would not have occurred.

One could just as easily say " A simple error of judgement , going below the company VMC minima of 6000ft, resulted in Erebus"

But that would be equally inaccurate.

[Old Fella]

As framer has said, the change to an INS coordinate made by AirNZ navigation staff was one factor which contributed to the loss of the DC10 and all on board. Descending below the area MSA whilst believing to be visual, but in fact being in "white out" conditions, was just as much to blame. Having flown into the nearby McMurdo Base a number of times in the previous summer (1978),and having been thoroughly briefed beforehand an the perils of "white out", we maintained a regular sked with McMurdo en-route. If the trend was favouring a "white out" happening we would return to Christchurch before PNR. Incidentally, the McMurdo Rescue Crews were fearful of an accident involving a sight-seeing polar flight. They knew that even if the impact was survived they did not have the resources to conduct a rescue of such magnitude, especially as most on those flights would have been in light clothing and would quickly succumb to the extreme low temperature.

[Teal]

KAL007

I thought they were off course for the entire journey due to incorrect INS inputs made prior to departure from Anchorage. In any event, 'cutting corners' should not have taken the aircraft over the Kamchatka Peninsula.

Chart (http://en.wikipedia.org/wiki/File:KA_Flight_007.gif)



http://en.wikipedia.org/wiki/File:KA_Flight_007.gif
(http://en.wikipedia.org/wiki/File:KA_Flight_007.gif)

[Enderby-Browne]

A simple mistake concerning the figures into an Ins, although not in the cockpit, resulted in Erebus.
You're fundamentally correct, of course, but as always this mistake was only ONE of what became the long chain of errors, assumptions, oversights and second-guessing which led to a totally avoidable accident.

[LLuke]

Big question, of course, is whether it was
-finger trouble or
-using wrong figure from loadsheet, or
-insert in wrong place or
-zillions of other possibilities,
that caused this incident?

Always wondered with my own company why the layout of our ACARS loadsheet wasn't changed (e.g. separate header with just figures used for input), same for layout on FMS performance page, etc...

I feel sorry for the crew they had to resign, but now they can give honest feedback (f.i. if they think that factors like schedule contributed) with no pressure from anybody. This will hopefully lead to useful feedback/recommendations.

[Oilhead]

Two careers and family lives shattered - all for a possible finger input or other unintentional human error.

This should have been addressed/reported as part of a Just Culture policy, encouraging full and open reporting, ASAPs voluntarily filed, learn from what happened, apply lessons learned, share the information gained openly, train to proficiency if determined to be appropriate by the Event Review Committee, and move on.

Two "resignations" make the owners happy I guess, and they will sleep well tonight. But if I am going to be fired, sorry - resign, for an honest non premeditated error, I will not be offering any debrief information to help determine what happened. Why should I hand them the gun?

[LLuke]

all for a possible finger input or other unintentional human error.

Just assuming here ofcourse, it is sad to realise that it happened before, will happen again, while it can be easily avoided.

Separate loadsheet header, dual entry (from both pilots) in FMS, etc...

[Tyres O'Flaherty]

I'm editing myself for relevance or lack of it :)

[BusyB]

Oilhead,
I agree with you and have to say I'm very disappointed by the apparent lack of support by their colleagues on these threads.
I just hope its not representative of how they are actually being treated in DXB:confused:

[brokenenglish]

...I'm very disappointed by the apparent lack of support by their colleagues on these threads...


Well, it took me less than five minutes to pull these out:

have flown with the captain in the past. He is a reasonable and capable chap.Cut him some slack.The report will be published eventually.
We are all only as good as out last flight .. I have 5000 hours on the 330/345 and can understand why errors can be made from a pilots perspective that might lead to this event/similar
The jet is not fool proof as AB would have us believe.
Neither is the 777 that I fly now and there have been several cases of 'almost's' with that jet too.
I know at least one of the guys on the incident jet, and cannot be lead to believe that any errors would have been made without mitigating factors - as there always are.
I'm surprised that although most posters here like to be considered the "professionals" that this websites name implies, they are the first to draw guns against another pilot and/or the aeroplane.
Why are so many of us so damned willing - (indeed, almost tripping over ourselves in our eagerness to make our very own accusation)- to "eat our young" in situations such as these?

Posted mostly from EK crew I believe. There are more.



And the following might explain why there are relatively few posts like the above amongst the 30+/- pages:

It is certainly frustrating to see the same points and the same questions arise so early in the thread, when they have been dealt with in one form or another in earlier posts.
some real muppets on this thread..... v biased un-professional comments.
Other than the obviously informed comments here, the rest follows the usual pattern of nonsense we can all expect when reading of incidents and accidents.

[aguadalte]

In my airline, we prepare our T/OFF Perf. Page with the Estimated Take-Off Weight of our OFP while we have time and are not in a hurry to close doors.

We get an EZFW from our operations in order to correct our Fuel numbers (normally the maintenance guy is waiting for Captains finnal decision to complete the refueling process, that has stoped 2 tons before the initial estimated figure) as soon as we get to the aircraft. That estimate will show us a weight trend (compared to the TOW of the OFP).

When the Load Sheet arrives, the Captain dictates to the Co-Pilot the actual numbers. Actual numbers are therefore compared with the ones we have on our OFP and the Co-Pilot annouces to the Captain when entering the Actual ZFW on the FMGC, that we are "x Tons" below or above the EZFW of the Flight Plan. He goes to the RTOW's and finds the new V1, Vr, V2 and FLEX.

Closes the RTOW Book and hands it to the Captain. The Captain gives him a copy of the Load Sheet and finds his own speeds and Flex on the RTOW to compare with the ones just entered on the FMGC by the F/O.

During our Take-Off briefing we positively identify the aircraft we are flying that day. We fly 3 different types (lato sense) of aircraft: A340-300 and A330 PW or GE equipped (Different weights, different engines). As a general rule, it is a good help to check for two or three limitation items like MTOW, Max EGT, if that particular bird has Brake-Fans (or not) if it has Fuel Dump (or not). It helps you to sit in the right aircraft.

I understand that there is no panacea to avoid accidents. I'm very sorry for our colleagues.

[BusyB]

brokenenglish,
Yes, there is a few in 638 posts. It would be nice to hear of a groundswell of support to keep them employed!:confused:

[brokenenglish]

It would be nice to hear of a groundswell of support to keep them employed

It would be a fine thing but any worthwhile action would likely lead to further job losses.

I guess you're not familiar with how things work in the Middle East. But your location suggests you are familiar with the 49ers.


Not everyone takes the moderate view however, the following was posted by a Training Captain at said airline on page 19 of this thread:
I have written several statements and cancelled/deleted them. I wait for the report , but if the guys in the 2 front seats used 100T too little in the comp then good luck in your future jobs but dont make it a career in aviation!!!

[Andu]

Two more comments from earlier in the tread that I think many EK pilots would agree with.

I think there'd be very few professional pilots who would not say "that could never have happened to me", even with every safety measure known to man in place.

As someone has said before me, the two operating pilots, how ever badly they may - (stress, at this stage, may) - have screwed up initially, did an excellent job in revovering the aircraft from the initial situation and then getting it back on the ground in one piece without injuring anyone among their passengers and crew, (I'm sure very ably assisted by the B crew).

I'd like to think I would be able to half as good a job as they did after the initial problem reared its head and pray to God I never have to.

and

I think I speak for quite a few EK pilots when I say that I am deeply saddened if the story I have read here about the way the pilots were invited to resign is true. I would like to think that the management pilots who asked them to do so were doing so on orders from above and acting very much against their will.

[Michael Birbeck]

These posts bring to mind the tragic case of Glen Stewart who was prosecuted by the British CAA after a go around following an approach error at Heathrow. I guess all who read these forums know that Captain Stewart eventually committed suicide and the cause of aviation safety was not improved one jot by that prosecution. Better that a man like Glen Stewart (14000 hrs in command at the time) should have been around to tell up and coming pilots why that approach went wrong as opposed to drumming him out of the industry. We must admit that there are honest mistakes and that a mistake can be made by anyone at any time. We should live, learn and give a little, both in our attitudes and the skills we can impart to others in whatever walk of life we are in. Some understanding for the guys in this case might not go amiss.

[sevenfoursharer]

Probably one of the most powerful learning techniques is putting a good man in front of a group of peers and have him explain how he came to make a mistake. Organize a structured discussion on the contributing factors and possible mitigating measures. We then all walk away more aware and safer.
Lifting the maker of an honest mistake out of the system and dumping him/her by the wayside will have no beneficial effects whatsoever. Quite the contrary. It demonstrates short term focus and a lack of vision and commitment to systematically improve an operation. Not to mention the destruction of a transparent reporting culture.

[Al E. Vator]

Michael Birbeck - quite right and well put.

For airlines to sack/force pilots involved in incidents such as this to resign will do nothing. Perhaps this is the aviation equivalent of lashing a muslim woman because she has been seen in the company of another man. Primitive and ultimately ineffective.

Certainly some retraining and perhaps even disciplinary action may be justified but how will sweeping this matter under the carpet by terminating those involved in any way rectify human-factors based errors?

It never will and employers who use such tactics are simpletons.

Unfortunately their human factors based errors (poorly planned expansion, dismal fuel hedging plans, engaging in illegal freight cartels etc)rarely physically injure people, these employers just tootle off to the next company willing to pay impressive bonuses etc.

About time sime mature and forward-looking tactics were used to try to counter such errors rather than this primitive foolishness.

[framer]

their human factors based errors (poorly planned expansion, dismal fuel hedging plans, engaging in illegal freight cartels etc)rarely physically injure people,
I've often wondered if they do injure people .
Here's one example, if an airline schedules a half hour turn-around that can't be met due to taxi times etc, and the crew are always under pressure to depart on time, and one day a crew make a mistake entering data or taxiing or selecting flap or whatever.....isn't that directly a result of poor management? ie if they had an extra 15mins up their sleeve they most certainly wouldn't have felt rushed etc. I think that the workload and pressures in this job are increasing, while the working conditions and remuneration are slipping, and pilots being pilots, cover it up as best they can in their natural desire to perform efficiently.

[fastrobert]

Quote:

"For airlines to sack/force pilots involved in incidents such as this to resign will do nothing. Perhaps this is the aviation equivalent of lashing a muslim woman because she has been seen in the company of another man. Primitive and ultimately ineffective."

You're missing the point. The pilots, it seems, made a cock-up. That cock-up almost resulted in a major disaster. and apparently wrote off an aircraft. Everyone can learn from it but there's no way they can keep their jobs after that. We all make mistakes and we can all sympathise but there are mistakes and there are mistakes if you know what I mean.

From a line manager's perspective, the confidence is blown and the trust is gone. From a senior management perspective they're looking at two chaps who almost cost them their airline.

[4PW's]

I tend to feel the same way that there are accidents, and there are accidents. Yet in the drive to remain united as a pilot group, there is pressure to stay with the party line that this could have happened to anyone, therefore the pilots should remain onboard.

As pilots, does anyone seriously expect to remain part of the team if allowing a breakdown in procedure and safety resulting in not just a gross error, which is pardonable, but damage, which is not?

Wilful errors are violations of law. We're not talking about those, which are instances that usually validate instant dismissal. Next down the chain are unwitting errors, which are just that. They are not violations, and would not validate instant dismissal.

Nonetheless, unwitting errors made by a new First Officer are unacceptable in the grading system we use, and will inhibit a First Officer's promotion. We all know this to be true. Been there, done that perhaps.

I suspect we all agree that this was an unwitting error, by a crew, not an individual, and the issue of how it transpired is becoming a question of systemic error or operator error.

For those not in the know, systemic errors are system-based, suggesting the system needs to be changed to capture the error. Operator errors, on the other hand, require further training. Or not, if the error is gross enough.

'There go I but for the grace of God' as a logical approach to this issue just doesn't cut it for me. 'I could have made a mistake like this' is also limited in usefulness. Both are perfectly true statements, but they are not the basis of training a pilot group to ensure accidents don't happen.

**** does happen.

In the Turkish accident thread, few of the more experienced pilots suggest allowing the pilots in that accident, were they alive, the privilege of retaining their jobs. Why was this accident any different? How? It wasn't systemic, but operator-induced.

Pilots have a very big responsibility involving, amongst many other things, ensuring all errors along the chain are captured and either mitigated or erased so as to have little or no impact on the safety of the operation. That's a big task, and if it means taking off 22 minutes late, so be it.

In the rough and tumble of life, to ignore this truth (at least as I see it) is to ignore reality and, to follow on, what comes with it.

Don't lose sight of the ball.

[GMDS]

I could agree with the above, however up to a certain point only.
Operator error is certainly present here, but to dismiss systemic error is wrong. As long as only the first and most serious error is looked at, the dismissal of the crew might be sustained. But we have to look further and check if any systemic error contributed or lead to the operators one.
Not pretending all the factors contributed here, we nevertheless have to check:
- fatigue
- distraction in cockpit preparation
- bad place/rest/implementation management for augmenting crew
- company stress (multiple factors)
- MFF problems
- (others I might forgot)

If eventually there are contributing factors, then not only the crew have to brunt consequences, but the company just as much.
If there is no other outcome than losing collegues, if there is no improvement of some blatant shortcomings of EK, then all will remain a farce. One we have seen too many times alredha, ehh, sorry, already.

[vino]

Everyone can learn from it but there's no way they can keep their jobs after that.....
Some really good points made, but...............
-do the medical profession castigate for a single, catastrophic failure? Nup- have medicos in the family and this doesn't happen -to this extent at least.
-do the banking/corporate sector sanction error-prone members (no comment required)
-do airline CEO's suffer exile for poor performance and repeated examples of bad judgement? Aahm- do I have to supply names here
-the list goes on.
The critical issue is whether the cause is rationally judged as systemic or otherwise.
Pre-departure cockpit mayhem is something I've watched in Europe for 10+ years of a 30 year career and the common thread to my objection is- 'that's just the way it is!'
I can rest assured there will be some changes resulting from this event-all for the better we hope.
Keep their jobs?
Yes-in an appropriate capacity-because they remain professionals who, we assume, on the day, were striving for a vastly better result.
Word of mouth says the PF did a very cool job trading speed/height until climb away was initiated(that would be an unknown V2).
And- simmers and locomotive drivers/spotters- don't bother replying.....
please re-visit the PPRUNE acronym....-and go back to your day jobs!
No offence intended- but discussing peoples careers is inappropriate unless you are in the industry
Vino

[4PW's]

You are perfectly correct.

There are many issues involved, and I'm not aware of the intrinsic complications in the EK operation over and above what is obvious. It is very hard, perhaps impossible, for an outsider to make an assessment of the what, where, how and why of this accident. However, there has been an accident.

Whether or not external issues are involved is perhaps where the upcoming Commander's meeting for EK dudes might provide a useful forum. Certainly more so than this one. I hope they are in a position to take up arms against what seems to be a common foe for all pilots in that company, not just Commanders.

It appears, repeating, appears to be an operator error. If that were the case, dismissal is what I would prepare for. The horror of being in such a position must be pretty tough. Which is probably why there's been a lot of responses on the forum. Who would want that to be thrown on a friend or colleague?

No-one, which brings to mind some final points, for me at least:

1. Don't misunderstand the risks involved in being a pilot.

2. Recognise the absolutely critical nature of takeoffs and landings.

3. Force yourself to be sharp in those phases, even if fatigued.

4. Rid the flight deck of identifiable distractions, period.

5. Rest well as you can in the cruise.

[4PW's]

I've re-read my last post and hope it's not taken out of context.

My focus is on how I will capture the errors on my next start up, taxi out, departure, climb, cruise, descent, landing and shutdown at the gate.

Regarding doctors, bankers & other professionals: guess you may be right in that sense.

[vino]

yep-you got the gist of what I am saying.
I think it's an interesting mix of culture, machine and money at the moment.
As I imminently approach an Airbus conversion, I'm even more interested when Mr Cock-up comes knocking!
Just because -I don't have the warm blanket of familiarity to protect me.
And, sorry, we are now way off thread....
Vino

[Joetom]

Lets say crew noticed problem during the early part of the take off run and applied TOGA or stopped and aircraft was not damaged.

1. would they have been sacked/asked to leave ?

I think some of the last 10 posts or so have the correct views on learning and not having the blame culture.

Blame culture just watches time pass by, every event that is not reported and thus not understood/learnt is just the sort of building blocks needed to have a (Blame Culture) Accident.

F1 champ Lewis trashed my car | The Sun |News (http://www.thesun.co.uk/sol/homepage/news/article2383113.ece)

The above link shows even the best of us can get it wrong from time to time !

[TO MEMO]

MB,

you mencioned the tragic Glen Stewart case.

Does anyone have a copy of the excellent "Pilot" magazine article on his story?

Cheers

[Payscale]

Bla bla bla... what a lot of fertilizer in this thread. Expert my.....bla bla bla
Bottom line is.
One pilot made a calculation mistake
The other didnt catch it.
6 or 7 people in the cockpit IS distracting..
At high speed they realized it.
Their flying skills and experience safe their lives...and a bunch of others.
Anyone could the made the first mistake.
Not all pilots could have safed it afterwards.
Hope they left with big cheques in their pockets to keep quite

Good wind and gods speed to the crew.....

[Capt Groper]

I don't condone EK management’s disciplinary actions however take a step back and look at it form a different angle.

After reading the more sensible replies it would seem that SOPs aren't correctly enforced allowing for a variety of TOW/LPC inputs to be tolerated with the eventual undetected GIGO result. There are many holes in Swiss cheese, they aren't going away, we just have to make sure they aren't all aligned.

An unfortunate product of the need for more efficiency in aviation is computer driven task management. Pilots need to be more effective managers in this area and also more importantly the computer software should be more robust to self check logical data entry and output.

Pilots are the last line in defence, don't lower your guard.

[Brian Abraham]

Does anyone have a copy of the excellent "Pilot" magazine article on his story
TO MEMO, have a look at my post #31 at http://www.pprune.org/rumours-news/302417-pilot-sick-qf-flight-2.html

[CONF iture]

Excellent reading Brian !
Thanks for your effort.

[Oilhead]

Interesting comments in this thread for sure but I would ultimately ask the above question.....

Are their employees comfortable reporting safety concerns, even if they involve an error on the part of the employee? I would argue that having two pilots removed from the property after an unintentional act such as this drives the reporting and errors underground. The employees are in fear of their jobs now.

I wonder when a non-reprisal policy will be signed by the CEO there! The buck stops with The Boss for all matters safety. I am just aghast that two livelihoods have been lost because of the arguable lack of a Just Culture there.

[donal barber]

Thank you Payscale. I did try and make this point earlier, the bottom line is the safty of the paying customers.

[Minimbah]

Isn't there supposed to be a preliminary report by 30 days after the incident. Not so far at ATSB
200901310 (http://www.atsb.gov.au/publications/investigation_reports/2009/AAIR/aair200901310.aspx)

[groundfloor]

For Vino re Airbus take - offs: All white lights out, Big weight = high speeds - lotsa thrust, small weight = low speeds - low thrust. straight from a very senior training Capt at Airbus during training.

So as you line up, take some time ie step back - no white lights, take off green no blue. Cross reference weights and speeds and off you go and enjoy!

Good luck to the EK boys - there but for...

[OpaAussie]

Isn't there supposed to be a preliminary report by 30 days after the incident. Not so far at ATSB 200901310 (http://www.atsb.gov.au/publications/investigation_reports/2009/AAIR/aair200901310.aspx)

ATSB don't seem to have a great record in producing timely reports. Oldest still outstanding are Incident 200702402 (19 Apr 07), Serious Incident 200607202 (27 Nov 06) and Accident 200603722 (17 Jul 06). :=

[B772]

Rumour circulating that Airbus has agreed to repair the A345 at the request of EK. The aircraft will be issued with a permit to fly and ferried to Toulouse depressurised. The rear pressure bulkhead will be replaced. There are still some concerns of other damage caused by the tail impacts and high speed overweight landing.

[Whiskey Papa]

A-340 At Melbourne To Be Scrapped — Civil Aviation Forum | Airliners.net (http://www.airliners.net/aviation-forums/general_aviation/read.main/4392259/)

[Wiley]

I think this has a lot to do with the construction of the A340, in fact, all Airbus types. For years now, engineers have complained that, where you could slap on a patch on other types (note I'm trying not to turn this into a boeing versus Airbus rant), with an Airbus, because everyting is tweaked down to absolute minimum tolerances, the simple patch job is impossible and it involves a major structural replacement.

I think what was said in the link above is also true - it all comes down to ecomomics. Someone, hopefully EK, should make a small killing on spare parts, as the aircraft will be cannabilised before the remainder is turned into frying pans.

[woftam]

Having seen the scrape marks for myself recently while lining up on RWY34, I cannot believe how lucky they were not to have become a horrible statistic!!
:eek:
The scrape marks are VERY evident right up to the end of the clearway/stopway and then into the grass at the end of the runway.
SOOOO CLOSE !!!!!! :uhoh:

[Captain-Crunch]

Wow. They don't get any closer than that!


This is a huge airline management failure imho. For years decisions made by senior managers have loaded up the crews to the point where less than an hour will not cut it.

It starts with too many block hours and skimping on good quiet hotels and ends with security hassling people and delaying the crew from arriving on time at the aircraft. You need a full hour at the gate to cope with the unexpected distraction; a full hour to cope with the unexpected loading FUBAR. Most of the time you won't use that extra time. Read a magazine or take a quick combat nap and hope inept, toady managers won't see you doing it.

Then, on the departure that turns into mayhem, instead of dealing with headaches right up until brake release, the capt has a few extra minutes before pushback to double check the killer items ZFW, flex pwr, fuel ticket (remaining plus added), flap & trim setting, runway length.... do they make sense?

Again, just like the disappearance of manual line flying, basic airmanship has evaporated off the syllabus of the Brave New Button-pusher of tomorrow. Just "suck-it-up" they used to tell me. "This is the real world."

Well, the real world sucks.

Recall that pilots used to be blamed and fired for busting altitudes. Then ALPA, in concert with industry, developed the altitude alerter which is now a part of every flight. Altitude busts are much rarer today.

Since government and business seem only interested in reacting to events and interested only in finding a scapegoat to fry, may I suggest a worldwide SOS (suspension of service) until we can bypass security and arrive at the airplane on time.

You need to strengthen your unions gentlemen.

Crunch - out

[jackbauer]

False alarm. Quote from EK
Emirates Airlines decided on Apr 21st, that the airplane will be repaired in Melbourne to a point, where it can perform an unpressurized ferry to Airbus Industries in Toulouse, where repairs will be completed.

[411A]

Again, just like the disappearance of manual line flying, basic airmanship has evaporated off the syllabus of the Brave New Button-pusher of tomorrow. Just "suck-it-up" they used to tell me. "This is the real world."

Well, the real world sucks.



Oddly enough, in my airline, the 'brave new button-pusher of tomorrow' has not yet arrived.
I don't care if we are delayed, we do what is necessary.
Management backs me up, every time.

Case closed.

[pool]

So your airplane actually has pushbuttons?
Wouldn't have thought so, considering your contributions 411A.

[parabellum]

Pool - I think you will find that the L1011 is the original push-button aircraft, goes back to the early seventies!:ok:

[CONF iture]

Woftam, by chance any picture ?
How long would you estimate the scrape mark ?
Do you see repetitive marks or is it a single one ?

[HectorusRex]

Pilot of Emirates flight that nearly crashed at Melbourne Airport was sleep-deprived
[url=http://www.news.com.au/travel/story/0,28318,25387505-5014090,00.html]
Ellen WhinnettSunday Herald SunApril 26, 2009 12:01am

Concerns ... the Emirates Airbus that had to land at Melbourne Airport after it was damaged during take off / Brad Marsellos

The pilot of the Emirates flight that nearly crashed at Melbourne Airport with 225 passengers on board had almost no sleep the previous day and was following the airline's orders to take off at reduced power to save money on fuel.

Several sources told the Sunday Herald Sun that Emirates - like many modern airlines - ordered its pilots to take off at reduced thrust when possible to cut fuel costs, emissions and wear on the aircraft.

The thrust or power settings are determined by factors such as aircraft weight, weather conditions, the surrounding terrain and runway length.

But an Emirates source said the March 20 flight - EK407 to Dubai - was set at the "absolute minimum" thrust, leaving little room for error.

"There was no margin for error," the source said.
"This is all about the money."

Emirates yesterday issued a statement saying safety was a top priority for the airline.

"Safety is at the forefront of all operations within the Emirates group," a spokeswoman said.

Sources said a report due on Thursday was expected to show the near-catastrophic accident happened after the incorrect weight was typed into the plane's computers, causing it to set an inadequate take-off speed.

Air safety investigators are examining Emirates' staff records, including the work rosters of some of its pilots, to see if there are systemic safety problems within the airline that could have contributed to the near disaster.

The Sunday Herald Sun learned that the pilot of the plane was also almost at the threshold of the number of hours he was legally able to fly.

Emirates pilots are permitted to fly a maximum 100 hours each 28 days.

Investigators are examining whether pilot fatigue was a factor after being told the pilot had barely slept the day before the flight.

Several sources confirmed that Australian Transport Safety Bureau investigators were also looking at whether any other "human factors" needed to be addressed.

The inspection of Emirates' records is part of the bureau's investigation - expected to take up to a year - into the reasons behind the error.

The inquiry will investigate issues such as cockpit distractions and crew resource management.

A source said it was not possible for one person alone to commit the error.

"It happens because a range of things come together at the right time," the source said.

An Emirates source said the airline was in a risky situation because it did not have a culture that encouraged people to voice their safety concerns.

The source said some Emirates pilots were badly fatigued, but people were afraid to speak out.

"There is a limit to how far you can push people," the source said. "Those long-haul flights are really, really fatiguing and demanding.

"But a punitive culture means people are too afraid to speak out.

"Two things, (flight safety and the punitive culture) in my view, that do not match in 2009 and in a major airline.

"A very bad cocktail."

It can also be revealed that:

THE tail crashed into the runway with such force that passengers heard a loud scraping noise and some saw a heavy shower of sparks.

THE impact ripped a hole in the fuselage, causing what appeared to be smoke and dust to swirl into the cabin.

THE pilot made three announcements during the next 35 minutes as he circled Port Phillip Bay to dump fuel before returning to land.

NONE of the announcements told passengers how serious the situation was and the passengers were not in the "brace position" when the plane landed.

THE weight error was made before the plane left the departure gate.

PASSENGERS, including Anita and Ray Chappel, escaped uninjured after the plane landed safely.

The two pilots involved in the accident were forced to resign 48 hours after they were flown back to Dubai.

Safety Bureau and Civil Aviation Safety Authority officials are thought to be concerned about the action taken against the pilots, but have no jurisdiction to intervene.

Emirates pilots, using false names, have flooded the internet to express their concern about rostering, fatigue and the action taken against the two pilots.

The men are expatriates and at least one has since returned to his home country.

The United Arab Emirates does not allow unions, so more than 2000 Emirates pilots employed worldwide are not covered by a union.

Investigations by the Sunday Herald Sun further revealed the pilot was no stranger to the runways at Tullamarine, flying into Melbourne for almost five years, about once every two months.

The pilots - two operating pilots and two augmenting pilots - and 14 crew members returned to their hotel in Melbourne immediately after the accident.

The next day, bureau investigators came to the hotel to conduct interviews.

The man leading the inquiry is investigator Paul Ballard.

Emirates is sending some of its senior managers to Australia to handle the fall-out from Thursday's release of the preliminary report.

Andrew Parker, an Australian now based in Dubai as Emirates' senior vice-president of public, government and environmental affairs, will arrive in Australia this week with Capt Alan Stealey, Emirates' divisional senior vice-president of flight operations.

Emirates declined to comment on the March 20 accident because of the bureau's investigation.

But the company said it had continuously reached international safety standards and had been a founding member of the Gulf Flight Safety Committee - a Middle East aviation body.

The company denied it had a punitive culture that discouraged open discussion about safety concerns.

"Emirates has a positive and open safety reporting culture that helps management understand safety issues before they become significant concerns," a spokeswoman said.

The company would not answer direct questions about reduced-thrust take-offs, the fate of the pilots and the future of the damaged aircraft.

[fo4ever]

Nothing new in all this

She must be reading pprune

[Accelerator]

Thoughts?

Pilot of Emirates flight that nearly crashed at Melbourne Airport was sleep-deprived | Travel News | News.com.au (http://www.news.com.au/travel/story/0,28318,25387505-5014090,00.html)

[MrMachfivepointfive]

Pretty much garbage. Author hasn't got a clue what a flex takeoff is and that flex/ derate/ assumed temp are best industry practice. Fatigue has already been ruled out as a factor. Preliminary report is due out soon. EK made a mistake with less than proactive media work though, which is I believe in the process of being rectified.

Actually the Melbourne 2001 engine surge comes to mind. EK claimed rightfully that there was no fire and then somebody came up with a video of a huge fireball belching out of the N1 fan (which is to be expected during a surge but is absolutely not an engine fire). EK ended up appearing defensive pointing this out and were seen as liars by the uninitiated crowd.

[LLuke]

"Fatigue has already been ruled out as a factor."

I will be curious about the motivation for this one...

[pool]

The Mach 5.5 did it again!

If you use the word garbage, be careful, it might bite back.

Regarding flex/derate/assumed take off:
You cite best industry practice. Well, it's not completely true. With the EK software, you can only go for full thrust or max reduction. Any in-between, which is used a lot elsewhere for a little more safety margin but not full thrust, is not recommedable here, because the gross error trapping procedure a la EK will no longer be possible. It's not in the SOP, so either full or full reduction, which I believe is not best practice.

Regarding surge and fireballs:
A surge does NOT necessarily have a fireball, and you pretend it is to be expected. It may or it may not. If there is a fireball however, I would NEVER rule out a possible real fire, as you so brilliantly do by pretending that this is absolutely no fire.

By the way: How do you know that fatigue has already been ruled out? The prelim is not out yet, isn't it?

The more you post, the more you seem like a seat cushion warmer in the obscene palace, but not someone confronted with the real garbage happening on line with EK.

[vino]

so-pilot's only thanks-
do we really think, that on a Max Flex/Red thrust (Airbus/Boeing) take-off, at night, we can differentiate/identify correct acceleration for
-a 3700m runway
-a 3500m runway
-a 3900m runway with a second segment limit
-a 3200m uphill runway with tailwind component
etc etc.
Of course we can't. The only reality is staring at the red/whites and knowing you need to be airborne -soonish!
Regardless.
This crew responded to an impending threat
So forget the 'perception/should 'ave caught it/ rule of thumb', theories. The only thing that 'got 'em' was an input error.
Now- if you read back an altitude, and wind in something else in the window,you have a potential breakdown in separation=potential collision. However, there are still a couple of protection levels available (TCAS, ATC).
Typing in an incorrect weight has only one error trapping mechanism- the other pilot.
Some more work needed here perhaps?
Like many others here- I feel for the crew.
And perhaps EK need a gentle 'Taser up the Rear' to re-define their culture.
At the moment, despite nice new kit, flashy terminal, they are looking rather shabby.
No offense to the highly professional line aircrew there.
Cheers

[MrMachfivepointfive]

Pool: Didn't they tell you to stop posting after a couple of stiff ones? Okay - I ll respond to the stuff that's worth to be qualified.
EK performance software are the 1:1 Boeing and Airbus factory modules. In terms of what it does, dial up the Pelesys module or Wiki and look for 'balanced V1'.
In the MEL surge case the media hype about a fire cooked up days after it was established that there hasn't been any. Media just got onto it because the footage was too good. For the rest of your post: Yes, I love you too.

[rob_ginger]

Mr Mach5.5:

Fatigue has already been ruled out as a factor.Would you be kind enough to share with us the source of this information ? ATSB investigator ? EK management ? Tarot cards ? And while you're at it you could also let us know exactly what your relationship is with EK.

EK made a mistake with less than proactive media work..Otherwise an old cynic like me might think that the pro-active media work has already started :).

Regards

[etrang]

Fatigue has already been ruled out as a factor.

Fascinating. Would you care to provide anything to substantiate this claim?

[Wiley]

Fatigue has already been ruled out as a factor. Source: eeekayspinnmethinks

[etrang]

Source: eeekayspinnmethinks

I must admit that I used to think of EK as a fairly well run airline. If they are resorting to trolling on pprune, poorly writen trolling at that, then I will have to substantially revise downward that impression.

[MrMachfivepointfive]

Wait till Thursday.

[chase888]

Typing in an incorrect weight has only one error trapping mechanism- the other pilot.

If this is true, it could not be that difficult to flag a query.
A simple extra line like "souls on board" and distance to go could easily trap a typing error?:ugh:

[helen-damnation]

Typing in an incorrect weight has only one error trapping mechanism- the other pilot.

Complete tosh :=

The SOPs have been devised to catch just this sort of mistake.
The question is... Why didn't the mistake get caught :confused:

[Ndegi]

MEDIA ALERT Adjust font size:



2009/04
ATSB Preliminary Factual Report: A340-500 Tail Strike at Melbourne Airport, 20 March 2009
28 April 2009

A media conference to release the Preliminary Factual Report on the investigation into the circumstances surrounding the A340-500 Tail Strike at Melbourne Airport on 20 March 2009, will be held on: Thursday 30 April 2009

Where: ATSB offices, Level 2, 62 Northbourne Avenue, CANBERRA

Time: 10:30 am (local time)

Mr Julian Walsh, Director of Aviation Safety Investigation will discuss factual information known to the investigation team at this time and will outline the investigation process.


Media Contact: 1800 020 616

[xman80]

Weight of Emirates tail-strike plane queried

By Geoff Easdown
Herald Sun
April 29, 2009 08:01am

AIR accident investigators probing the near-disastrous Emirates tail-strike incident at Melbourne Airport are concerned that wrong load numbers were punched into the jet's flight computer. The Herald Sun has been told the take-off load could have been up to 100 tonnes more than the weight recorded.

The ATSB will release its report tomorrow on the March 20 incident at Tullamarine, which it has already billed as “significant”. The report, which details everything that happened that night, is said to include graphic pictures taken by airport security cameras. Other photos show damage to the runway as well as burns in surrounding grass caused by the plane's four jet engines.

Two senior Emirates executives have flown to Melbourne from the airline's Dubai headquarters to carry out media briefings. Sources told the Herald Sun (http://search.news.com.au/search//0/?us=ndmnews&sid=5014090&as=news&ac=travel&q=Herald Sun)yesterday that the situation may have arisen because too many people were on the flight deck before the aircraft pulled back from the terminal.

Apart from the four pilots usually in Emirates cockpits on long-haul flights, between two and four other people could have been present in the pre-flight check period. ”There is a great deal of conjecture about, that wrong load numbers were punched into the FMC (Flight Management Computer),” International Air Pilots' Association spokesman Barry Jackson (http://search.news.com.au/search//0/?us=ndmnews&sid=5014090&as=news&ac=travel&q=Barry Jackson)said last night. Pilots are handed a load chart for each flight before takeoff. It includes fuel levels, cargo and passenger loadings.

Emirates Flight EK407, with 225 passengers, was racing down runway 16 at 280km/h when the pilot and first officer realised almost too late they had insufficient power to lift the big jet into the air. Their last-minute action saved the passengers. Emirates refused to confirm if it had demoted its vice-president of airline safety.


Weight of Emirates tail-strike plane queried | Travel News | News.com.au (http://www.news.com.au/travel/story/0,28318,25403080-5014090,00.html)

[limelight]

See here 200901310 (http://www.atsb.gov.au/publications/investigation_reports/2009/AAIR/aair200901310.aspx)

[Old Fella]

To all those who pointed fingers, refer Post # 27 and Post # 31.

[preset]

Not making excuses but from the official report Capt & F/O hours for the last 30 days were 98.9 & 89.7 respectively, fatigue has to play a part in there somewhere & airlines better start taking some notice of this issue :ugh:

[Old Fella]

Four round trips DXB-MEL-DXB in a month would give more than those hours.

[david1300]

Not a pilot, just trying to understand something. Would the hours referred to in the report (98.9 and 89.7 respectively) refer to DUTY hours or IN COCKPIT hours or FLYING hours (defined loosely as, say, hours in cockpit with engines running).

If it is duty hours (from when arriving at place of work until leaving place of work), then:

1 - if half the 30 days were non-duty days this averages to 6.7 duty hours per day (based on 100 hours). This would not sound like an overworked person, only working 1 day in 2, and only for approx 7 hours a day.

2 - if this was compared to 'the average worker' (whoever that is) working 5 days on, 2 days off, then there would be a maximum of 20 duty days in this 30-day cycle, which equals 5 duty hours per day. This also sounds like a reasonably non-overworked person - working 5 days in 7 for an average of 5 hours a day.

Now averages are misleading - given, but I am trying to understand the basis for comments like "... fatigue has to play a part...."

If the hours cited are actual IN COCKPIT hours (and not DUTY hours), what is a reasonable estimate of the actual DUTY hours these pilots may have done in the past 30 days?

[WellingtonFF]

There are some highly intelligent questions asked by the press during the press conference that are worthwhile listening to (or perhaps they are not) It will be interesting to read the press coverage in the next day or so.

[WellingtonFF]

During the press conference, in reply to a question, it was said that fatigue had not been found to be an issue

[malcolmyoung90]

Capt & F/O hours for the last 30 days were 98.9 & 89.7 respectively


Is 98.9 hours for a 30 day period near to the limit that is allowed by Emirates?

[WellingtonFF]

From the press conference again

A typical take off weight for the aircraft would be of the order of 362 tonnes

The takeoff weight that was entered was 100 tonnes less.

The takeoff weight on the paperwork given to the cockpit was correct.

The error was made in the cockpit whether human or by the laptop in computing the figures.

Comment as SLF, but with a very much a technical backgound. A takeoff weight that is almost 40% more than that entered into the systems is a hell of a difference. The professionals would be able to say what that would mean in terms of the accident.

[Wiley]

I see "The Australian's" leader writer got it utterly wrong with his headline:

Emirates A340 that scraped its tail was 100 tonnes too heavy | The Australian (http://www.theaustralian.news.com.au/story/0,25197,25408597-2702,00.html)

[WellingtonFF]

One could say that - it was 100 tonnes heavier than the figure that finished up in the plane's computer systems :)

Anyway enough said from SLF for now - the professionals should take over, but I will be fascinated to follow the debate on systems design that allowed the figure to get into the system in the first place, and how the systems will be modified to decrease the likelihood that it will happen again.

[ITman]

The ATSB report is interesting in that it provides considerable detail on the accident, however there is no mention of any human factors mentioned or impact of same in causing the accident.... rather odd.

[NO LAND 3]

2 - if this was compared to 'the average worker' (whoever that is) working 5 days on, 2 days off, then there would be a maximum of 20 duty days in this 30-day cycle, which equals 5 duty hours per day. This also sounds like a reasonably non-overworked person - working 5 days in 7 for an average of 5 hours a day.

Now averages are misleading - given, but I am trying to understand the basis for comments like "... fatigue has to play a part...."


As you say: averages are misleading. Bear in mind that flight duty limits are designed with public safety in mind rather than flight crew lifestyle. What is commonly overlooked by the casual observer comparing flight duty to office duty is the cumulative effect of time zone changes, environment, and the irregular 24/7 nature (ie usually involves flying all night and weekends). Imagine how you felt afterwards last time you flew as a passenger on a 7, 10 or even 17 hour flight. Now do again the day after tomorrow. Repeat twice a week or more for the rest of the month. And year. Continue till made redundant or medical lost. Relocate to other side of world. Repeat. Now you are gaining an insight!

Flight time is calculated blocks off to blocks on, ie actually operating the aircraft.
EK limit is max 100hrs in last 28 days in order to commence a flight. Pretty much industry standard. This crew were at the upper end but theoretically ok to fly.

[FrequentSLF]

Report


The investigation is ongoing and will include examination of:....

....the risks associated with reduced power takeoffs and how they are
managed

Looking to get that part of the report

[fred_the_red]

Just an interested observer (please be gentle). If figures mentioned before in this post are correct, the typical take off weight is around 360 tonnes and the weight entered into the aircraft systems was 100 tonnes less - around 30%.

I assume that, as the take-off was not a '100%' power (please insert correct terminology), the computer systems calculate the amount of thrust required for safe take-off based on, amongst other factors, the entered aircraft weight? Would not such a large discrepancy - 30% - be noticeable, in terms of aircraft performance, early into the the take-off? Putting it simply, if my car tried pulling away from traffic lights using 30% less power, it would be noticed immediately.

[WellingtonFF]

Actually, I heard listening to the press conference that the investigation was honing in on that as one of the aspects that they were certainly concentrating on.

Somewhere there has been an error made either in input to the laptop, or in the laptop software (very unlikely), or in the transfer from the laptop output to the aircraft's systems, and the design of the system cross checks for such a fundamental input, whether human or computer hasn't picked it up. As I said above, a 40% difference in takeoff weight is fairly fundamental.

[rascott3888]

The full report can be found here - it takes a while to download.

http://www.atsb.gov.au/publications/investigation_reports/2009/AAIR/pdf/AO2009012_Prelim.pdf

The report gives an account of what happened - with pictures and graphics. But it gives no consideration to why it happened.

There are no comments on the content of the CVR.

I suspect the press q and a would be a little more revealing.

The Sun Herald asks the "WHY" question in its report:

How was the wrong weight entered in Emirates cockpit? | Herald Sun (http://www.news.com.au/heraldsun/story/0,21985,25408255-661,00.html)


RAS

[Hempy]

ITman, it's only a preliminary report.

p.s.

http://i87.photobucket.com/albums/k144/h3mpy/Scrape.jpg

:ouch:

[limelight]

I would like to see the program used for the T/O calcs. Especially the cross checks built in to make sure data is near correct. For instance, if it asked the flight duration, then some basic assumptions can be made about weight. Or am I assuming there are cross checks??

[denabol]

There has been stuff all media on the press conference so far but I notice the guy who writes Plane Talking points to a 60 second delay from brakes off to any sort of reaction in the cockpit, and that TOGA wasn't slotted into position until the plane was hitting stuff at the end of the runway.

How Emirates flight EK 407 struck it lucky three times leaving Melbourne and no-one died - Plane Talking (http://blogs.crikey.com.au/planetalking/2009/04/30/how-emirates-flight-ek-407-struck-it-lucky-three-times-leaving-melbourne-and-no-one-died/)

[Jofm5]

Not a pilot in any respect however...

As much as the documentation on this incident points to a manual error and whilst I am glad it was not a tragic outcome - I cant help but feel that more could have been done to avert this situation from a systems point of view.

I am not for a second criticising the crew although it would appear from the report that a large element of the blame seems to lay there. My concern is simply mis-typing one digit into a laptop or during transferring the data to the FMC is what is alledged to be what has been the fundamental underlying issue.

As a software developer myself and not a pilot this seems to be a case of the software and procedure biting the crew in the ass. In my own personal opinion the crew is not so much to blame as the procedure. Humans may not intend to make the odd typo here and there but we do, and yes we should be double checking and triple checking things but it is a fact of life when we look at things we tend to see what we expect to see not what is really there (check this if you want to see how good the mind can be at correcting what is actually there with what you expect to see Do You Have An Amazing Mind? (http://www.scribd.com/doc/50470/Do-You-Have-An-Amazing-Mind)) - we can be our own worst enemies without even knowing or realising it quite easily.

I think the aviation industry should not just be concentrating on what the errors were with what was entered in the FMC but more with how the software can deal with such erroneous entries. For a start eliminating the step of transfer from a laptop to the FMC would be good but it would be better if the the FMC could (maybe it can I dont know) check that the parameters entered are acceptable with axel weights - Pressures on the axels would not have to be that accurate and could probably be easily measured on oleo movement all that would be required would be an acceptable margin.

Apologies for my tuppence worth but I think the problem highlighted is alot bigger than pilot error. As the saying goes - to err is human, to really cock things up requires a computer (add in a few stages in between and your asking for trouble).

[Wiley]

There's a really east to implement procedure that would be a great aid to avoiding a gross error, and that would be for the optimum takeoff figures for the expected runway (which is already included in the flight plan) and the planned ZFW and fuel load to be included in the printed flight plan immediately above where the actual figures are to be hand written.

These figures would not be used by the operating crew other than to provide a crosscheck with the figures they come up with after recieving the latest information (actual ZFW and runway/weather conditions.)

It wouldn't be fool-proof. (For instance, the runway actually used is frequently different to the one planned, and notams may or may not become an issue.) However, it would provide a gross error check, and I can't help but think this would be more useful than both pilots doing separate calculations immediately before engine start.

[Obie]

What a load of nonsense!
The procedures to ensure these mistakes do not happen have been in place for the last 40 yrs!
Apply standard operating procedures, as per your company's manual, and standard ops will occur.
The crew stuffed up, that's obvious, let's find out why! :ok:

[b_sta]

Why did it take right up until crossing the threshold before the PF decided the situation warranted TOGA thrust?

[Jofm5]

What a load of nonsense!
The procedures to ensure these mistakes do not happen have been in place for the last 40 yrs!
Apply standard operating procedures, as per your company's manual, and standard ops will occur.
The crew stuffed up, that's obvious, let's find out why! http://static.pprune.org/images/smilies/thumbs.gif


The A345 came into service in 2002 so where did the other 33 years of procedures come from ? I am sure they were not calculating weights etc with laptops and typing them into the FMC 40 years ago especially with the A345 in mind.

These pre-emptive 33 years took into account human error I guess - your assertion is that the crew did not follow SOP's - people do however make mistakes, that you will never eliminate - but you can at least try to spot them.

[Border Reiver]

One question here, how many similar events have occured using paper calculations as opposed to laptops? 2 events using laptops spring straight to mind, this and MK, none from paper.

I should add that I've never used a laptop for TO calcs only ACARs and far too many years of performance manuals.

[Obie]

One doesn't need a laptop plus an Fmc to work out that EW+Fuel+Pax+Freight=TOW.

If you do then I suggest you shouldn't be in the job! :ok:

[ekwhistleblower]

Simple GIGO. The EK procedure is designed to try and trap the errors via Gross Error Checks and a final cross check of the lap top Green Dot, Minimum Clean speed and the Minimum Clean Speed in the FMS.

At 360 tons GD would have been about 265 ish, at 260 tons 30 kts or so less. If they had followed the mandated procedure they would have caught the error. However even if they hadn't followed the procedure I would hope most pilots would have the awareness to recognise that a 360 ton A345 needs Flap 3 not Flap 1, 170kts ish to rotate and 265 kts for minimum clean with a flex somewhere in the 30s not 74. That a crew did not know that is a concern and the lack of awareness maybe points to a complacent rather than questioning culture. Also reading the report I wonder how many of us would have selected TOGA having reached the 900m to go markers without any obvious signs of getting airborne.

Earlier someone questioned the level of thrust reduction. The max reduction from Flex is around 25% depending on the airport so they would have had probably 20% less thrust than expected during the take off roll.

Some may think I am harsh but I feel sorry for the guys on a personal level but not professionally.

[Mister Warning]

EkwhistleBlower,
There but for the grace of God go you or I.
A professional crew that makes a fundamental error = contributing factors.
None of us are immune fom error.
And by the way, the error in your post is that at 360 tonnes the flex off Rwy 16 in Mel is 45 - not in the 30's.
So much for your awareness - now I'm concerned for you!

[helen-damnation]

ekwhistleblower

needs Flap 3 not Flap 1,

Not necessarily so. I'd be interested to see the figures for that.

I would hope most pilots would have the awareness to recognise

Depends what you've been flying recently and on what sectors you've been flying in the a/c and how tired you are. With the mix of types and the ability to be legal on the 340 but not fly the specific "variant" for months that doesn't hold true.

Also reading the report I wonder how many of us would have selected TOGA having reached the 900m to go markers without any obvious signs of getting airborne.

With the introduction of RAAS, I'll be using that as a trigger if the speed trend isn't where I think it should be.

[BigHitDH]

Is there no system on the A330/40 to make a reasonable calculation of aircraft weight/balance based on oleo compression? I'm not familiar with airbus aircraft but they seem to do just about everything else! :rolleyes:

[david1300]

@ No Land 3 - thanks for the answer to my post - much appreciated.

[Capn Bloggs]

EKwhistleblower,
Also reading the report I wonder how many of us would have selected TOGA having reached the 900m to go markers without any obvious signs of getting airborne.
There are no such markers on the runway at YMML. Where are they?

Putting it simply, if my car tried pulling away from traffic lights using 30% less power, it would be noticed immediately.
Well, if you customarily slammed your foot to the floor on the green light, you probably would. But if you just cruised off from the lights like most, I'm not so sure... I would just put my foot down a bit more, if I did notice.

[fred_the_red]

I'm not so sure... I would just put my foot down a bit more, if I did notice. That's my point though - 'User Input' - would the pilot not increase power accordingly during the take-off when he noticed there wasn't the required power? Would an experienced pilot not have a 'feel' for a take-off (ie. sluggish performance, etc) regardless of what the instruments were saying?

[Oakape]

fred_the_red,

Taking off in a large jet, using balanced field length figures for every departure, is not the same as taking off in a light aircraft. At high gross weights all take-offs seem sluggish to start with. Then the acceleration picks up & you rotate with the end of the runway rushing towards you. Sometimes I wonder how we would ever stop from V1 in the runway remaining at that point, but you have to trust the figures.

If you look at the initial tailstrike location in the diagram in the accident preliminary report & allow for the 9 second time interval between initiating the rotate & first tail contact that is also in the report, the rotate position on the runway was about right for a normal take-off.

The extra 100 tonnes over the weight used for the calculations would have some effect on the time to reach rotate speed, but I don't think it would have been that significant. The big problem was that the speed attained was some 20kts short of what was required for the aircraft to fly at the weight it actually was.

The crew would have had very little indication that things were not right until they rotated & the aircraft did not fly. The aircraft 'always' flys when you rotate at Vr & the crew would have been wondering wtf was wrong. With the end of the runway rapidly approaching & not knowing what the problem was, the captain's first reaction was to command more pitch in an attempt to get the thing in the air. When that didn't work the only other option was to push the thrust right up & hope for the best.

When they finally staggered into the air I would be willing to bet that they still didn't know why the aircraft didn't want to fly at Vr. They may have thought of an incorrect flap setting, a screw up by the loaders & extra weight not accounted for in the figures or a number of other possibilities. It would have only been at some stage during this trouble shooting discussion that they would have realised what the problem was.

It is just extremely lucky that it was on 16 at Melbourne & they had the overrun & relatively obstacle free departure path that they had, or the result could have been vastly different.

[B772]

It appears the thread could now be renamed "EK407 Accident at MEL".

I am surprised the Preliminary Report did not make reference to the crews
A330-200 experience or highlight the 37 tonne overweight landing.

In my view there was little in the report to reflect the time taken to table it.

[fred_the_red]

Hi Oakape - thanks for the reply :)

Another, maybe overly simple idea (for a non-pilot), why not engage full throttle for all take-offs and adjust throttle back when safely airborne, either manually or via automated flight systems? I'll duck for cover now :ouch:.

[Old Fella]

fred_the_red. When Max thrust is used for take-off that thrust is only used until shortly after take-off when it is reduced to Climb Thrust. Reduced thrust is used when possible to enhance engine life. The turbine section is like an elephant, it has an enduring memory and every time a temperature higher than a previous one is reached it is "remembered". The cumulative effect on the turbine determines it's operational life. Reduced thrust take-off procedures are in themselves not dangerous. What can lead to an incident/accident like Emirates is a reduced thrust setting being used when not appropriate.

[Ex Cargo Clown]

The crew would have had very little indication that things were not right until they rotated & the aircraft did not fly.

Are you sure about that ?

Surely the PNF calling out rotate at a speed that was clearly insufficient would have rung alarm bells.

I can't believe they operate any ULH revenue routes where Vr could be such a low figure.

There are definitely some serious human factors involved in this, I cannot believe fatigue does not play a part.

[JulieFlyGal]

With the end of the runway rapidly approaching & not knowing what the problem was, the captain's first reaction was to command more pitch in an attempt to get the thing in the air.

Wouldn't increasing the pitch aggravate the situation even more, ie, cause airspeed to decay? Would have thought the first reaction would be to apply full throttle if the aircraft didn't lift off at Vr.

Anyway, it's easy for us to say all this in hindsight, but the guys upfront only had seconds to decide what to do. I'm very much appreciative of their handling of the abnormal take-off and so too are my grandparents who live in Keilor not too far off from the runway 16 centreline.

[YoDawg]

The extra 100 tonnes over the weight used for the calculations would have some effect on the time to reach rotate speed, but I don't think it would have been that significant.

With the incorrect TOW entered into the laptop, the computed VR is also incorrect, for starters, so the aircraft will not become airborne properly when that incorrect VR is reached. (ie: a higher than normal body-angle is required or a tail-strike occurs during)

Since the thrust is appropriate for the wrong weight, the aircraft will not even accelerate correctly to that incorrect VR, let alone the correct VR.

Incorrect VR is reached further down the runway than computed. And in this case, even the correct VR was not reached on the runway.

That's my point though - 'User Input' - would the pilot not increase power accordingly during the take-off when he noticed there wasn't the required power? Would an experienced pilot not have a 'feel' for a take-off (ie. sluggish performance, etc) regardless of what the instruments were saying?

The pilots DID increase power. The question is (or was) when.

In your car, you can determine normal acceleration quite easily. Engine noise and visual cues from being a foot above the ground are easy to judge. Even throttle position with your foot can help. The Airbus throttles go to the same position EVERY time (except TOGA takeoffs).

In an airliner, with eye-height that far above the ground, acceleration oftens looks insignificant. Then there's the added factor of night-time conditions which can reduce the visual cues to a series of points of light.

As for noticing the "feel", pilots are not jedi knights and The Force does not help them. Flying the same type on the same route, yes, you could reasonably expect a pilot to notice this sort of event early on.

But with the variations in conditions experienced on THREE different types of Airbus with many different weight ranges, runway lengths, airport elevations and temperature extremes, you can reasonably question whether or not the "feel" can be relied upon.

why not engage full throttle for all take-offs and adjust throttle back when safely airborne, either manually or via automated flight systems? I'll duck for cover now

If you're ducking for cover, you must have some idea what sort of suggestion you're making but you make it anyway. :confused: I think it's been covered by now that the flex procedure is quite normal and not, in itself, a threat to safety. In the right conditions, this accident could've also happpened using rated thrust if a critical error had been made during performance calculations.

[J.O.]

With this preliminary information now available, it seems to me that the airline's claims in the media of having safety as their highest priority are decidedly hollow. Given that the crew involved have been gassed by their employer, how much of a safety culture do they actually expect going forward? I can see many more ASRs going in the bin with a culture like that in play.

JMHO

[HundredPercentPlease]

I am surprised the Preliminary Report did not make reference to the crews A330-200 experience

I have heard some interesting stuff about this, but could someone more knowledgeable answer:

What aircraft were they rated on and when (330/340)?
What sort of ratio of time spent on each type?

Obviously what I'm getting at is, could it be that they were experienced on the 330 and entered a 330 kind of weight when in a 340, and could training/experience of the 340 have had anything to do with this error? Are we back to Kegworth (differences course)?

Apols if off target, but this thinking came from an EK driver.

[Oakape]

Ex Cargo Clown,

Surely the PNF calling out rotate at a speed that was clearly insufficient would have rung alarm bells.
The PNF called rotate at the bugged Vr, where he was supposed to. This call is a backup call & the PF is required to commence rotation at the bugged Vr, whether the call is made or not. Therefore, he/she is required to monitor the speed during the take-off as well as the PNF. I put it to you that the speed wasn't clearly insufficient, as there are a number of occasions where the speeds are discussed prior to the aircraft commencing the take-off roll, & the crew obviously thought that they were sufficient at these points in time! They are only clearly insufficient with 20/20 hindsight. However, the fact that 4 pilots did not feel that the v-speeds that were generated were somewhat low is something that should be looked at. Many things could lead to this, including cross-type qualification, distraction, inadequate cross check & fatique, to name just a few. To try & pin down a reason at this stage would be pure speculation.


There are definitely some serious human factors involved in this, I cannot believe fatigue does not play a part.
Of course there are human factors involved in this error. I would put it to you that this part of the accident chain is purely human factors related, as opposed to a technical issue.

JulieFlyGal,


Wouldn't increasing the pitch aggravate the situation even more, ie, cause airspeed to decay? Would have thought the first reaction would be to apply full throttle if the aircraft didn't lift off at Vr.
This is a very good question. From the preliminary report the aircraft started to rotate at 152 kts. 8 seconds later the aircraft was still accelerating as the speed was 156 kts when the tail contacted the runway. A slow acceleration for sure, but still an acceleration. However, from this point, the aircraft did not get above 157 kts until after it was airborne. So even though maximum thrust was applied, the aircraft did not continue to accelerate - possibly due to excessive pitch, or due to the extra drag from the tail scrapes & the main gear rolling over grass rather than paved runway, or a combination of both. Perhaps someone with a good knowledge of the theory of flight could shed some more light on this.

YoDawg,


Since the thrust is appropriate for the wrong weight, the aircraft will not even accelerate correctly to that incorrect VR
I agree, but still feel that the difference to the physical position on the runway that Vr was reached wouldn't have been large enough to have a visual impact on the pilots during the take-off roll. Particularly at night & if they hadn't flown this sector off rwy 16 at Melbourne for a while. My reasoning for this is based on the position on the diagram in the preliminary report that shows the location of the start of the first tail strike & guessing how far before this point the crew commenced the rotation, given the fact that the rotation was commenced 9 seconds before this point.

Perhaps some of the geniuses on this forum could compute the distance from the commencement of the take-off roll to the rotate point, using the figures that the crew used & also using the correct figures. I would be interested to see what the difference in distance would be.

[CONF iture]

Obviously what I'm getting at is, could it be that they were experienced on the 330 and entered a 330 kind of weight when in a 340, and could training/experience of the 340 have had anything to do with this error?
Virtually similar cockpit but so much different aircraft regarding the weights. One guy can enter 262 tonnes and feel very confident as it is pretty close to MTOW for the 340-300 he may have flown the week before ...

Flying so different aircrafts but from so similar cockpits must be part of the problem.
Add up fatigue and that's when you turn complacent.

[Ex Cargo Clown]

Of course there are human factors involved in this error. I would put it to you that this part of the accident chain is purely human factors related, as opposed to a technical issue.


I was suggesting that there were two points that the error could have been "trapped", on entering the ZFW figures into the Laptop and on entering the V speeds into the FMC.

Surely one of the issues with this is that by bugging the speedtape through the FMS unless you are on the ball it is quite easy to enter an erroneous figure, ie one which the laptop says is correct but logic says isn't. Thus on takeoff the Rotate call will be made parrot-fashion without the usual, expected climb out.

Would things be any different if they were on old-fashioned steam-driven instruments, ie clockwork ASI with manually set bugs ? Maybe the picture would then have looked completely wrong, wrong enough to have been "trapped" before departure.

[DonLeslie]

I was suggesting that there were two points that the error could have been "trapped", on entering the ZFW figures into the Laptop and on entering the V speeds into the FMC.Which is why our performance program has been modified to ask for confirmation of any entered TOW below 300t for the A340-600 and both pilots have to do their calculations independently. Then we compare our figures and enter them into the FMS. Only way to prevent these things from happening.

Cheers,
DL

[wowzz]

As an impartial SLF observer can I just say how unhappy I am with Emirates [can I use that word?] handling of this whole issue. As an outside observer it seems to me that the airline is taking an ostrich like approach to the whole issue rather than facing it head on [sorry for the cliche]. Surely in such a large company 'collective responsibilty' sholud be the management mantra rather than trying to find convenient scape-goats.

The issue of allocating blame seems incidental compared to the number of lives that could have been lost had not the flight crew been aware of the nature of the danger they were in, and taking the appropriate remedial eaction. Emirates seem reluctant [under-statement!]to give appropriate thanks to the flight crew- the 'sweep under carpet approach' seems more appropriate.

Given the choice on the routes operated by Emirates, I think I might prefer to choose other airlines, until Emirates become a little more open and honest in their dealings with the people who really matter.

[RatherBeFlying]

The thrust is calculated so that at any speed below V1, the a/c can be stopped on the remaining runway. Often that distance is less than that required to continue a takeoff after losing an engine.

In order to provide the basis for takeoff performance charts and, these days, software, engineers determine by experimentation and interpolation braking distance from various speeds, weights and runway conditions and then add the mandated margins.

The fancy new takeoff performance software in the laptop uses the braking distance in its calculations.

Now if the laptop software also told the pilots that braking distance and if remaining distance signs were available for distances beyond 3000' where the first runway marks appear (for those cases where more than 3000' is required to stop from V1), the crew would know when the required braking distance came up before V1 that either the weight is wrong or that they did not obtain sufficient thrust at a point where they can get the a/c stopped before going off the end.

[Oakape]

The fancy new takeoff performance software in the laptop uses the braking distance in its calculations.

Now if the laptop software also told the pilots that braking distance and if remaining distance signs were available for distances beyond 3000' where the first runway marks appear (for those cases where more than 3000' is required to stop from V1), the crew would know when the required braking distance came up before V1 that either the weight is wrong or that they did not obtain sufficient thrust at a point where they can get the a/c stopped before going off the end.

The software needs a number of variables, including aircraft weight, in order to calculate braking distance. Where does it get the weight? You guessed it - from pilot input! Different weight - different braking distance.

So this would not trap a pilot input error, as happened in Melbourne.

[Runaround Valve]

I had an fellow Licensed Engineer who became a Flight Engineer. He told me one day, that on a Boeing 747SP going from Sydney to Wellington they used a reduced thrust take off. After gear retraction the Captain called for climb thrust, so he advanced the thrust levers. !!!

[Old Fella]

Runaround Valve. Nothing at all unusual in increasing thrust from a Reduced Thrust Take-off EPR to initial Climb Thrust. Not an everyday event, but nonetheless not a rare event by any means.

[Bula]

consider night time, perception fatigue adn the few seconds they had to consider the "what the" factor.

[White Knight]

DonLeslie - the 345s don't just do heavy ULR sectors but very often we operate them on short sectors such as the 3 hour trans Tasman hops, Europe, Middle East stuff.. Anyway - if you follow the SOPS that we had at the time then the error would have been picked up!!

Saskatoon - ECAM screens old bean, not Eicas:ugh:

[fotoguzzi]

@DonLeslie: (Not a pilot. No need to respond)

a) Could crosscheck calculations reveal: You have enough fuel for roughly forty hours in the air (or some other ridiculous figure)? (I'm presuming they had enough fuel onboard to keep that extra 100 tonnes airborne for the planned duration.)

b) A large US manufacturer will apply minimal paint upon request. The manufacturer's weight is monitored that closely. Couldn't the weight and balance calculations produce a figure somewhat in line with that original measure for the specific air frame?

To belabour: The weight and balance sheet for a short flight with ping pong balls would look vastly different than that for an automobile axle shipment halfway around the world. But, in both cases, a similar tare weight should emerge.

Edit: typos

[Obie]

...now look guzzi, I gotta tell ya...

you've hit the nail on the head with your post!...

you are definitely, The Man!!

as a matter of fact, you're my Hero! :ok::ok::ok:

[DonLeslie]

@ White Knight:

Anyway - if you follow the SOPS that we had at the time then the error would have been picked up!!That's what I thought. I would have been surprised if your procedures differed greatly from ours but I didn't want to accuse anybody of not following SOPs without knowing exactly what these SOPs are.

Cheers,
DL

[mensaboy]

To address a few questions put forth.
1-TOGA thrust WAS applied after the 2nd Rotate call after no rotation was apparent at the incorrect Vr speed. Therefore they made the correct response but unfortunately by this time the tail was scaping the runway.

2-Flex takeoff thrust does not supply less power than climb thrust (part of the computer program), unlike on some older aircraft types. Therefore, retarding the thrust levers to climb thrust at acceleration height, will not result in more thrust from the engines. I am basing that on past performance training, since these particulars were not taught at EK. Performance training on the Airbus, is less than ideal at EK and I don't think anyone would disagree with that fact.

3-One fellow was discussing how there can be some instances when it is still possible to get airborne on the remaining runway with a failed engine BEFORE V1. Sometimes this might be the case, but there are too many factors to even consider this option. VMCG is one of those factors. Engine failure before V1= rejected takeoff.

On the other hands, sometimes there is obviously enough runway available to STOP an aircraft AFTER V1 with an engine failure, but it is not an option. In fact, the experts have determined that a pilot should be GO MINDED after 100kts and up until V1, which of course means AFTER V1 a pilot should never consider trying to stop on the remaining runway, unless it is obvious the aircraft will not get airborne (something catastrophic in other words)

The manufacturers takes the view that it is better to get airborne after a problem occurs at high speed on the runway (below V1) except in a few instances. Airbus gives 5 examples when a pilot should consider rejecting a takeoff above 100kts and below V1.

Since these guys rotated at what they thought was the correct speed, and given the inherent time delay, they had but one option and that was to apply TOGA thrust and continue the takeoff. Perhaps it was possible to stop in the remaining distance, who knows, but it was not an option.

So they made one mistake, entering a number into either the laptop, MCDU or both computers. The question remains why?

4-Another fellow mentioned that being qualified on 3 types of airbus, each with vastly different performance, weights, (number of engines too) might be a factor. I agree. It was a causal factor and one that should be addressed. It is not uncommon to lose currency on either the A340/A332, which means more than 90 days without a takeoff and landing in one of the types. (A343 and A345 are considered one and the same, in spite of the fact they have much different characteristics on takeoff and landing)

The aviation gods at EK will say there is no issue flying the different types but isn't it interesting that both major and near catastrophic accidents at EK in the past 5 years occured as a direct/indirect result of CCQ on the Airbus. The Johannesburg accident was a direct result of cross-training and the MEL accident was likely in part caused by this policy as well. The Joburg guys had never even flown an A343 prior to their takeoff from a high elevation airport, in an underpowered (relatively speaking) aircraft, and with improper training. This fact, rather explicity demonstrates EK's attitude wrt to cross-training.

In any event, it is more likely for pilots to remain oblivious to an input error in the computers, if they are not as familiar on type. I hope this factor is addressed by the authorities.

[Old Fella]

fotoguzzi - I think I know what you are driving at. 40 hours fuel - Not on this aircraft. Minimal paint - irrelevant in this instance. Tare weight - I guess you mean Aircraft Empty Weight. Mate, the problem occurred because an error was made in entering the Takeoff weight and from that error the resultant V speeds were incorrect and a lower than required thrust setting for takeoff was used. No rocket science, just an undetected error made which had the potential to cause a much worse outcome. I recommend the post by mensaboy to you, it is well thought out and makes a lot of sense, to me at least.

[Kennytheking]

mensaboy, well said.

If I may add......

The fate of this flight was sealed the moment the laptop was put away.

Many people do not understand 4 engine take-off performance and that is why they reason "could the pilot not feel there was a problem". On day 1 of my A340 conversion, I was told "You are going to see a lot more of the departure end of the runway" and this is a fact. A correctly calculated takeof performance will optimally utilise every inch of runway and is very often TORA limited rather than the 2nd segment climb limits that usually dog the twins. In the MEL case the guys would have run most of the runway and then close to the end would have rotated at the calculated Vr(albeit an incorrect one).......why would the pilot have thought anything was amiss until the airplane did not lift off.

In terms of knowing the numbers....well, I don't think I have done a 350 ton take off in a 340 since my CCQ and I have been here a while(I have seen it done many time from the blind seat in the rear right corner). This is an academic point because do you really want to rely on the pilot operating on the wrong side of the clock to sense an error, or would you rather see more robust SOP's in place.

I also don't believe that these guys just ignored SOP.....I have never flown with a captain that did not do the performance check. The question should rather be did they follow the correct procedure(training) and if so, how did the error slip through. I personally have had to sit down and have a good review of the procedure. I don't know why the FCOM3 brings the qrh into the greeddot check. I think we should simply have a dispatch calculated greendot next to the Estimated TOW(on the LIDO flightplan)and next to this we write the laptop GD and the MCDU GD. If these 3 are close together you cannot have a gross error in TOW.

I might also add that the pre-departure workflow is total chaos. This has been identified as a problem but not addressed. It is like a ping pong ball in a jacuzzi.....all over the place. It is highly probable that the performance check was interrupted by some obscure requirement like security demanding their checklist be signed.......:rolleyes:

Anyway, just my tuppence worth.......

[Al Fakhem]

Given today's sensor technology, it is surprising that not at least one of the following solutions has been adopted:


"weighbridge" concept: a/c passes over a strip of load cells on taxiway or at runway threshold, where actual take-off weight is determined and relayed to cockpit crew for verification of their loadsheet calculationsor


built-in weighing capability by using load cells in landing gear suspension to continuously monitor actual aircraft weight at any given moment on the ground.Neither solution is prohibitively expensive and could, essentially, even be integrated into take-off weight calculation software.

[Wiley]

If something similar to Kennytheking's comment (below) isn't part of the final report, I'll be very, very surprised.I might also add that the pre-departure workflow is total chaos. This has been identified as a problem but not addressed. It is like a ping pong ball in a jacuzzi.....all over the place. It is highly probable that the performance check was interrupted by some obscure requirement like security demanding their checklist be signed.......

[TWT]

Self weighing aircraft ? Been discussed before,e.g.

http://www.pprune.org/questions/152389-planes-weigh-themselves.html

As for tarmac weighbridges,who pays for installation,maintenance,calibration ?

[Dropp the Pilot]

Never, ever, going to happen - refer to post #280.

[GMDS]

Kennytheking


How I love your misspelling (please don't go and edit it!):


greeddot


It is so fitting for EK, almost freudian

[White Knight]

Mensaboy - the JNB incident was because the captain derotated the aircraft trying to maintain the 'german cross' at 9 degrees. It may have been bad gen from a TRI or TRE or LTC but since when do you derotate a large, heavy bird at take-off?????

I personally have no problem with flying MFF - in fact I haven't flown 343 for 4 months but would be more than happy to jump in one tomorrow. Some of you guys try to turn a simple job into rocket science and want to get your astronaut wings issued too:ugh: I also know very few guys that have gone out of recency. It has happened but is not that common.... And I think the responsibility of maintaining currency is up to you the pilot, so if you mensaboy are going out of currency on 330 or 340 then I have no sympathy if you then have to go sim:E:E

Kenny - good post. I don't think the 2 guys were ignoring SOP but for both to miss the figures is somewhat startling.. I'm sure the loadsheet wasn't 130 tonnes out was it?

[CONF iture]

Dropp the Pilot, I certainly agree with your comment on post #280 (http://www.pprune.org/rumours-news/366754-ek407-tailstrike-ml-14.html#post4815539) but that was clearly not the case for EK407.
As the report did not mention any cargo, the average weight for each pax + his baggage was already over 200 kg (440 pounds)

The report is interesting for the pictures, but I would have loved to see a copy of the W&B, also the perf figures how they should have been, where the rotation should have taken place ?

Also no indication if in this scary situation the Captain touched its sidestick ... ?

[Oakape]

Like everyone else I am not privy to what went on in the flightdeck that night. However, it would surprise me if the crew were not aware of the weight of the aircraft. It would have been discussed during the flight plan review, during the final fuel decision & passed to load control for the load sheet.

The problem as I see it, is that the weight was incorrectly entered into the laptop in what appears to be a simple typo. Then, for reasons not yet known, the error was not picked up on the cross-check of the laptop. Nor did the V-speeds look wrong for the weight, to 4 qualified pilots. If this does turn out to be the case, no amount of weighing the aircraft & delivering this weight to the crew would have prevented the accident in Melbourne.

Perhaps an SOP, that in this procedure simply required one crew member to check a bunch of figures entered into a computer by another crew member, is not an adequate error trap, particularly considering the serious safety impilcations of getting it wrong. I would have thought that with what is now known regarding human error, particularly in regard to aviation, that a more robust method of error trapping for this critical aspect of flight preparation would have been devised & formalised in the SOPs.

That being said, this accident hopefully will serve as a warning to all flight crew of the serious nature of the business & how quickly & easily it can bite you. It is certainly a sober warning to me of the need to constantly review my performance & the need to ensure that if I am required to cross-check something that I actually do a thorough & deliberate check, rather than just glancing over it because I am busy, distracted or tired & it has always been correct in the past.

[ishe]

sorry i have not read every reply in this thread so maybe this may have been posted already elsewhere, if it has sorry, it is a very easy and possible error to enter the ZFW instead of TOW???

[J.O.]

Looking at the man-machine interface aspects, I have another question relating to the laptop tool in use at Emirates. Does it transpose the computed takeoff weight from the load and trim software directly to the takeoff performance software, or does the crew have to manually transpose the figure from one to the other?

Thanks in advance.

[MrMachfivepointfive]

Nope. Just TOW-100tons. 2xx iso 3xx.

[sanddude]

White Knight if life was that easy mate:ugh:.

Check out post 734. Did most major airlines in europe see something coming, that EK didn,t ?
Why is EK in that respect always behind the curve. Is it because of the old school thinkers ,like yourselfs, in to many keypositions, or is it a moneything( software cost for example). Hell ,even the low cost boys have the more expensive airbus fcom software on there laptop!

[Abacus]

Forgive me if I am missing something blindingly obvious here!
Most of the previous threads refer to the possibility of entering erroneous figures into THE laptop, and transposing figures from THE laptop to the MCDU.

When I did my 'FOVE' course at Airbus we were taught that both pilots did the performance calculation independently and the results were compared between the TWO laptops. That precluded the possibilty of two incorrect calculations. This is standard SOP in my company.
It could well of course be that on the day, with many distractions that abound on a flight deck just prior to departure when everything comes together in the last few minutes, that caused the error to go un-noticed.

I presume EK use the same laptop system, so is it not SOP's for both pilots to do the performance calculations? If so, then presumably the problem started earlier in the chain.
Without, of course, any knowledge of what happened, the old adage with computers - 'rubbish in = rubbish out' springs to mind! :confused:

[mensaboy]

Whitenight,

It was not ''bad gen'' from the training department, it was the wrong technique being taught by some individuals. Many pilots were instructed to use the german cross, but thankfully the line guys knew better and most of us did not perform our first real takeoff in an A343 out of Joburg! Remember how ''avoid a tail-strike'' was literally beat into us, pretty much at the exclusion of everything else? So for you to explain away the accident simply by blaming the pilot for derotating, is to ignore the true causal factors.

I have no problem flying MFF either; you missed the point. It CAN be a contributing factor especially if currency is somewhat lacking. I'll bet you anything, the average A343 pilot who only flies an A343 will be more proficient than the average pilot who flies 3 types and as you put it, only once in 4 months.

I never complained about losing currency either. My currency has lapsed and the rostering department was advised well in advance, yet they did nothing to fix the problem. According to YOU, it is still the pilots fault even if he tried his best to fix the error coming out of rostering.

Some pilots who decree that this job is simple, MFF is never an issue or use the ''it's not rocket science'' argument, tend to expound on these topics in an attempt to convince people that 'they' manage things fine, so therefore they should be viewed as a better pilot than someone with the audacity to believe that MFF might be a contributing factor.

I once flew with a guy who spoke almost the exact same words you wrote in your post, yet on departure when ATC asked us to expedite our departure climb thru 2000', he went on a tirade about ATC not understanding the capabilities of the A340. Yet he continued accelerating past S speed, past green dot speed (about 240kts). Not too bright, and not exactly rocket science either.........but I have no doubt he still views himself in much the same light as you view yourself.

I enjoy MFF flying because it makes my job more interesting and it also makes my schedule better. But to go 89 days since your last flight on type, is not exactly ideal under some circumstances. Rostering 2 pilots for their first takeoff on the A343 out of Joburg, is just dumb.

To view yourself as maintaining the exact same proficiency on 3 types as opposed to 1 type, is a tad arrogant. To criticize pilots who realize it is more probable to omit something due to MFF, smacks of an attitude not conducive to safety or perhaps reality.

I truly hope you never forget some obscure OEB or FCI pertaining to one aspect of your flight on a given day. Do you base the success and skill of your flight solely on your landing too? Just wondering... kind of fits the pattern.

[VH-RMV]

Three EK pilots speak off the record to the Herald-Sun about fatigue concerns:


Tired pilots plea | Herald Sun (http://www.news.com.au/heraldsun/story/0,21985,25419687-661,00.html)