EK407 - Tailstrike YMML 20 March
Join Date: May 2008
Location: Abu Dhabi
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Our sops require that both laptops are used independently, by that I mean you are required to copy the atis independently and enter all data without the other pilots input.
If one laptop is inoperative, then one pilot enters all the data, gets the numbers and shuts down the FOVE. The other pilot has to start the program up again, this helps to makes certain that he will have to enter all data again.
If both Laptops are u/s we are required to get old style performance charts from our dispatch department.
No system is full proof and we are all susceptible to making mistakes.
If one laptop is inoperative, then one pilot enters all the data, gets the numbers and shuts down the FOVE. The other pilot has to start the program up again, this helps to makes certain that he will have to enter all data again.
If both Laptops are u/s we are required to get old style performance charts from our dispatch department.
No system is full proof and we are all susceptible to making mistakes.
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Just in from the ATSB
SAFETY ACTION
Aircraft operator
On 17 April 2009, the aircraft operator informed the Australian Transport Safety
Bureau that based on their internal investigation the following areas were under
review:
•
human factors – including review of current pre-departure, runway
performance calculation and cross-check procedures; to determine if
additional enhancement is feasible and desirable, with particular regard to
error tolerance and human factors issues.
•
training – including review of the initial and recurrent training in relation to
mixed fleet flying and human factors.
•
fleet technical and procedures – including introduction of a performance
calculation and verification system which will protect against single data
source entry error by allowing at least two independent calculations.
•
hardware and software technology – including liaising with technology
providers regarding systems for detecting abnormal take-off performance.
Subject: More on Emirates - close call at YMML.
Emirates flight 407: seconds and centimetres from death
Ben Sandilands writes:
Emirates flight EK 407 and the 275 people on board were seconds and centimetres from a fiery death when it left Melbourne Airport, still touching the ground, on a flight to Dubai on the night of 20 March.
The critical moments of this incredibly screwed up takeoff have been laid bare in words and graphics in the preliminary factual report into the accident released today by the Australian Transport Safety Bureau.
It happened because the pilots entered the wrong weight figures into the flight management computers -- they were 100 tonnes under the true weight -- and didn’t engage full thrust until they reached the end of the 3657 metre runway and hitting navigational antennas and lights at a velocity of 290.8 kmh.
The Airbus A345 didn’t begin climbing until it was still blasting over grassy slopes slightly lower than the end of the runway and 292 metres beyond it pointed in the general direction of Keilor Park.
The jet then climbed to 7000 feet and did a fuel dump circuit over Port Phillip Bay before making an emergency landing back at the airport.
No-one was injured. The jet may have been damaged beyond repair and the pilots, who appeared to have flown more hours than many pilots would consider normal or prudent in their previous 30 days, have "resigned" from Emirates.
The airline is quoted by the ATSB as saying it will review some of its procedures.
These are the critical moments as detailed by the preliminary accident report.
The jet was using (as almost all airliners do) a reduced thrust "flexible" take off process that saves on engine wear and tear but is calculated to produce a safe takeoff, even with an engine failure, on the runway available, provided the data used by the flight management computers is the RIGHT data.
It began its take off roll with 3540 metres of the 3657 metre runway available. Not until 61 seconds later does the first officer start to rotate the nose of the jet up with 964 metres of runway left after a very leisurely take off roll.
About a second later the nose of the jet is pulled back much harder and higher. Eight seconds after this with 229 metres of runway left the first of three damaging tail strikes occur.
Two seconds later the jet has run out of runway and is smashing through lights and antennas in an extreme nose high attitude.
Almost immediately, and 115 metres past the end of the runway the main gear wheels register as "uncompressed" meaning they off the ground.
A further seconds later and 292 metres beyond the end of the runway and over falling ground a positive rate of climb is achieved.
But almost a minute passes before the wheels are retracted, cleaning up the air flow of the jet and aiding its ability to climb.
The captain had flown for 98.9 hours in the previous 30 days, or nearly 20 hours longer than most Qantas pilots might expect from a roster, while the first officer had racked up 89.7 duty hours.
These factual disclosures by the ATSB ought to cause a serious review by Emirates of key aspects of its operations.
Or they could set the scene for a truly horrific accident if left unaddressed, and one which no amount of generous sponsorship deals could ever overcome.
(Reference: Crikey, 30/04/09)
Aircraft operator
On 17 April 2009, the aircraft operator informed the Australian Transport Safety
Bureau that based on their internal investigation the following areas were under
review:
•
human factors – including review of current pre-departure, runway
performance calculation and cross-check procedures; to determine if
additional enhancement is feasible and desirable, with particular regard to
error tolerance and human factors issues.
•
training – including review of the initial and recurrent training in relation to
mixed fleet flying and human factors.
•
fleet technical and procedures – including introduction of a performance
calculation and verification system which will protect against single data
source entry error by allowing at least two independent calculations.
•
hardware and software technology – including liaising with technology
providers regarding systems for detecting abnormal take-off performance.
Subject: More on Emirates - close call at YMML.
Emirates flight 407: seconds and centimetres from death
Ben Sandilands writes:
Emirates flight EK 407 and the 275 people on board were seconds and centimetres from a fiery death when it left Melbourne Airport, still touching the ground, on a flight to Dubai on the night of 20 March.
The critical moments of this incredibly screwed up takeoff have been laid bare in words and graphics in the preliminary factual report into the accident released today by the Australian Transport Safety Bureau.
It happened because the pilots entered the wrong weight figures into the flight management computers -- they were 100 tonnes under the true weight -- and didn’t engage full thrust until they reached the end of the 3657 metre runway and hitting navigational antennas and lights at a velocity of 290.8 kmh.
The Airbus A345 didn’t begin climbing until it was still blasting over grassy slopes slightly lower than the end of the runway and 292 metres beyond it pointed in the general direction of Keilor Park.
The jet then climbed to 7000 feet and did a fuel dump circuit over Port Phillip Bay before making an emergency landing back at the airport.
No-one was injured. The jet may have been damaged beyond repair and the pilots, who appeared to have flown more hours than many pilots would consider normal or prudent in their previous 30 days, have "resigned" from Emirates.
The airline is quoted by the ATSB as saying it will review some of its procedures.
These are the critical moments as detailed by the preliminary accident report.
The jet was using (as almost all airliners do) a reduced thrust "flexible" take off process that saves on engine wear and tear but is calculated to produce a safe takeoff, even with an engine failure, on the runway available, provided the data used by the flight management computers is the RIGHT data.
It began its take off roll with 3540 metres of the 3657 metre runway available. Not until 61 seconds later does the first officer start to rotate the nose of the jet up with 964 metres of runway left after a very leisurely take off roll.
About a second later the nose of the jet is pulled back much harder and higher. Eight seconds after this with 229 metres of runway left the first of three damaging tail strikes occur.
Two seconds later the jet has run out of runway and is smashing through lights and antennas in an extreme nose high attitude.
Almost immediately, and 115 metres past the end of the runway the main gear wheels register as "uncompressed" meaning they off the ground.
A further seconds later and 292 metres beyond the end of the runway and over falling ground a positive rate of climb is achieved.
But almost a minute passes before the wheels are retracted, cleaning up the air flow of the jet and aiding its ability to climb.
The captain had flown for 98.9 hours in the previous 30 days, or nearly 20 hours longer than most Qantas pilots might expect from a roster, while the first officer had racked up 89.7 duty hours.
These factual disclosures by the ATSB ought to cause a serious review by Emirates of key aspects of its operations.
Or they could set the scene for a truly horrific accident if left unaddressed, and one which no amount of generous sponsorship deals could ever overcome.
(Reference: Crikey, 30/04/09)
Join Date: Jul 2003
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BITE System's SOP rules
Pool, I hear what you are saying. However just because something is the way it is, it doesn't mean it can't or shouldn't be changed for the better. Again I hear you with regards to the difficulties you face daily at work and I'm not being critical.
Basically our professional attitudes determine how we deal with dodgy SOP's to make them work for us.
Looking at what BITE System says it would seem they (the airline) have mastered that part of the performance calculation SOP's. It's obvious that no SOP is totally fool-proof as BITE System says as humans are involved in the process and ultimately even machines would make mistakes as they are designed by humans.
But using independant LPC's is way better than only using one without re-entering the data. I do believe that the idea is to reenter the data, but nobody does it. That could count against anybody experiencing a mishap with regards to that SOP. That's why the SOP should be changed to prevent complacency of just accepting the data.
We can all learn from BITE System's airline's SOP in this regard.
Basically our professional attitudes determine how we deal with dodgy SOP's to make them work for us.
Looking at what BITE System says it would seem they (the airline) have mastered that part of the performance calculation SOP's. It's obvious that no SOP is totally fool-proof as BITE System says as humans are involved in the process and ultimately even machines would make mistakes as they are designed by humans.
But using independant LPC's is way better than only using one without re-entering the data. I do believe that the idea is to reenter the data, but nobody does it. That could count against anybody experiencing a mishap with regards to that SOP. That's why the SOP should be changed to prevent complacency of just accepting the data.
We can all learn from BITE System's airline's SOP in this regard.
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Herald Sun editorial
Herald Sun - Editorial 3 May
EMIRATES pilots are telling the Sunday Herald Sun that fatigue is a problem within the airline.
Further, they believe that fatigue might have played a role in the EK407 tail-strike accident at Melbourne Airport on March 20.
Three current Emirates pilots, speaking after the release of the preliminary report into the near catastrophe, have spoken to this newspaper in the past few days.
They have directly contradicted the airline's claims that its pilots are not flying fatigued.
"When people are tired these mistakes happen - there is more chance that errors will be made," said one pilot.
"There is a huge issue with fatigue."
A second Emirates pilot said: "They're working us like dogs. If there is going to be a fatigue-related accident it is probably going to be an Emirates plane."
A third Emirates pilot said that internal reports examining air safety and fatigue were not being taken seriously by management.
In releasing the preliminary report last week into the near-tragedy, the Australian Transport Safety Bureau's director of aviation safety investigation, Julian Walsh, said the crew's work patterns were being looked at, but concluded: "Having said that, the information we have received from the crews through interviews plus other evidence, at this stage, is not indicating to any problem with fatigue."
Emirates executives were at pains to reject the possibility that fatigue played a part in the incident at Melbourne Airport.
In a letter sent to the Sunday Herald Sun yesterday, Emirates flight operations senior vice president, Captain Alan Stealey, said the airline closely monitored its crews for fatigue.
"Emirates is confident that pilot fatigue had no role to play in the March 20 event."
Last week, the Sunday Herald Sun - using impeccable sources - revealed that the pilot of EK407 was on the brink of reaching his 100-hour flying limit in a month.
Our front page report, headlined SLEEPLESS PILOT, and again based on impeccable sources, also revealed that the pilot had barely slept in the 24 hours before the incident.
The ATSB's report confirmed that the pilot had, in fact, reached 98.9 hours in the preceding 30 days.
The ATSB preliminary report has found a wrong load calculation entered into the plane's computer caused it to take off without enough speed.
As a result, EK407's tail struck the tarmac three times before the jet managed to just take-off, dump fuel over Port Phillip Bay and, thanks to some skilful flying, return 257 passengers safely to the ground.
Emirates pilots say at the heart of the problems within the airline is a "punitive culture" that spies on pilots and renders them too scared to speak up on safety matters for fear of being sacked.
One of the three Emirates pilots interviewed this week was scathing of the airline's management style.
"They report anyone for anything. You get a phone call and are called into the office," he said.
Clearly something is not right within Emirates.
One Emirates source has described the culture as a "very bad cocktail".
The ATSB must see through the airline spin and listen to the concerns of the pilots. Perhaps the time has come for authorities to take a broader look at Emirates and not simply limit their inquiry to the March 20 tail strike.
The pilots are, after all, the people who are directly responsible for the lives of hundreds of people every time they walk into the cockpit.
EMIRATES pilots are telling the Sunday Herald Sun that fatigue is a problem within the airline.
Further, they believe that fatigue might have played a role in the EK407 tail-strike accident at Melbourne Airport on March 20.
Three current Emirates pilots, speaking after the release of the preliminary report into the near catastrophe, have spoken to this newspaper in the past few days.
They have directly contradicted the airline's claims that its pilots are not flying fatigued.
"When people are tired these mistakes happen - there is more chance that errors will be made," said one pilot.
"There is a huge issue with fatigue."
A second Emirates pilot said: "They're working us like dogs. If there is going to be a fatigue-related accident it is probably going to be an Emirates plane."
A third Emirates pilot said that internal reports examining air safety and fatigue were not being taken seriously by management.
In releasing the preliminary report last week into the near-tragedy, the Australian Transport Safety Bureau's director of aviation safety investigation, Julian Walsh, said the crew's work patterns were being looked at, but concluded: "Having said that, the information we have received from the crews through interviews plus other evidence, at this stage, is not indicating to any problem with fatigue."
Emirates executives were at pains to reject the possibility that fatigue played a part in the incident at Melbourne Airport.
In a letter sent to the Sunday Herald Sun yesterday, Emirates flight operations senior vice president, Captain Alan Stealey, said the airline closely monitored its crews for fatigue.
"Emirates is confident that pilot fatigue had no role to play in the March 20 event."
Last week, the Sunday Herald Sun - using impeccable sources - revealed that the pilot of EK407 was on the brink of reaching his 100-hour flying limit in a month.
Our front page report, headlined SLEEPLESS PILOT, and again based on impeccable sources, also revealed that the pilot had barely slept in the 24 hours before the incident.
The ATSB's report confirmed that the pilot had, in fact, reached 98.9 hours in the preceding 30 days.
The ATSB preliminary report has found a wrong load calculation entered into the plane's computer caused it to take off without enough speed.
As a result, EK407's tail struck the tarmac three times before the jet managed to just take-off, dump fuel over Port Phillip Bay and, thanks to some skilful flying, return 257 passengers safely to the ground.
Emirates pilots say at the heart of the problems within the airline is a "punitive culture" that spies on pilots and renders them too scared to speak up on safety matters for fear of being sacked.
One of the three Emirates pilots interviewed this week was scathing of the airline's management style.
"They report anyone for anything. You get a phone call and are called into the office," he said.
Clearly something is not right within Emirates.
One Emirates source has described the culture as a "very bad cocktail".
The ATSB must see through the airline spin and listen to the concerns of the pilots. Perhaps the time has come for authorities to take a broader look at Emirates and not simply limit their inquiry to the March 20 tail strike.
The pilots are, after all, the people who are directly responsible for the lives of hundreds of people every time they walk into the cockpit.
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It might be time for such revelations, yes. The only thing I fear is that the medieval mentality of the main players (AAR + upwards) will first and foremost act in a reactionary and taliban-like style. They will oppress the pilots and front line workers even more, trying to avoid the bare truth to be revealed.
Those who risk losing power and face always react in such ways.
We will feel the pinch before things improve, so brace for impact.
Those who risk losing power and face always react in such ways.
We will feel the pinch before things improve, so brace for impact.
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"I can't go into that, it's confidential between an employer and an employee, all I can repeat is they offered their resignation and the company accepted," Mr Stealey said.
Leading by example!!! Bunch of liars!
Leading by example!!! Bunch of liars!
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I think I saw one of those PDAs ONCE - and that was back when we did JFK twice daily on 345...
And how about the comment on advice to crew as to sleep,rest etc? How the hell does that tie in with set meal times in Lagos, HK for brekkie and all that!!
And how about the comment on advice to crew as to sleep,rest etc? How the hell does that tie in with set meal times in Lagos, HK for brekkie and all that!!
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fatigue & swiss cheese model & SOP's
We are all aware of the fact that an incident/accident hardly ever if never results from just one error in the so-called error chain.
As most have pointed out here, fatigue seems to have played a large role. That is very easy to believe. And I too would have a serious look at that issue, however in conjunction with other factors.
Let's say for argument's sake that fatigue was the common denominator i.e. the first hole (or one of the first) in the swiss cheese model.
Now the thin red line (thread) that manages to wangle itself through all the holes has passed the first hole (fatigue). It then approaches the next cheese slice and looks for the next path of least resistance. What could that be? It could be a number of things.
The next cheese slice happens to be an SOP called performance data check. The thin red line (thread) looks for a gap in that SOP and hey bingo it finds the hole...
The hole being an SOP itself which needs to be revised.
But hey this could happen to anybody. The 345 and 343 have a max MTOW difference of approximately 100 tons, so the figures that were seen seemed normal perhaps.
Fatigue certainly would not be the first cheese slice in the cheese model, but a huge contributing factor that was not eliminated by good SOP's.
So work needs to be done on FTL's and SOP's. This is not about pointing fingers, but about pointing at the issues that affect us all.
As most have pointed out here, fatigue seems to have played a large role. That is very easy to believe. And I too would have a serious look at that issue, however in conjunction with other factors.
Let's say for argument's sake that fatigue was the common denominator i.e. the first hole (or one of the first) in the swiss cheese model.
Now the thin red line (thread) that manages to wangle itself through all the holes has passed the first hole (fatigue). It then approaches the next cheese slice and looks for the next path of least resistance. What could that be? It could be a number of things.
The next cheese slice happens to be an SOP called performance data check. The thin red line (thread) looks for a gap in that SOP and hey bingo it finds the hole...
The hole being an SOP itself which needs to be revised.
But hey this could happen to anybody. The 345 and 343 have a max MTOW difference of approximately 100 tons, so the figures that were seen seemed normal perhaps.
Fatigue certainly would not be the first cheese slice in the cheese model, but a huge contributing factor that was not eliminated by good SOP's.
So work needs to be done on FTL's and SOP's. This is not about pointing fingers, but about pointing at the issues that affect us all.
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Shame on you, fatbus! Fatigue has nothing to do with one sector/pairing! Fatigue is a result of continuous bad rostering practices and who are you to say that this was not the day/night when the operating crew felt the effects of it? 
With friends/colleagues like you - who needs Ed et all?
With friends/colleagues like you - who needs Ed et all?
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How many ASRs have gone in from the 380 crews wrt disruptive rest in the CRCs? What has been done? NOTHING
Can anyone confirm?
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Well ekpilot - I understood what fatbus was saying.. You are definitely barking up the wrong tree
There are no ASRs for 406/407, 412/413 and now 434/435 because it is NOT a fatiguing pattern. In fact I would say it's one of the more restful trips that we do - and before you start giving me sh1t about it, yes I have operated these rotations many times myself.. The issue is fatigue BEFORE these trips and how you can deal with it (not helped by our wonderful leaders!!)
There are no ASRs for 406/407, 412/413 and now 434/435 because it is NOT a fatiguing pattern. In fact I would say it's one of the more restful trips that we do - and before you start giving me sh1t about it, yes I have operated these rotations many times myself.. The issue is fatigue BEFORE these trips and how you can deal with it (not helped by our wonderful leaders!!)
I understood that Ed has posted the worst offenders back to the 340
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Forgive a non pilot's question but just a thought -
The same crew would have flown the Auckland turn the previous day. What would the likely take off weight be for the Auckland hop compared to the 360 or so tonnes for MEL - DXB. Tired and distracted, could the oversight in numbers be in part because the number was familiar?
I have been lurking here reading the ME threads and want to add one comment on this whole subject. I have a vested interest. My wife is EK CC. All of the EK cockpit crew that I have met have generously put up with my questions and curiosity; always with humour and a real pleasure and professionalism in what they do.
We are in a massive economic crisis; I suspect EK will come through it in better shape than CX, SQ or TG for instance. Terms and conditions are not just under threat at EK.
Now that we are here as hired help - and we all came here for a reason - the best we can do is keep demanding best practice from our management (in any industry - my old management must have learned from EK - or worse!) and from ourselves and our colleagues. It has to get better !
Good luck.
RAS
The same crew would have flown the Auckland turn the previous day. What would the likely take off weight be for the Auckland hop compared to the 360 or so tonnes for MEL - DXB. Tired and distracted, could the oversight in numbers be in part because the number was familiar?
I have been lurking here reading the ME threads and want to add one comment on this whole subject. I have a vested interest. My wife is EK CC. All of the EK cockpit crew that I have met have generously put up with my questions and curiosity; always with humour and a real pleasure and professionalism in what they do.
We are in a massive economic crisis; I suspect EK will come through it in better shape than CX, SQ or TG for instance. Terms and conditions are not just under threat at EK.
Now that we are here as hired help - and we all came here for a reason - the best we can do is keep demanding best practice from our management (in any industry - my old management must have learned from EK - or worse!) and from ourselves and our colleagues. It has to get better !
Good luck.
RAS