Emirates A340-300 incident @ JoBurg. Report is public
Está servira para distraerle.
Thread Starter
Emirates A340-300 incident @ JoBurg. Report is public
--------------------------------------------------------------------------------
+++++++++++++++++++++++++++++
Airbus says pilot misunderstood use of sidestick position indicator, causing him to inadvertently reduce pitch-up after VR
The Airbus Emirates A340-300 take-off overrun incident at Johannesburg in April was caused by an elementary blunder in the crew's use of instruments to judge pitch attitude during rotation, Airbus says.
Flight International has learned that the crew misused an indicator showing sidestick position to select rotation angle - an unapproved and flawed technique - which resulted in the Dubai-bound A340-300 failing to get airborne until it had passed beyond the end of the 4,420m (14,490ft) -long runway. As the aircraft overran the runway end, it struck lighting, bursting three main gear tyres and damaging the flaps - which subsequently locked in a partly deployed position (Flight International, 20-26 April). After the incident on 9 April, the aircraft, with 230 people on board, returned to Johannesburg after dumping fuel.
The bizarre circumstances surrounding the incident were revealed in a flight operations telex (FOT) issued by Airbus to A330/A340 operators earlier this month, and confirmed to Flight International by the manufacturer's chief test pilot Jacques Rossay.
<snip>
Rossay says that the pilot flying incorrectly believed that the sidestick position symbol could be used to select pitch attitude for rotation. This is thought to be an unprecedented error, and Rossay cannot explain why the pilot thought it was a valid technique.
<snip>
The official investigation into the incident is ongoing, with an interim report expected within a couple of months.
Emirates' senior vice-president for flight operations Chris Knowles recently resigned, but the airline has revealed no reason for his departure (Flight International, 8-14 June).
++++++++++++++++++++
More at www.flightinternational
+++++++++++++++++++++++++++++
Airbus says pilot misunderstood use of sidestick position indicator, causing him to inadvertently reduce pitch-up after VR
The Airbus Emirates A340-300 take-off overrun incident at Johannesburg in April was caused by an elementary blunder in the crew's use of instruments to judge pitch attitude during rotation, Airbus says.
Flight International has learned that the crew misused an indicator showing sidestick position to select rotation angle - an unapproved and flawed technique - which resulted in the Dubai-bound A340-300 failing to get airborne until it had passed beyond the end of the 4,420m (14,490ft) -long runway. As the aircraft overran the runway end, it struck lighting, bursting three main gear tyres and damaging the flaps - which subsequently locked in a partly deployed position (Flight International, 20-26 April). After the incident on 9 April, the aircraft, with 230 people on board, returned to Johannesburg after dumping fuel.
The bizarre circumstances surrounding the incident were revealed in a flight operations telex (FOT) issued by Airbus to A330/A340 operators earlier this month, and confirmed to Flight International by the manufacturer's chief test pilot Jacques Rossay.
<snip>
Rossay says that the pilot flying incorrectly believed that the sidestick position symbol could be used to select pitch attitude for rotation. This is thought to be an unprecedented error, and Rossay cannot explain why the pilot thought it was a valid technique.
<snip>
The official investigation into the incident is ongoing, with an interim report expected within a couple of months.
Emirates' senior vice-president for flight operations Chris Knowles recently resigned, but the airline has revealed no reason for his departure (Flight International, 8-14 June).
++++++++++++++++++++
More at www.flightinternational
Only half a speed-brake
Re: The Emirates A 340-300 incident report is public
OK. The question to all (bearing in mind that the bus' "german cross" is not a flight instrument yet mixed fleet flying has its difficulties): how early on rotation do you look down to the screens?
FD
(the un-real)
FD
(the un-real)
"The INTRODUCER"
Join Date: Aug 2000
Location: In my skin
Posts: 66
Likes: 0
Received 0 Likes
on
0 Posts
Re: The Emirates A 340-300 incident report is public
There are two runways in Jo’burg a 3400 (03R 21L) and a 4400 m (03L 21R) long.
They landed relatively deep on the shortest runway (03 R 3400m), knowing they had multiple tyre failure (ATC) with auto brakes armed and flaps in Take Off position at MLW.
The longer 4400 m runway was available in CAVOK conditions served by a non-precision approach.
The ATIS was favouring runway 21R (4400 m) however ATC in contradiction to the ATIS advised runway 03 R wind conditions were better.
The A 340-300 was not fitted with TPI (tyre press ind) however the crew was also qualified on another type that was fitted with TPI.
There is no checklist in case of low TPI indication. The crew has to use common sense in order to conclude that without tyre……. there is no transducer ……hence no antiskid …..hence not to use autobrakes.
Landing on 21 R and the use of reversers in order to transfer the deceleration on the engines iso the gear would have been completely compatible with a 4400 m runway.
They landed relatively deep on the shortest runway (03 R 3400m), knowing they had multiple tyre failure (ATC) with auto brakes armed and flaps in Take Off position at MLW.
The longer 4400 m runway was available in CAVOK conditions served by a non-precision approach.
The ATIS was favouring runway 21R (4400 m) however ATC in contradiction to the ATIS advised runway 03 R wind conditions were better.
The A 340-300 was not fitted with TPI (tyre press ind) however the crew was also qualified on another type that was fitted with TPI.
There is no checklist in case of low TPI indication. The crew has to use common sense in order to conclude that without tyre……. there is no transducer ……hence no antiskid …..hence not to use autobrakes.
Landing on 21 R and the use of reversers in order to transfer the deceleration on the engines iso the gear would have been completely compatible with a 4400 m runway.
Join Date: Jan 2004
Location: Sky
Posts: 180
Likes: 0
Received 0 Likes
on
0 Posts
Re: The Emirates A 340-300 incident report is public
I believe we are all in agreement that the only thing that saved a disaster in Jo'burg was a huge amount of luck. The information that has since come into the public eye is a perfect example of what can happen when people not suitably qualified, even with the best of intention, try to perform the function of a flight testing department. Historically, pilots are renowned for trying to tinker, adjust and improve their aircraft - hence the pilot and dog 'ideal' cockpit - sometimes with devastating consequences.
I don't think anybody can come out of this smelling of roses. Airbus' flight testing department, who will argue that the sole reason for this occurrence was a blatant disregard of approved operating procedure, should question whether their brain-storming session on 'what ways can those stupid lineys kill themselves?' was extensive enough.
As much as Emirates' ambition to reduce tailstrike occurrences is understandable, the first thing they should have done once they had created this new procedure and before approving it, should have been to phone or fax Toulouse and let the professionals both run it on the computer and on a real aircraft to allow a go/no go answer.
The pilot himself was in a very difficult situation. Inexperienced on type, and no doubt very aware of the potential for a tailstrike on such a long aircraft, he would obviously be very susceptible to accepting helpful tips to reduce the chances of such an event. The fact this help seems to have come directly from the airline and not from another line pilot would only increase his susceptibility. Some people will argue that, as a pilot, you are paid big money to look after the folks on the other side of the door, who expect the person at the controls to operate their aircraft in accordance with approved methods only, and that he chose not to do so, inviting Sod’s Law.
Lastly, there is also the issue about this being only both pilots' second actual flight in this particular variant. Not knowing either pilot's previous flying experience, nor having the experience to comment on the significance of actual time on type compared to simulator time, especially when starting on a new variant, I will leave this for those who have the experience to make comment to do so.
If there are others out there who are using their own tweaked version of the aircraft flight manual or operations manual, hopefully this event may encourage them to fax the manufacturer and make sure what they are doing is safe.
If I remember correctly, the P.F. is a pprune member and made a posting after this particular flight. We are all glad you are still with us and know you will have learned so much since then. Take the flak, dust yourself down and get back on the horse. I wish you well in the future.
Happy flying!
VC10 Rib22
I don't think anybody can come out of this smelling of roses. Airbus' flight testing department, who will argue that the sole reason for this occurrence was a blatant disregard of approved operating procedure, should question whether their brain-storming session on 'what ways can those stupid lineys kill themselves?' was extensive enough.
As much as Emirates' ambition to reduce tailstrike occurrences is understandable, the first thing they should have done once they had created this new procedure and before approving it, should have been to phone or fax Toulouse and let the professionals both run it on the computer and on a real aircraft to allow a go/no go answer.
The pilot himself was in a very difficult situation. Inexperienced on type, and no doubt very aware of the potential for a tailstrike on such a long aircraft, he would obviously be very susceptible to accepting helpful tips to reduce the chances of such an event. The fact this help seems to have come directly from the airline and not from another line pilot would only increase his susceptibility. Some people will argue that, as a pilot, you are paid big money to look after the folks on the other side of the door, who expect the person at the controls to operate their aircraft in accordance with approved methods only, and that he chose not to do so, inviting Sod’s Law.
Lastly, there is also the issue about this being only both pilots' second actual flight in this particular variant. Not knowing either pilot's previous flying experience, nor having the experience to comment on the significance of actual time on type compared to simulator time, especially when starting on a new variant, I will leave this for those who have the experience to make comment to do so.
If there are others out there who are using their own tweaked version of the aircraft flight manual or operations manual, hopefully this event may encourage them to fax the manufacturer and make sure what they are doing is safe.
If I remember correctly, the P.F. is a pprune member and made a posting after this particular flight. We are all glad you are still with us and know you will have learned so much since then. Take the flak, dust yourself down and get back on the horse. I wish you well in the future.
Happy flying!
VC10 Rib22
Join Date: Aug 2000
Location: In my skin
Posts: 66
Likes: 0
Received 0 Likes
on
0 Posts
Re: The Emirates A 340-300 incident report is public
According to the report EK started operations in 1986 and the UAE CAA came into being in 1996.
So EK has effectively been operating without a CAA for about ten years.
Hence a lot of very personnel interpretations of training and performance issues by the few in control, became law. Effectively the EK FOM a complilation of notes and FCI's was the bible and there were many serious mistakes in it.
During this period EK hired the wrong people to run it’s OPS department, people that also bluntly ignored the advice of many very capable pilots in the EK pilot pool.
Genuine professionals were slaughtered in their attempt to raise important safety related issues and some others simply resigned.
To setup an aviation authority that is effective and efficient takes a very long time. It is time that EK realizes that pilots, who are critical, often do so because they are genuinely concerned. If mistakes are made they should be admitted and corrected.
Those that knew that things were wrong were afraid to stand up against it and they were right not to do so. It's too dangerous.
I feel sorry for the Captain and First Officer on that flight. They were not given the tools to do their job properly and were rostered to a restricted or even a restricted + Airport.
I am pleased to see that for the A 380 induction, EK has chosen a capable chap but he needs all the help he can get.
Good luck James and thanks for your help in the past.
Flight Detent.
On the B 737-800 we have the same problem, it’s very critical.
I look outside during the takeoff run and rotation. As soon as directional cues disappear I transfer inside.
Rotation continues but never above 10° pitch until I am airborne.
To determine that, I use the “click noise” that emerges from the solenoid in the gear handle locking mechanism.
It’s very difficult to judge a rotation rate; the issue is not to go to high in pitch with the gear on the ground. As long as Boeing does not provide us with a specially designed tool to determine that moment we have to use something else.
Maybe we could use the radio-altimeter but I don’t think I could do that (get it in my scan) since I really need to focus on that pitch, my ears do the rest.
On the A 340 the click could be replaced by the disapearing of the SSOI indicator. I do not agree with the conclusions of the report to use the nose gear air/ground sensor iso the main gear sensor to remove the SSOI from the PFD.
Hope that answers your question.
So EK has effectively been operating without a CAA for about ten years.
Hence a lot of very personnel interpretations of training and performance issues by the few in control, became law. Effectively the EK FOM a complilation of notes and FCI's was the bible and there were many serious mistakes in it.
During this period EK hired the wrong people to run it’s OPS department, people that also bluntly ignored the advice of many very capable pilots in the EK pilot pool.
Genuine professionals were slaughtered in their attempt to raise important safety related issues and some others simply resigned.
To setup an aviation authority that is effective and efficient takes a very long time. It is time that EK realizes that pilots, who are critical, often do so because they are genuinely concerned. If mistakes are made they should be admitted and corrected.
Those that knew that things were wrong were afraid to stand up against it and they were right not to do so. It's too dangerous.
I feel sorry for the Captain and First Officer on that flight. They were not given the tools to do their job properly and were rostered to a restricted or even a restricted + Airport.
I am pleased to see that for the A 380 induction, EK has chosen a capable chap but he needs all the help he can get.
Good luck James and thanks for your help in the past.
Flight Detent.
On the B 737-800 we have the same problem, it’s very critical.
I look outside during the takeoff run and rotation. As soon as directional cues disappear I transfer inside.
Rotation continues but never above 10° pitch until I am airborne.
To determine that, I use the “click noise” that emerges from the solenoid in the gear handle locking mechanism.
It’s very difficult to judge a rotation rate; the issue is not to go to high in pitch with the gear on the ground. As long as Boeing does not provide us with a specially designed tool to determine that moment we have to use something else.
Maybe we could use the radio-altimeter but I don’t think I could do that (get it in my scan) since I really need to focus on that pitch, my ears do the rest.
On the A 340 the click could be replaced by the disapearing of the SSOI indicator. I do not agree with the conclusions of the report to use the nose gear air/ground sensor iso the main gear sensor to remove the SSOI from the PFD.
Hope that answers your question.
Last edited by Streamline; 10th Jan 2006 at 15:08.
Join Date: Dec 2005
Location: mars
Posts: 50
Likes: 0
Received 0 Likes
on
0 Posts
Re: Emirates A340-300 incident @ JoBurg. Report is public
We are so worried half the time about the FOM and FCI's and covering our a*s, that we forget to fly the plane. We claim to be professionals, yet we brief each other to death. We talk about CRM; aren't we both there in the flight deck...just fly.
Join Date: Aug 2000
Location: In my skin
Posts: 66
Likes: 0
Received 0 Likes
on
0 Posts
Re: Emirates A340-300 incident @ JoBurg. Report is public
Bigilla
There is a difference between discrediting a pilot and pointing out that inadequate training may be the cause.
I consider the pilots concerned to be a victim of the system. In order to do so you have to point out the shortcomings. I never attacked the pilots, only made observations about the decision making process and I consider that a training issue.
As such what I said was very relevant and it now seems to turn out that the error made was training induced.
As far as the thread you refer to is concerned , I would like to mention that it now turns out that I was completely right.
Maybe the pilots concerned should have refused to apply the rotation technique as it was being trained and get fired. Your choice.
They were actually fired and the only reason why they are still there is that the incident happened outside the UAE and got an international dimension that needed their cooperation.
There is a difference between discrediting a pilot and pointing out that inadequate training may be the cause.
I consider the pilots concerned to be a victim of the system. In order to do so you have to point out the shortcomings. I never attacked the pilots, only made observations about the decision making process and I consider that a training issue.
As such what I said was very relevant and it now seems to turn out that the error made was training induced.
As far as the thread you refer to is concerned , I would like to mention that it now turns out that I was completely right.
Maybe the pilots concerned should have refused to apply the rotation technique as it was being trained and get fired. Your choice.
They were actually fired and the only reason why they are still there is that the incident happened outside the UAE and got an international dimension that needed their cooperation.
Last edited by Streamline; 10th Jan 2006 at 20:20.
Join Date: Jun 2001
Location: Rockytop, Tennessee, USA
Posts: 5,898
Likes: 0
Received 1 Like
on
1 Post
Re: Emirates A340-300 incident @ JoBurg. Report is public
>>According to the report EK started operations in 1986 and the UAE CAA came into being in 1996.
So EK has effectively been operating without a CAA for about ten years.<<
Well, they had a DGCA or something before 1996 since a lot of us have UAE ATPL's from earlier years...
So EK has effectively been operating without a CAA for about ten years.<<
Well, they had a DGCA or something before 1996 since a lot of us have UAE ATPL's from earlier years...
Join Date: Aug 2005
Location: fairly close to the colonial capitol
Age: 55
Posts: 1,693
Likes: 0
Received 0 Likes
on
0 Posts
Re: Emirates A340-300 incident @ JoBurg. Report is public
Does anybody have a hyperlink to the actual report please?
One thing of interest I didn't know was that the Emirates A340's came by way of !! Boeing from SN. (part of a 777 deal with SN to takeover the A343's they had)
Poor poor training !
Join Date: Aug 2000
Location: In my skin
Posts: 66
Likes: 0
Received 0 Likes
on
0 Posts
Re: Emirates A340-300 incident @ JoBurg. Report is public
Originally Posted by vapilot2004
I've looked in all of the usual places. I wanted to post the link after reading it myself - but no luck thus far.
One thing of interest I didn't know was that the Emirates A340's came by way of !! Boeing from SN. (part of a 777 deal with SN to takeover the A343's they had)
Poor poor training !
One thing of interest I didn't know was that the Emirates A340's came by way of !! Boeing from SN. (part of a 777 deal with SN to takeover the A343's they had)
Poor poor training !
Elaborate please, very unclear what you want to point out here.
The report states that the crew did a magnificent job when recovering directional control of the aircraft during the landing roll after they became aware that they had lost complete braking due to ANTISKID failure.
I agree with that but one must look at the reason why they got into such a situation. Again, I contribute this to poor training.
One of the main objectives of training is to focus on the weak spots a certain Aircraft design has and it’s consequences.
Today’s Aircraft design is based on high performance engines, wings and light weight. However these advantages can not be used when they are not matched with very effective braking technology.
As a consequence the penalties on landing and take off with ANTISKID inoperative are often the highest.
In other words; when one looks at a single failure that has the biggest consequences on landing performance; ANTISKID is very high up in the list; often more restrictive than flaps up landing.
These issues need to be pointed out in training and should be known by hart.
I would even urge the manufacturers to publish advisory tables on landing distances (deceleration till about 80 kts) using reversers only or at least demonstrate it in the sim. Often it is stated that the crew should use sound judgement. These tables would be useful tool for any condition where braking is seriously impaired for whatever reason.
Last edited by Streamline; 11th Jan 2006 at 09:33.
Join Date: May 2003
Location: Sheraton, Hilton....
Posts: 164
Likes: 0
Received 0 Likes
on
0 Posts
Re: Emirates A340-300 incident @ JoBurg. Report is public
if you ask anybody who did the 330 to 340 conversion in EK he would tell you it's a load of s**t.
the standards in EK went down the drain the last few years and for sure the management will operate like that until the loose an A/C or they retire with their big bonuses, whatever comes first.
even 6 month after the incident I was told by an not so popular TCI or TCE, whatever he is, to use the german cross.
told him to forget about it I rotate it like the 330 or any other widebody
A/C.
the CAA in UAE is ruled by the royal family who owns EK, the EK CEO is the head of the CAA.
the whole thing is a joke
the standards in EK went down the drain the last few years and for sure the management will operate like that until the loose an A/C or they retire with their big bonuses, whatever comes first.
even 6 month after the incident I was told by an not so popular TCI or TCE, whatever he is, to use the german cross.
told him to forget about it I rotate it like the 330 or any other widebody
A/C.
the CAA in UAE is ruled by the royal family who owns EK, the EK CEO is the head of the CAA.
the whole thing is a joke
Join Date: Jul 2002
Location: manchester
Posts: 164
Likes: 0
Received 0 Likes
on
0 Posts
Re: Emirates A340-300 incident @ JoBurg. Report is public
even 6 month after the incident I was told by an not so popular TCI or TCE, whatever he is, to use the german cross.
Jesus!!!
Emirates need to sort this out before they kill 350 passengers who are sadly unaware of thier omissions in pilot training.
Jesus!!!
Emirates need to sort this out before they kill 350 passengers who are sadly unaware of thier omissions in pilot training.
Join Date: Aug 2000
Location: In my skin
Posts: 66
Likes: 0
Received 0 Likes
on
0 Posts
Re: Emirates A340-300 incident @ JoBurg. Report is public
If that is true then ask the UAE CAA to release the complete safety audit report done on them by ICAO and ask the FAA why they took IMMEDIATE action AGAINST EK!
Also, why did the others do nothing while they knew very well what was going on.
Also, why did the others do nothing while they knew very well what was going on.
Join Date: May 2004
Location: UK
Posts: 5
Likes: 0
Received 0 Likes
on
0 Posts
Re: Emirates A340-300 incident @ JoBurg. Report is public
For those who wish for a copy of the report, if you ask the South African CAA they could send it to you. We contacted them and they were very helpful, but despite our request for an electronic version of the report the CAA preferred to send us a hard copy.
We originally got our information that the report was available from an interested party who had been sent a copy and kindly gave us access to it. So the report's existence was not exactly publicised.
DL
We originally got our information that the report was available from an interested party who had been sent a copy and kindly gave us access to it. So the report's existence was not exactly publicised.
DL
Keeping Danny in Sandwiches
Join Date: May 1999
Location: UK
Age: 76
Posts: 1,294
Likes: 0
Received 0 Likes
on
0 Posts
Re: Emirates A340-300 incident @ JoBurg. Report is public
David
In the interests of Safety you wouldn't like to scan it onto Adobe and place it on the Flight website ( with the permission of the SA CAA). I've looked on their website and they are about a year behind on electronic publication.
In the interests of Safety you wouldn't like to scan it onto Adobe and place it on the Flight website ( with the permission of the SA CAA). I've looked on their website and they are about a year behind on electronic publication.