The first official report into the worst non-fatal air accident in Australia involving damage to an airliner, Emirates flight EK 407, has just been released.
The Crikey bulletin this afternoon will examine the report and separately, the media amnesia that set in for more than two weeks after the accident.
A full report will also be posted here later this afternoon.
This is the ATSB summary and a link which leads to the actual 4.8 MB document.
Today the Australian Transport Safety Bureau (ATSB) is releasing its Preliminary Factual report into the tail strike involving Airbus A340-500, A6-ERG, during takeoff at Melbourne Airport at approximately 10:31 PM on the evening of 20 March 2009. The aircraft was being operated on a scheduled passenger flight from Melbourne to Dubai in the United Arab Emirates.
It is important to note that the information contained in the preliminary factual report, as the name suggests, is limited to preliminary factual information that has been established in the initial investigation of the accident. Caution should be exercised as there is the possibility that new evidence may become available that alters the circumstances as depicted in the report. Analysis of the factual information and findings as to the factors that contributed to the accident are subject to ongoing work and will be included in the final report.
The ATSB investigation, assisted by a number of other organisations and agencies, including the United Arab Emirates General Civil Aviation Authority (GCAA), the French Bureau d’Enquetes et d’Analyses (BEA), Emirates and Airbus, has determined that during the take-off roll on runway 16, the captain called for the first officer to rotate (lift off). However, when the aircraft was slow to respond, the captain commanded and applied maximum take-off thrust (TOGA). The aircraft’s tail struck the runway and the aircraft lifted off shortly afterwards. During the take-off, the aircraft’s tail contacted the ground beyond the end of the runway and a number of airport landing aids came into contact with the aircraft.
After becoming airborne, the flight crew received a cockpit message that a tail strike had occurred and so they contacted Air Traffic Control (ATC) and requested a return to Melbourne. The aircraft was radar vectored by ATC over Port Philip Bay to dump fuel to reduce the aircraft’s weight for landing. While reviewing the aircraft’s performance documentation in preparation for landing, the crew noticed that an incorrect weight had been inadvertently entered into the laptop when completing the take-off performance calculation prior to departure. The performance calculations were based on a take-off weight that was 100 tonnes below the actual take-off weight of the aircraft.
The result of that incorrect take-off weight was to produce a thrust setting and take-off reference speeds that were lower than those required for the aircraft’s actual weight. During the return to land at Melbourne, a cabin crew member reported smoke in the cabin. The aircraft subsequently landed safely at 11:36 PM and was able to be taxied to the terminal where the passengers were disembarked. There were no reported injuries.
Damage to the aircraft included abraded skin to the rear, lower fuselage and damage to the rear pressure bulkhead. There was also damage to a fixed approach light, an instrument landing system (ILS) monitor antenna and the ILS localiser antenna.
The aircraft was fitted with a Flight Data Recorder (FDR), Cockpit Voice Recorder (CVR) and a Digital Aircraft Condition Monitoring System Recorder (DAR). The FDR was dislodged from its mounting in the rear of the aircraft during the tail strike and only recorded data up to that point. The CVR and DAR recorded data for the entire flight.
The investigation is continuing and will examine:
- human performance and organisational risk controls
- computer-based flight performance planning, including the effectiveness of the human interface of computer based planning tools.
- reduced power takeoffs, including the associated risks and how they are managed.
The aircraft operator has informed the ATSB that based on their internal investigation, the following areas are under review:
- human factors
- training
- fleet technical and procedures
- hardware and software technology.
The investigation is ongoing and the ATSB continues to work closely with representatives from the UAE GCAA, French BEA, Emirates and Airbus. While the investigation is likely to take some months, should any critical safety issues emerge that require urgent attention, the ATSB will immediately bring such issues to the attention of the relevant authorities who are best placed to take prompt action to address those issues.
2 Comments
So its looking like one hell of an expensive and dangerous typo
As a now retired (and redundant) Flight Engineer I could be accused of being biased with some justifiction. That having been acknowledged, I am yet to be convinced that there was ever a need to remove the Flight Engineer from the flightdeck of large aircraft, nor was there any real financial benefit. The contribution made by professional Flight Engineer’s is, I believe, well understood and acknowledged by the vast majority of those pilots who shared the flightdeck with a F/E. The “bean counters” have been able to convince manufacturers and operators that saving are made by reducing the crew numbers.
Of course, to err is human. I would never contend that any F/E could more closely monitor aircraft systems than does the computer systems employed in modern aircraft, computers don’t get tired in the way a human does. By the same token a computer monitored and controlled system has limitations and cannot be turned to and asked “How do we get around this problem Eng?”
One area in which I believe the F/E is missed is that area where the Emirates and Singapore crews fell foul of the automated systems. Manually extracting the T/O data from Performance tables and writing that info onto a TOLD card gives more opportunities for gross errors to be picked up, especially when the TOLD card and a closed up Performance table is handed to the non-handling pilot for his independent check.
In the case of the Emirates Airbus and the Singapore Airlines B747-400 a gross error of 100,000 kg was made and went undetected. In both instances the potential for heavy loss of life existed and it points out, to me at least, that there has to be put in place a better method of ensuring the data used is correct and is correctly entered. The operating crews in each case were able to overcome the error made, something for which we should all be grateful and believe that lessons will be learned, quickly.