I don't think there can any longer be any doubt that Emirates is plain wrong in sacking the pilots of the Airbus A340-500 who made the error that led to the near-catastrophe in Melbourne.Australia's ATSB investigation agency has revealed its initial findings today and they make crystal clear that the whole question of electronic flight bag (EFB) use, at the centre of the incident, is going to be extensively investigated. Rightly so, this is unquestionably an industry-wide issue.
More remarkably, it turns out that Emirates has just introduced the practice of using a second EFB/laptop as a check against the first! So their position now is that the incident crew committed an error grievous enough to merit sacking, but they're worried that another crew might do the same thing.
So logically, if another crew makes the same error, but they catch it with the second laptop, then they should be sacked too for making the same error in the first place. And if they shouldn't be sacked, then neither should the incident crew since they didn't have the benefit of the second laptop.
Report and press conference highlights, with memorable pictures below. Emirates statement here.
Here's what I think are the key points from the report and briefing by ATSB director of aviation safety investigation Julian Walsh.
The immediate cause of the incident is confirmed as being the inadvertent entry of the wrong take-off weight into the laptop - which Walsh specifically calls an electronic flight bag (EFB - and the resulting too-low thrust-settings and V speeds.
The results were predictably dire, with three tailstrikes on the runway and two further contacts in the grass beyond the stopway. The landing-gear struck a strobe light and the localiser as the aircraft finally lifted off.
Here are the ground contact marks marked 1-5.
And here's the localiser anntena.
And some of the aircraft damage.
At today's briefing, Walsh said that, although they were still investigating, the ATSB did not think fatigue was a factor. (Significant, since some Emirates pilots have been suggesting that fatigue is an ongoing issue at the airline.) He also robustly defended the use of reduced power / flex take-offs, telling the assembled media it was proven and standard practice in the industry.
The captain, who was pilot non-flying on the take-off, incidentally had 8,195 hours total and 1,978 on the A340 of which 1,372 were on the -500; and the first officer had 8,316 hours total with 612 on the A340, of which 425 were on the -500. They'd flown respectively 98.9 and 89.7 hours in the preceding 30 days.
Regarding the error Walsh said this: "What we need to understand, and is the difficult part, is how the system allowed that to happen. And this is going to be quite a complex thing, to look at the operating environment and what was going on in the cockpit at the time. What sort of environmental issues there were with noise and distractions - that's where the hard work is."
And he also said that, since the drafting of the report, Emirates had changed its procedure. "Emirates has advised the ATSB that although there are a number of layers that are required to provide physical cross-checks during these calculations, in the interests of prudence, and until the circumstances are better understood, they have introduced a further level of independent cross-checking through the use of a second laptop computer."
So, now the ATSB is going to be investigating the following:
• human performance and organisational risk controls, including:
− data entry
− a review of similar accidents and incidents
− organisational risk controls
− systems and processes relating to performance calculations
• computer-based flight performance planning, including:
− the effectiveness of the human interface of computer based planning tools.
• reduced power takeoffs, including:
− the risks associated with reduced power takeoffs and how they are
managed
− crew ability to reconcile aircraft performance with required takeoff
performance, and the associated decision making of the flight crew
− preventative methods, especially technological advancements.
And the agency says Emirates told it on 17 April that "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.
You can read the whole report here, and listen to the press conference here.
And you can read about some of the things going on in Emirates here.
The immediate cause of the incident is confirmed as being the inadvertent entry of the wrong take-off weight into the laptop - which Walsh specifically calls an electronic flight bag (EFB - and the resulting too-low thrust-settings and V speeds.
The results were predictably dire, with three tailstrikes on the runway and two further contacts in the grass beyond the stopway. The landing-gear struck a strobe light and the localiser as the aircraft finally lifted off.
Here are the ground contact marks marked 1-5.
And here's the localiser anntena.
And some of the aircraft damage.
At today's briefing, Walsh said that, although they were still investigating, the ATSB did not think fatigue was a factor. (Significant, since some Emirates pilots have been suggesting that fatigue is an ongoing issue at the airline.) He also robustly defended the use of reduced power / flex take-offs, telling the assembled media it was proven and standard practice in the industry.
The captain, who was pilot non-flying on the take-off, incidentally had 8,195 hours total and 1,978 on the A340 of which 1,372 were on the -500; and the first officer had 8,316 hours total with 612 on the A340, of which 425 were on the -500. They'd flown respectively 98.9 and 89.7 hours in the preceding 30 days.
Regarding the error Walsh said this: "What we need to understand, and is the difficult part, is how the system allowed that to happen. And this is going to be quite a complex thing, to look at the operating environment and what was going on in the cockpit at the time. What sort of environmental issues there were with noise and distractions - that's where the hard work is."
And he also said that, since the drafting of the report, Emirates had changed its procedure. "Emirates has advised the ATSB that although there are a number of layers that are required to provide physical cross-checks during these calculations, in the interests of prudence, and until the circumstances are better understood, they have introduced a further level of independent cross-checking through the use of a second laptop computer."
So, now the ATSB is going to be investigating the following:
• human performance and organisational risk controls, including:
− data entry
− a review of similar accidents and incidents
− organisational risk controls
− systems and processes relating to performance calculations
• computer-based flight performance planning, including:
− the effectiveness of the human interface of computer based planning tools.
• reduced power takeoffs, including:
− the risks associated with reduced power takeoffs and how they are
managed
− crew ability to reconcile aircraft performance with required takeoff
performance, and the associated decision making of the flight crew
− preventative methods, especially technological advancements.
And the agency says Emirates told it on 17 April that "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.
You can read the whole report here, and listen to the press conference here.
And you can read about some of the things going on in Emirates here.
on April 30, 2009 4:27 PM | Reply
Thanks for the indepth on this. Clearly electronic tools are only as smart as the pilot's finger, and pilots are human.
Taking the margin out of flying using electronic tools is great - until you need that margin.
on April 30, 2009 5:06 PM | Reply
Welcome to the UAE. There is always somebody to blame, and it's certainly going to be an expatriate.
on April 30, 2009 5:39 PM | Reply
Well, the article on Flight says 100 tons less weight inputted; if correct that figure amounts to roughly a third of the t.o. weight. If indeed this is the case then the crew made a really gross mistake; you cannot leave such a discrepancy to the laptop, fms or what have you; a qualified pic should realize a t.o. weight of two hundred tons sounds silly on such a flight.
Sure the rote use of lists , efbs, finger punching and flying by the fms points to a systemic problem, but nevertheless if the information is correct they screwed up big time
on May 1, 2009 9:07 AM | Reply
surely the lap top computor can be programmed to refuse to accept an unrealisticly low take off weight put into it.
I would have thought that was a simple thing to do
With possibly an overide faciliy if you were doing a short test flight.
I do notice watching A340-500/600s flying out of heathrow,they do a very poor clime out ,creating a lot of noise over the sarounding suburbs due to their lowness.
I do think that A340s do overdo the part power take off a bit and this could compromise safety if an error is made in the imput figure.
The A340-500/600 is supposed to have a good reserve of power
on May 3, 2009 8:54 AM | Reply
A similar incident happend last year to a B747 of CargoB Airlines in Brussels. They also used labtops for performance calculations and
entered wrong weights by 100t albeit having two computers on board to cross check weights..
on May 4, 2009 7:03 AM | Reply
Kieran you are absolutely right - Emirates, is responsible. John Newton correctly identifies their incompetence. Clearly the data entry system should include checks and balances - having the lap-top understand minimum, typical and maximum weights for the sector to be travelled is one obvious one. A computer system which allows a pilot to make a potentially fatal data entry error without comment is a lousy system and Emirates are weasels for blaming the pilots.
on July 3, 2009 12:19 AM | Reply
The bottom line is ,the zombie state of mind, that most 330/340 crews are normally on.Initially you had to have 2 days off before an ULR, now sby works.In general the 12 hours between flights don't cater for what hours your body really sleeps and recharges, 12 hours is good has new day or night.But the most serious problem for me is crew flying the 332/343/345.The 345 is similar ,but different enough to bite you at the first distraction, The 345 in my humble opinion should be a different rating in Emirates
on July 8, 2010 9:08 AM | Reply
This looks like a lower T/O weight was entered so as setup for reduced power T/O to reduce fuel consumption.This has been another example of miscalculation as has happened with other Airlines in the past.No amount of Laptops in the Cockpit will change this.The Authorities should stop this practice for the sake of safety.