Status: | Accident investigation report completed and information captured |
Date: | Friday 20 March 2009 |
Time: | 22:32 |
Type: |  Airbus A340-541 |
Operator: | Emirates |
Registration: | A6-ERG |
MSN: | 608 |
First flight: | 2004-11-04 (4 years 5 months) |
Total airframe hrs: | 22526 |
Cycles: | 2598 |
Engines: | 4 Rolls-Royce Trent 553A2-61 |
Crew: | Fatalities: 0 / Occupants: 18 |
Passengers: | Fatalities: 0 / Occupants: 257 |
Total: | Fatalities: 0 / Occupants: 275 |
Aircraft damage: | Substantial |
Aircraft fate: | Repaired |
Location: | Melbourne-Tullamarine Airport, VIC (MEL) ( Australia)
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Phase: | Takeoff (TOF) |
Nature: | International Scheduled Passenger |
Departure airport: | Melbourne-Tullamarine Airport, VIC (MEL/YMML), Australia |
Destination airport: | Dubai Airport (DXB/OMDB), United Arab Emirates |
Flightnumber: | EK407 |
Narrative:At 22:31 local time, an Airbus A340-500 aircraft, registered A6-ERG, commenced the takeoff roll on runway 16 at Melbourne Airport (MEL) on a scheduled, passenger flight (EK407) to Dubai (DXB), United Arab Emirates. The takeoff was planned as a reduced-power takeoff and the first officer was the handling pilot for the departure. At 22:31:53, the captain called for the first officer to rotate. The first officer attempted to rotate the aircraft, but it did not respond immediately with a nose-up pitch. The captain again called 'rotate' and the first officer applied a greater nose-up command. The nose of the aircraft was raised and the tail made contact with the runway surface, but the aircraft did not begin to climb. The captain then selected TOGA on the thrust levers, the engines responded immediately, and the aircraft commenced a climb.
The crew notified air traffic control of the tail strike and that they would be returning to Melbourne. While reviewing the aircrafts performance documentation in preparation for landing, the crew noticed that a takeoff weight, which was 100 tonnes below the actual takeoff weight of the aircraft, had inadvertently been used when completing the takeoff performance calculation. The result of that incorrect takeoff weight was to produce a thrust setting and takeoff reference speeds that were lower than those required for the actual aircraft weight.
The aircraft subsequently landed at Melbourne with no reported injuries. The tail strike resulted in substantial damage to the tail of the aircraft and damaged some airport lighting and the instrument landing system.
As a result of the accident, the aircraft operator has advised the Australian Transport Safety Bureau that it is reviewing a number of procedures including human factors involved in takeoff performance data entry.
Probable Cause:
CONTRIBUTING SAFETY FACTORS:
- The first officer inadvertently entered the incorrect take-off weight into the electronic flight bag to calculate the take-off performance parameters for the flight.
- The captain was distracted while checking the take-off performance figures in the electronic flight bag, which resulted in him not detecting the incorrect take-off weight.
- During the pre-departure phase, the flight crew did not complete all of the tasks in the standard operating procedures, which contributed to them not detecting the error.
- When conducting the loadsheet confirmation procedure, the first officer called out 362.9 tonnes as the FLEX take-off weight, rather than the 262.9 tonnes that was recorded on the master flight plan, which removed an opportunity for the captain to detect the error.
- The first officer changed the first digit of the FLEX take-off weight on the master flight plan during the loadsheet confirmation procedure, believing it had been transcribed incorrectly, which removed an opportunity for the flight crew to detect the error.
- The lack of a designated position in the pre-flight documentation to record the green dot speed precipitated a number of informal methods of recording that value, lessening the effectiveness of the green dot check within the loadsheet confirmation procedure. [Minor safety issue]
- The flight crews mixed fleet flying routinely exposed them to large variations in take-off weights and take-off performance parameters, which adversely influenced their ability to form an expectation of the reasonableness of the calculated take-off performance parameters
CONTRIBUTING SAFETY FACTORS:
- The first officer inadvertently entered the incorrect take-off weight into the electronic flight bag to calculate the take-off performance parameters for the flight.
- The captain was distracted while checking the take-off performance figures in the electronic flight bag, which resulted in him not detecting the incorrect take-off weight.
- During the pre-departure phase, the flight crew did not complete all of the tasks in the standard operating procedures, which contributed to them not detecting the error.
- When conducting the loadsheet confirmation procedure, the first officer called out 362.9 tonnes as the FLEX take-off weight, rather than the 262.9 tonnes that was recorded on the master flight plan, which removed an opportunity for the captain to detect the error.
- The first officer changed the first digit of the FLEX take-off weight on the master flight plan during the loadsheet confirmation procedure, believing it had been transcribed incorrectly, which removed an opportunity for the flight crew to detect the error.
- The lack of a designated position in the pre-flight documentation to record the green dot speed precipitated a number of informal methods of recording that value, lessening the effectiveness of the green dot check within the loadsheet confirmation procedure. [Minor safety issue]
- The flight crews mixed fleet flying routinely exposed them to large variations in take-off weights and take-off performance parameters, which adversely influenced their ability to form an expectation of the reasonableness of the calculated take-off performance parameters
Accident investigation:
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Investigating agency: | ATSB (Australia)  |
Status: | Investigation completed |
Duration: | 2 years and 9 months | Accident number: | AO-2009-012 | Download report: | Final report
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Classification:
Forced landing on runway
Sources:
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SKYbrary
Follow-up / safety actions
ATSB issued 2 Safety Recommendations
Issued: 15-DEC-2011 | To: FAA | AO-2009-012-NSA-082 |
The Australian Transport Safety Bureau recommends that the United States Federal Aviation Administration take action to address the existing take-off certification standards, which are based on the attainment of the take-off reference speeds, and flight crew training that was based on the monitoring of and responding to those speeds, and do not provide crews with a means to detect degraded take-off acceleration. (Safety action pending) |
Issued: 16-DEC-2011 | To: FAA | AO-2009-012-SR-079 |
The Australian Transport Safety Bureau recommends that the United States Federal Aviation Administration take action to address the existing take-off certification standards, which are based on the attainment of the take-off reference speeds, and flight crew training that was based on the monitoring of and responding to those speeds, and do not provide crews with a means to detect degraded take-off acceleration. |
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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Melbourne-Tullamarine Airport, VIC to Dubai Airport as the crow flies is 11613 km (7258 miles).
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.