code

Dubai

Crash of a Boeing 777-31H in Dubai

Date & Time: Aug 3, 2016 at 1238 LT
Type of aircraft:
Operator:
Registration:
A6-EMW
Survivors:
Yes
Schedule:
Thiruvananthapuram - Dubai
MSN:
32700/434
YOM:
2003
Flight number:
EK521
Location:
Region:
Crew on board:
18
Crew fatalities:
Pax on board:
282
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7457
Captain / Total hours on type:
5123.00
Copilot / Total flying hours:
7957
Copilot / Total hours on type:
1292
Aircraft flight hours:
58169
Aircraft flight cycles:
13620
Circumstances:
On 3 August 2016, an Emirates Boeing 777-31H Aircraft, registration A6-EMW, operating a scheduled passenger flight UAE521, departed Trivandrum International Airport (VOTV), India, at 0506 UTC for a 3 hour 30 minute flight to Dubai International Airport (OMDB), the United Arab Emirates, with 282 passengers, 2 flight crew and 16 cabin crew members on board. The Commander attempted to perform a tailwind manual landing during an automatic terminal information service (ATIS) forecasted moderate windshear warning affecting all runways at OMDB. The tailwind was within the operational limitations of the Aircraft. During the landing on runway 12L at OMDB the Commander, who was the pilot flying, decided to fly a go-around, as he was unable to land the Aircraft within the runway touchdown zone. The go-around decision was based on the perception that the Aircraft would not land due to thermals and not due to a windshear encounter. For this reason, the Commander elected to fly a normal go-around and not the windshear escape maneuver. The flight crew initiated the flight crew operations manual (FCOM) Go-around and Missed Approach Procedure and the Commander pushed the TO/GA switch. As designed, because the Aircraft had touched down, the TO/GA switches became inhibited and had no effect on the autothrottle (A/T). The flight crew stated that they were not aware of the touchdown that lasted for six seconds. After becoming airborne during the go-around attempt, the Aircraft climbed to a height of 85 ft radio altitude above the runway surface. The flight crew did not observe that both thrust levers had remained at the idle position and that the engine thrust remained at idle. The Aircraft quickly sank towards the runway as the airspeed was insufficient to support the climb. As the Aircraft lost height and speed, the Commander initiated the windshear escape maneuver procedure and rapidly advanced both thrust levers. This action was too late to avoid the impact with runway 12L. Eighteen seconds after the initiation of the go-around the Aircraft impacted the runway at 0837:38 UTC and slid on its lower fuselage along the runway surface for approximately 32 seconds covering a distance of approximately 800 meters before coming to rest adjacent to taxiway Mike 13. The Aircraft remained intact during its movement along the runway protecting the occupants however, several fuselage mounted components and the No.2 engine/pylon assembly separated from the Aircraft. During the evacuation, several passenger door escape slides became unusable. Many passengers evacuated the Aircraft taking their carry-on baggage with them. Except for the Commander and the senior cabin crew member who evacuated after the center wing tank explosion, all of the other occupants evacuated via the operational escape slides in approximately 6 minutes and 40 seconds. Twenty-one passengers, one flight crewmember, and six cabin crew members sustained minor injuries. Four cabin crew members sustained serious injuries. Approximately 9 minutes and 40 seconds after the Aircraft came to rest, the center wing tank exploded which caused a large section of the right wing upper skin to be liberated. As the panel fell to the ground, it struck and fatally injured a firefighter. The Aircraft was eventually destroyed due to the subsequent fire. Following the Accident, the Operator (Emirates), the General Civil Aviation Authority (GCAA), Dubai Airports and Dubai Air Navigation Services (‘dans’) implemented several safety actions. In this Final Report, the AAIS issues safety recommendations addressed to the Operator, the GCAA, The Boeing Company, the Federal Aviation Administration (FAA), Dubai Airports, ‘dans’, and the International Civil Aviation Organization (ICAO).
Probable cause:
The Air Accident Investigation Sector determines that the causes of the Accident are:
(a) During the attempted go-around, except for the last three seconds prior to impact, both engine thrust levers, and therefore engine thrust, remained at idle. Consequently, the Aircraft’s energy state was insufficient to sustain flight.
(b) The flight crew did not effectively scan and monitor the primary flight instrumentation parameters during the landing and the attempted go-around.
(c) The flight crew were unaware that the autothrottle (A/T) had not responded to move the engine thrust levers to the TO/GA position after the Commander pushed the TO/GA switch at the initiation of the FCOM Go-around and Missed Approach Procedure.
(d) The flight crew did not take corrective action to increase engine thrust because they omitted the engine thrust verification steps of the FCOM Go-around and Missed Approach Procedure.
The Investigation determines that the following were contributory factors to the Accident:
(a) The flight crew were unable to land the Aircraft within the touchdown zone during the attempted tailwind landing because of an early flare initiation, and increased airspeed due to a shift in wind direction, which took place approximately 650 m beyond the runway threshold.
(b) When the Commander decided to fly a go-around, his perception was that the Aircraft was still airborne. In pushing the TO/GA switch, he expected that the autothrottle (A/T) would respond and automatically manage the engine thrust during the go-around.
(c) Based on the flight crew’s inaccurate situation awareness of the Aircraft state, and situational stress related to the increased workload involved in flying the go-around maneuver, they were unaware that the Aircraft’s main gear had touched down which caused the TO/GA switches to become inhibited. Additionally, the flight crew were unaware that the A/T mode had remained at ‘IDLE’ after the TO/GA switch was pushed.
(d) The flight crew reliance on automation and lack of training in flying go-arounds from close to the runway surface and with the TO/GA switches inhibited, significantly affected the flight crew performance in a critical flight situation which was different to that experienced by them during their simulated training flights.
(e) The flight crew did not monitor the flight mode annunciations (FMA) changes after the TO/GA switch was pushed because:
1. According to the Operator’s procedure, as per FCOM Flight Mode Annunciations (FMA), FMA changes are not required to be announced for landing when the aircraft is below 200 ft;
2. Callouts of FMA changes were not included in the Operator’s FCOM Go-Around and Missed Approach Procedures.
3. Callouts of FMA changes were not included in the Operator’s FCTM Go-Around and Missed Approach training.
(f) The Operator’s OM-A policy required the use of the A/T for engine thrust management for all phases of flight. This policy did not consider pilot actions that would be necessary during a go-around initiated while the A/T was armed and active and the TO/GA switches were inhibited.
(g) The FCOM Go-Around and Missed Approach Procedure did not contain steps for verbal verification callouts of engine thrust state.
(h) The Aircraft systems, as designed, did not alert the flight crew that the TO/GA switches were inhibited at the time when the Commander pushed the TO/GA switch with the A/T armed and active.
(i) The Aircraft systems, as designed, did not alert the flight crew to the inconsistency between the Aircraft configuration and the thrust setting necessary to perform a successful go-around.
(j) Air traffic control did not pass essential information about windshear reported by a preceding landing flight crew and that two flights performed go-arounds after passing over the runway threshold. The flight crew decision-making process, during the approach and landing, was deprived of this critical information.
(k) The modification of the go-around procedure by air traffic control four seconds after the Aircraft became airborne coincided with the landing gear selection to the ‘up’ position. This added to the flight crew workload as they attentively listened and the Copilot responded to the air traffic control instruction which required a change of missed approach altitude from 3,000 ft to 4,000 ft to be set. The flight crews’ concentration on their primary task of flying the Aircraft and monitoring was momentarily affected as both the FMA verification and the flight director status were missed.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 200 in Dubai

Date & Time: Oct 2, 2015
Operator:
Registration:
DU-SD4
Survivors:
Yes
Schedule:
Dubai - Dubai
MSN:
132
YOM:
1968
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful skydiving mission over the Dubai Drop Zone, the pilot was returning to his base. Upon landing on runway 06, the twin engine aircraft went out of control, veered off runway to the left, struck an embankment and came to rest with the right wing torn off. The pilot was uninjured and the aircraft was damaged beyond repair.

Crash of a Cessna 208B Grand Caravan in Dubai

Date & Time: Jul 7, 2015 at 0800 LT
Type of aircraft:
Operator:
Registration:
DU-SD1
Flight Phase:
Survivors:
Yes
Schedule:
Dubai - Dubai
MSN:
208B-1141
YOM:
2005
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After takeoff from Dubai-Skydive Campus Airfield, while climbing to a height of 2,500 feet, the pilot encountered engine problems. He elected to return to the airport but eventually attempted an emergency landing in a desert area close to the airport. The aircraft crash landed and came to rest, bursting into flames. All 15 occupants escaped uninjured and the aircraft was destroyed by a post crash fire.

Crash of a Boeing 747-44AF near Dubai: 2 killed

Date & Time: Sep 3, 2010 at 1941 LT
Type of aircraft:
Operator:
Registration:
N571UP
Flight Type:
Survivors:
No
Schedule:
Hong Kong - Dubai - Cologne
MSN:
35668/1393
YOM:
2007
Flight number:
UPS006
Location:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
11410
Captain / Total hours on type:
367.00
Copilot / Total flying hours:
6130
Copilot / Total hours on type:
78
Aircraft flight hours:
9977
Aircraft flight cycles:
1764
Circumstances:
The four engine aircraft was completing a cargo flight from Hong Kong to Cologne with an intermediate stop in Dubai with two pilots on board. One minute after passing the BALUS waypoint, approaching the top of climb, as the aircraft was climbing to the selected cruise altitude of 32,000 feet, the Fire Warning Master Warning Light illuminated and the Audible Alarm [Fire Bell] sounded, warning the crew of a fire indication on the Main Deck Fire - Forward. The captain advised BAE-C that there was a fire indication on the main deck of the aircraft, informing Bahrain ATC that they needed to land as soon as possible. BAE-C advised that Doha International Airport (DOH) was at the aircraft’s 10 o’clock position 100 nm DME from the current location. The Captain elected to return to the point of departure, DXB. The crew changed the selected altitude from 32,000 feet to 28,000 feet as the aircraft changed heading back to DXB, the Auto Throttle [AT] began decreasing thrust to start the decent. The AP was manually disconnected, then reconnected , followed by the AP manually disconnecting for a short duration, the captain as handling pilot was manually flying the aircraft. Following the turn back and the activation of the fire suppression, for unknown reasons, the PACK 1 status indicated off line [PACKS 2 and 3 were off], in accordance with the fire arm switch activation. There was no corresponding discussion recorded on the CVR that the crew elected to switch off the remaining active PACK 1. As the crew followed the NNC Fire/Smoke/Fumes checklist and donned their supplemental oxygen masks, there is some cockpit confusion regarding the microphones and the intra-cockpit communication as the crew cannot hear the microphone transmissions in their respective headsets. The crew configured the aircraft for the return to DXB, the flight was in a descending turn to starboard onto the 095° reciprocal heading for DXB when the Captain requested an immediate descent to 10,000 ft. The reason for the immediate descent was never clarified in the available data. The AP was disengaged, the Captain then informed the FO that there was limited pitch control of the aircraft when flying manually. The Captain was manually making inputs to the elevators through the control column, with limited response from the aircraft. The flight was approximately 4 minutes into the emergency. The aircraft was turning and descending, the fire suppression has been initiated and there was a pitch control problem. The cockpit was filling with persistent continuous smoke and fumes and the crew had put the oxygen masks on. The penetration by smoke and fumes into the cockpit area occurred early into the emergency. The cockpit environment was overwhelmed by the volume of smoke. There are several mentions of the cockpit either filling with smoke or being continuously ‘full of smoke’, to the extent that the ability of the crew to safely operate the aircraft was impaired by the inability to view their surroundings. Due to smoke in the cockpit, from a continuous source near and contiguous with the cockpit area [probably through the supernumerary area and the ECS flight deck ducting], the crew could neither view the primary flight displays, essential communications panels or the view from the cockpit windows. The crew rest smoke detector activated at 15:15:15 and remained active for the duration of the flight. There is emergency oxygen located at the rear of the cockpit, in the supernumerary area and in the crew rest area. Due to the persistent smoke the Captain called for the opening of the smoke shutter, which stayed open for the duration of the flight. The smoke remained in the cockpit area. There was a discussion between the crew concerning inputting the DXB runway 12 Left [RWY12L] Instrument Landing System [ILS] data into the FMC. With this data in the FMC the crew can acquire the ILS for DXB RWY12L and configure the aircraft for an auto flight/auto land approach. The F.O. mentions on several occasions difficulty inputting the data based on the reduced visibility. However, the ILS was tuned to a frequency of 110.1 (The ILS frequency for DXB Runway 12L is 110.126), the Digital Flight Data Recorder [DFDR] data indicates that this was entered at 15:19:20 which correlates which the CVR discussion and timing. At approximately 15:20, during the emergency descent at around 21,000ft cabin pressure altitude, the Captain made a comment concerning the high temperature in the cockpit. This was followed almost immediately by the rapid onset of the failure of the Captain’s oxygen supply. Following the oxygen supply difficulties there was confusion regarding the location of the alternative supplementary oxygen supply location. The F.O either was not able to assist or did not know where the oxygen bottle was located; the Captain then gets out of the LH seat. This CVR excerpt indicates the following exchange between the Captain and F.O concerning the mask operation and the alternative oxygen supply bottle location. The exchange begins when the Captain’s oxygen supply stops abruptly with no other indications that the oxygen supply is low or failing. Based on the pathological information, the Captain lost consciousness due to toxic poisoning. After the Captain left the LH cockpit seat, the F.O. assumed the PF role. The F.O. remained in position as P.F. for the duration of the flight. There was no further interaction from the Captain or enquiry by the F.O as to the location of the Captain or the ability of the Captain to respond. The PF informed the BAE-C controllers that due to the limited visibility in the cockpit that it was not possible to change the radio frequency on the Audio Control Panel [ACP]. This visibility comment recurs frequently during the flight. The Bahrain East controller was communicating with the emergency aircraft via relays. Several were employed during the transition back to DXB. The aircraft was now out of effective VHF radio range with BAE-C. In order for the crew to communicate with BAE-C, BAE-C advised transiting aircraft that they would act as a communication relay between BAE-C and the emergency aircraft. BAE-C would then communicate to the UAE controllers managing the traffic in the Emirates FIR via a landline, who would then contact the destination aerodrome at Dubai, also by landline. The crew advised relay aircraft that they would stay on the Bahrain frequency as they could not see the ACP to change frequency. All of the 121.5 MHz transmissions by the PF were keyed via the VHF-R, all other radio communication with BAE-C and the relay aircraft are keyed from the VHF-L audio panel. There are several attempts by the UAE’s Area Control [EACC] to contact the flight on the guard frequency in conjunction with aircraft relaying information transmitting on the guard frequency to the accident flight. The PF of the accident flight does not appear to hear any of the transmissions from the air traffic control units or the relay aircraft on the guard frequency. Around this time, given the proximity of the aircraft to the RWY12L intermediate approach fix, Dubai ATC transmits several advisory messages to the flight on the Dubai frequencies, for example DXB ARR on 124.9 MHz advise that ‘Any runway is available’. The Runway lights for RWY30L were turned on to assist the return to DXB. The Aircraft condition inbound as the flight approached DXB for RWY12L. The computed airspeed was 350 knots, at an altitude of 9,000 feet and descending on a heading of 105° which was an interception heading for the ILS at RWY12L. The FMC was tuned for RWY12L, the PF selected the ‘Approach’ push button on the Mode Control Panel [MCP] the aircraft captures the Glide Slope (G/S). The AP did not transition into the Localizer Mode while the Localizer was armed. ATC, through the relay aircraft advised the PF, ‘you're too fast and too high can you make a 360? Further requesting the PF to perform a ‘360° turn if able’. The PF responded ‘Negative, negative, negative’ to the request. The landing gear lever was selected down at 15:38:00, followed approximately 20 seconds later by an the aural warning alarm indicating a new EICAS caution message, which based on the data is a Landing Gear Disagree Caution. At 15:38:20 the PF says: ‘I have no, uh gear’. Following the over flight of DXB, on passing north of the aerodrome abeam RWY12L. The last Radar contact before the flight passed into the zone of silence was at 15:39:03. The flight was on a heading of 89° at a speed of 320 knots , altitude 4200 feet and descending. The flight was cleared direct to Sharjah Airport (SHJ), SHJ was to the aircraft’s left at 10 nm, the SHJ runway is a parallel vector to RWY12L at DXB. The relay pilot asked the PF if it was possible to perform a left hand turn. This turn, if completed would have established the flight onto an approximate 10 mile final approach for SHJ RWY30. The flight was offered vectors to SHJ (left turn required) and accepts. The relay aircraft advised that SHJ was at 095° from the current position at 10 nm. The PF acknowledged the heading change to 095° for SHJ. For reasons undetermined the PF selected 195° degrees on the Mode Control Panel [MCP], the AP was manually disconnected at 15:40:05, the aircraft then banked to the right as the FMC captured the heading change, rolled wings level on the new heading, the throttles were then retarded, the aircraft entered a descending right hand turn at an altitude of 4000 feet, the speed gradually reduced to 240 kts. The PF made a series of pitch inputs which had a limited effect on the descent profile; the descent is arrested temporarily. There then followed a series of rapid pitch oscillations. These were not phugoid oscillations, these were commanded responses where the elevator effectiveness decreased rapidly as the airspeed decayed and the elevators could not compensate for the reduced thrust moment from the engines to maintain level flight in a steady state. This was due to the desynchronization of the control column inputs and the elevators. At this point had the aircraft remained on the current heading and descent profile it would have intercepted the terrain at or near a large urban conurbation, Dubai Silicone Oasis. The PF was in VHF communication with the relay aircraft requesting positional, speed and altitude information. From this point onwards, approximately 50 seconds elapse prior to the data ending. The effectiveness of the pitch control immediately prior to the end of the data was negligible. The control column was fully aft when the data ended, there was no corresponding elevator movement. The aircraft lost control in flight and made an uncontrolled descent into terrain.
Probable cause:
Probable causes:
- A large fire developed in palletized cargo on the main deck at or near pallet positions 4 or 5, in Fire Zone 3, consisting of consignments of mixed cargo including a significant number of lithium type batteries and other combustible materials. The fire escalated rapidly into a catastrophic uncontained fire.
- The large, uncontained cargo fire, that originated in the main cargo deck caused the cargo compartment liners to fail under combined thermal and mechanical loads.
- Heat from the fire resulted in the system/component failure or malfunction of the truss assemblies and control cables, directly affecting the control cable tension and elevator function required for the safe operation of the aircraft when in manual control.
- The uncontained cargo fire directly affected the independent critical systems necessary for crew survivability. Heat from the fire exposed the supplementary oxygen system to extreme thermal loading, sufficient to generate a failure. This resulted in the oxygen supply disruption leading to the abrupt failure of the Captain’s oxygen supply and the incapacitation of the captain.
- The progressive failure of the cargo compartment liner increased the area available for the smoke and fire penetration into the fuselage crown area.
- The rate and volume of the continuous toxic smoke, contiguous with the cockpit and supernumerary habitable area, resulted in inadequate visibility in the cockpit, obscuring the view of the primary flight displays, audio control panels and the view outside the cockpit which prevented all normal cockpit functioning.
- The shutdown of PACK 1 for unknown reasons resulted in loss of conditioned airflow to the upper deck causing the Electronic Equipment Cooling [EEC] system to reconfigure to “closed loop mode”. The absence of a positive pressure differential contributed to the hazardous quantities of smoke and fumes entering the cockpit and upper deck, simultaneously obscuring the crew’s view and creating a toxic environment.
- The fire detection methodology of detecting smoke sampling as an indicator of a fire is inadequate as pallet smoke masking can delay the time it takes for a smoke detection system to detect a fire originating within a cargo container or a pallet with a rain cover.
Contributing Factors:
- There is no regulatory FAA requirement in class E cargo compartments for active fire suppression.
- Freighter main deck class E fire suppression procedures which relay on venting airflow and depressurisation as the primary means of controlling a fire are not effective for large Class E cargo fires involving dangerous goods capable of Class D metal fire combustion.
- No risk assessment had been made for the failure of the cargo compartment liner based on the evolution of cargo logistics and associated cargo content fire threats, cargo hazards and bulk carriage of dangerous goods.
- The regulation standards for passive fire suppression do not adequately address the combined total thermal energy released by current cargo in a large cargo fire and the effect this has on the protection of critical systems.
- FAA and EASA regulatory requirements do not recognize the current total fire risk associated with pallets, pallet covers and containers as demonstrated by the NTSB/FAA testing.
- Class 9 Hazmat packing regulations do not address the total or potential fire risk that can result from lithium battery heat release during thermal runaway. Although non-bulk specification packaging is designed to contain leaks and protect the package from failure, the packaging for Class 9 does not function to contain thermal release.
- The growth rate of container and pallet fires after they become detectable by the aircraft’s smoke detection system can be extremely fast, precluding any mitigating action and resulting in an overwhelming total energy release and peak energy release rate for a standard fire load that cannot be contained.
- The course to return to Dubai required a series of complex radio communication relays due to the Pilot Flying’s inability to view and tune the radio transceivers.
- The relay communication between the Pilot Flying, relay aircraft and the various ATC stations resulted in communication confusion, incomplete and delayed communications, which contributed to the escalated workload and task saturation for the Pilot Flying.
- The Fire Main Deck non-normal checklist in the QRH was not fully completed by the crew or adhered to regarding the fire suppression flight level or land at nearest airport instruction.
- Task saturation due to smoke and multiple systems failures prevented effective use of the checklist by the crew.
- Communications between the ATCO units involved multiple stages of information exchange by landline and the destination aerodrome was not fully aware of the specific nature of the emergency, the difficulty that the Pilot Flying was experiencing or the assistance required.
- The Pilot Flying had not selected transponder code 7700, the emergency code, when radio communication with the destination aerodrome was not established.
Final Report:

Crash of an Airbus A310 in Dubai

Date & Time: Mar 12, 2007 at 0630 LT
Type of aircraft:
Operator:
Registration:
S2-ADE
Flight Phase:
Survivors:
Yes
Schedule:
London - Dubai - Dhaka
MSN:
698
YOM:
1996
Flight number:
BG006
Location:
Region:
Crew on board:
14
Crew fatalities:
Pax on board:
236
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from Dubai Intl Airport runway 12L, after V1 speed, the crew heard a loud bang then noticed severe vibrations when the nose gear collapsed. The captain abandoned the takeoff procedure and initiated an emergency braking manoeuvre. The aircraft slid on its nose for few hundred metres and came to rest just before the end of the runway, slightly to the left of the centerline. All 250 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
Failure of the nose gear during the takeoff roll after it impacted a half wheel rim which was broken off during the takeoff from a previous aircraft.