Description

On 3 August 2016, a Rolls Royce Trent 892-powered Boeing 777-300 (A6-EMW) being operated by Emirates on a scheduled international passenger flight from Trivandrum, India to Dubai as EK 521 commenced a go around shortly after touchdown on runway 12L at destination in day VMC but almost immediately sank back onto the runway and veered to the right towards its end before stopping. All 300 occupants escaped but four of the cabin crew were seriously injured and 21 passengers, 6 cabin crew and one of the pilots sustained minor injuries. The aircraft was completely destroyed by a combination of impact damage and the fire which developed quickly thereafter and eventually culminated in an explosion. This explosion occurred after the evacuation of all 282 passengers and most of the 18 crew had been completed. One fire fighter was killed, and five others and two police officers sustained minor injuries at the crash site. Damage was caused to the runway surface and to manoeuvring area lighting and signage.

Investigation

A comprehensive Investigation was carried out by the UAE GCAA Air Accident Investigation Sector. Both the solid-state Flight Data Recorder (FDR) and the Cockpit Voice Recorder (CVR) were recovered from the wreckage in a heat-damaged condition but their data were successfully downloaded by the Aircraft Accident Investigation Branch (UK) (AAIB) and found to be valid up to the point where the post crash explosion had occurred. A Preliminary Report giving some initial findings was issued on 5 September 2016 and the Investigation was subsequently completed and published early in 2020.

The Flight Crew

The two pilots had not previously operated together. It was found that the 34 year-old Captain, who had been PF for the accident flight, had accumulated 7,457 total flying hours including 5,123 on type. He had joined the operator as a cadet and begun his operational flying career in 2004 as a co-pilot on the Airbus A330 before transferring to the Airbus A340 as a co-pilot in 2008. In 2009, he had then transferred to the Boeing 777 as a co-pilot, completing his conversion training in 2009. After accumulating 3,950 hours as a co-pilot on Boeing 777, he had been promoted to Captain on the type in 2015 and had since accumulated a total of 1,173 hours in command on type. An examination of his training records whilst on the Boeing 777 did not indicate any cause for concern about his competency and it was noted that “the Operator considered that he was trained to competency and achieved the required acceptable standard”. It was noted that the Operator’s recurrent training programme, which was considerably in excess of minimum regulatory requirements, included practising a go around commenced after touchdown. The Captain had last completed this exercise when still a B777 co-pilot but it had been conducted as planned with the A/T and FDs off, in contrast to the normal situation for go around after a manual landing touchdown where these aids would be routinely active.

The 37 year-old First Officer had accumulated a total of 7,957 flying hours of which 1,292 were on type, the latter all obtained after joining the Operator a little under two years prior to the accident and completing his Boeing 777 type rating. His training during his time on the type had not included any simulator sessions that had involved “automatic or manual go-arounds flown from below 50 feet agl or (commenced) after touchdown” or any bounced landing recovery practice. It was noted that his training records contained no adverse remarks in relation to competency.

What Happened

The aircraft track from just before touchdown to the point of impact and final stopping position. [Reproduced from the Final Report]

It was established that a briefing for the expected radar vectors for an RNAV/GNSS approach to 3,600 metre-long runway 12L with flap 30 as the final setting and a (correctly calculated) VREF of 147 KIAS noted. The arrival ATIS received during descent gave a light easterly breeze and included a not-unexpected caution of “wind shear all runways”, which was briefly discussed by the crew. However when the flight checked in with Dubai APP, no mention was made of the wind shear, although the Captain then mentioned previous experience of “wind shift” at Dubai to the First Officer. The subsequent landing clearance from TWR was accompanied by a spot wind of 340°/11 knots - a change from a small headwind component to a small tailwind component that had been included in the current TAF as likely to occur in the period during which the approach was taking place.

The approach flown was stabilised as the aircraft descended through 1000 feet agl and DFDR data showed that the AP had been disengaged shortly afterwards. As per the applicable SOPs, the A/T had remained engaged in SPEED mode until automatically transitioning to IDLE mode at 25 feet agl during the flare to land. The aircraft passed over the runway threshold at the prescribed height but following the flare to land, the aircraft floated just above the runway as the indicated airspeed increased to 14 knots above VREF and it touched down just over 1000 metres past the threshold. After just six seconds with (only) one or both the main landing gear assemblies in ground contact, the Captain, aware that the TDZ had been mostly overflown and suspecting that the difficulty in achieving touchdown had been caused by thermals rather than any windshear, had pressed the TO/GA switches on his control column and called a go-around. A “Long Landing” Alert from the RAAS followed almost immediately.

Since the TO/GA switch selection had no effect on the A/T with the aircraft on the ground, the thrust remained at idle as the aircraft was pitched up to approximately 7.5°. The Captain called “Flaps 20” and the aircraft became airborne at VREF + 6.5 knots. The aircraft continued to gain height and as it passed a recorded 47 feet agl, the First Officer called “Positive Climb” by reference to the vertical speed indication on the PFD. The Captain responded by calling “Gear Up” as the aircraft passed 58 feet agl and was reaching its maximum rate of climb of just over 600 fpm. TWR then re-cleared the flight to climb straight ahead to 4000 feet and, after the gear up instruction had been repeated and actioned by the First Officer as the aircraft passed 77 feet agl, he then read back the re-clearance to TWR. Two seconds later, the aircraft, still over the runway, reached its maximum height of 85 feet agl and began to descend.

Three seconds after this descent had begun, with the aircraft passing 67 feet agl, the Captain called “Windshear TOGA” and the A/T mode changed from ‘IDLE’ to ‘THR’. One second later, he manually advanced both thrust levers to maximum as an EGPWS Mode 3 ‘Don’t Sink ‘ Alert was annunciated and the First Officer’s “Check Speed” call was followed by an ‘AIRSPEED LOW’ caution at 128 KIAS and a second ‘DON’T’ SINK’ annunciation. The aircraft was now descending at 800 fpm and the Captain’s increase in the pitch attitude to a recorded 9.2 degrees did not arrest this. Three seconds after the thrust levers had been set to maximum and 18 seconds after the go-around had been initiated, the aircraft rear fuselage hit the runway at a recorded forward speed of 124 KIAS - above the prevailing Vs - approximately 2530 metres from the beginning of the runway and with the landing gear still in transition to the ‘up’ position. The aircraft slid along the runway for approximately 800 metres (see the illustration below) for the next 32 seconds before veering to the right, turning through 120° and stopping with the No. 2 engine/pylon assembly - already on fire - detached from the rest of the aircraft and near the right wingtip. Fire was also evident coming from beneath the No. 1 engine and there was dense smoke coming from the right hand side of the fuselage in the vicinity of the right main landing gear bay.

The initial impact point (1) and the ground track to the final stopping position (2). [Reproduced from the Official Report]

Once the aircraft had come to a final stop, the Captain immediately made a PA “Cabin Crew to Stations”. One minute after this, during which some passengers had already left their seats, he then ordered an evacuation over the PA and declared a MAYDAY to ATC advising that an evacuation was under way. Shortly afterwards, the first two of a number of ARFFS vehicles arrived and began applying fire extinguishing agent. The First Officer left the aircraft via exit R2 to direct evacuated passengers away from the aircraft.

On receipt of the evacuation command, all but one of the 10 passenger cabin emergency exits were initially opened but only 5 of them were ultimately useable. Smoke and fire outside prevented the use of the two over wing exits at L3 and R3 and the slides at three other exits were not used - the L1 slide detached from the aircraft when deployed and the slides at L2 and L4 could not be not used because the wind blew them up against the door. A questionnaire to passengers was subsequently used by the Investigation to map the use of the available exits (see below).

Passenger seat occupancy and emergency exit use. [Reproduced from the Official Report]

As the evacuation proceeded, white smoke already in the centre cabin changed colour to grey and became very dense, dramatically reducing visibility and effectively creating a barrier between the front and rear of the aircraft. Many passengers left the aircraft with their carry-on baggage with the cabin crew judging that to intervene would slow the evacuation. Although the aircraft passenger cabin was only 77% occupied by the 282 passengers on board, these included 4 adults who had required assistance during boarding, 60 children and 7 infants. The evacuation took “approximately 6 minutes and 40 seconds” to complete.

Two minutes after this, the centre fuel tank explosion occurred and debris from it led to the death of the attending fire fighter. At this time, only the Captain and the Senior Cabin Crew Member (SCCM) were still on board searching the cabin for any remaining passengers. The explosion caused intense smoke to fill the whole aircraft and they both initially tried to evacuate from the flight deck emergency window exits but when they could not locate the evacuation ropes, they both left the aircraft by jumping from the L1 door onto the inflated slide on the ground below. Following the explosion, the fire began to enter the cabin interior and then the under floor hold leading to the complete destruction of the aircraft.

Relevant Flight Crew Procedures

The documented Flight Crew SOPs for a go around initiated after touchdown were examined and the following was noted:

• The Flight Crew Training Manual (FCTM) states that "an automatic go around cannot be initiated after touchdown". It also states that "as thrust levers are advanced, auto speedbrakes retract and autobrakes disarm. The F/D go-around mode will not be available until go-around is selected after becoming airborne".
• The Flight Crew Operating Manual (FCOM) states that the TO/GA switches are inhibited when on the ground and enabled again when in the air for a go around. It then states that the first push of the TO/GA switches once airborne will command the A/T to change from IDLE mode to THRUST mode and set sufficient thrust to establish a minimum 2000 fpm rate of climb.
• The FCOM Go-Around and Missed Approach Procedure requires that the PF pushes the TO/GA switch and calls 'FLAPS 20' and then verifies that "rotation to go around attitude" and "thrust increase" occur. The PM sets the requested flap and then "verifies that the thrust is sufficient for the go around". The PM must then, after verification of this on the altimeter, follow with a PM call of 'Positive Climb'. Upon hearing this call, the PF then checks that there is positive climb on their own altimeter and, having done so, calls for 'Gear Up'.

In respect of the operation of the TO/GA switches as the normal way to set thrust for a go around, it was noted that they are inhibited just prior to touchdown once the aircraft descends to less than 2 feet agl for three seconds. They will then remain so for as long as this height is not subsequently reached/exceeded and the weight-on-wheel (WoW) system for at least one main landing gear assembly indicates that the aircraft is in ‘ground’ rather than ‘flight’ mode. If, as is the case during landing in accordance with the prevailing SOPs, the A/T is armed and active with the aircraft less than 2 feet agl, then the thrust levers must be advanced from idle manually. This will result in the A/T disconnecting and a corresponding EICAS message being displayed but there is no EICAS alert if a go around is commenced without concurrent thrust lever movement towards the TO/GA position.

Findings

A total of 156 Findings from the Investigation were documented in respect of the accident and its aftermath with the content of many of them reflected in safety recommendations. They were categorised as relevant to ‘the Aircraft’, ‘the Flight Crew’, ‘Flight Operations’, ‘the Operator’, ‘Air Traffic Control’, ‘Airport Weather Information’, ‘Airport Rescue and Firefighting Services’, ‘Medical Aspects’, ‘Survivability’, ‘GCAA Safety Oversight’ and ‘FAA Aircraft Certification Specifications’ They included the following:

The Aircraft

• The EGPWS manufacturer document Product Specification Mode 7 Windshear Alerting was capable of providing a windshear caution alert for aircraft performance increasing due to increasing headwind (or decreasing tailwind) and severe updrafts. However, this feature was not available to the flight crew because it was not enabled on the Aircraft.
• During the evacuation, the prevailing wind speed and angle were within the technical standard order (TSO) certification conformity testing criteria (but) due to the aircraft coming to rest on its lower fuselage, the escape slides deployed at an angle of approximately 14 degrees. As per design, the escape slide deployed slope angle range is between 27 to 35 degrees, with the landing gear extended.

The Cabin Crew

• The cabin crew were not trained in evacuation situations where the escape slides are affected by wind.
• The cabin crew managed the passenger evacuation to the highest professional standard, in line with their training.

Flight Operations

• In the eight minutes prior to the attempted landing of the accident aircraft, two aircraft performed go-arounds from beyond the runway threshold and two aircraft landed uneventfully.
• The Captain started to flare the aircraft at approximately 40 feet agl (when) approximately 100 metres beyond the threshold. The FCTM recommends initiation of the flare when the main gear is approximately 20 to 30 ft above the runway surface.
• The wind conditions that existed up to 10 feet agl (during landing) did not have a decreasing and/or increasing performance effect on the aircraft (but after) passing 7 feet agl, the aircraft floated over the runway and (by) 2 feet agl, the IAS (had) reached 165 knots. (Concurrently), there was a 12 knot airspeed increase (over) approximately four seconds, during which time the descent rate decreased.
• When the Captain initiated the go-around, his perception was that the aircraft was still airborne and had not touched down.
• During the attempted go-around, the Captain said that he became focused on the go-around manoeuvre and described his state (of mind) as “tunnel visioned”.
• After pushing the left TO/GA switch, the Captain did not recognise that there was no tactile feedback of thrust lever movement.
• Neither pilot observed that the FMA modes did not change and that the flight director was not giving pitch guidance. They were (also) unaware that the A/T mode had remained at ‘IDLE’.
• Contrary to the FCOM Go-around and Missed Approach Procedure, after the ‘flaps 20’ (call) neither pilot verified the engine thrust and (they subsequently) continued to action the procedure from the ‘positive climb’ item.

The Aircraft Operator

• The Operator’s OM-A policy required the A/T to be engaged for engine thrust management for all phases of flight including approach and landing. This policy did not consider pilot actions that would be necessary during a normal go-around initiated while the TO/GA switches were inhibited.
• The Operator’s training program for the B777 was based on the aircraft manufacturer and FAA approved training program, which did not include the TO/GA inhibition logic.
• The Operator’s procedure, as per FCOM Flight Mode Annunciations (FMA), requires FMA changes to be announced by the PF and checked by the PM except for landing when the aircraft is below 200 feet.
• In developing the training for a go-around after touchdown as referenced in the Operator’s B777 Training Manual, scenarios for a go-around in automatic flight and in manual flight with the A/T armed and active were not considered. The TO/GA switch inhibit logic was also not considered, and as a result was not part of the training syllabus.
• Full information related to the TO/GA switch inhibit logic was not available either in the FCOM or the FCTM (and) no reference was contained in these manuals as to why the A/T mode will not change when the TO/GA switches become inhibited.
• The Operator’s normal go-around training did not contain guidance on how to perform a normal go-around when the TO/GA switches become inhibited prior to and after touchdown.
• The Operator’s training and operational systems did not identify hazards associated with normal go-arounds performed (from) close to the runway or after touchdown.

Air Traffic Control

• Other than for a high speed rejected takeoff, no guidance was included in the MATS to direct air traffic controllers to avoid distracting flight crew with unnecessary radio calls during times of high workload such as go-arounds, especially those initiated at low altitudes, or from the runway.
• Various essential information was not communicated to the flight crew including in respect of recent missed approaches, a pilot report of windshear on short final and the wind shift at the runway 12L threshold during which the headwind component was replaced by a tailwind component shortly before landing.
• Other than for a high-speed rejected takeoff, no guidance was included in the MATS directing air traffic controllers to avoid distracting the flight crew with unwarranted radio calls during high flight crew workload situations, such as go arounds, especially those initiated at low altitudes, or from the runway.

Airport Weather Information

• Neither the flight crew nor the Tower was aware that the wind (direction) shift along runway 12L was after the runway aiming point and before the end of the runway touchdown zone.

Airport Rescue and Firefighting Services (ARFFS)

• The response time of the first responding fire vehicles was within the regulatory requirements, however, the first two responding Major Foam Vehicles (MFV) were positioned behind the trailing edge of the right wing and obstructed the escape paths of the evacuating passengers.
• The fire commander did not correctly establish incident sectors and did not cover the area that extended from the right wing leading edge to the aircraft nose. His view of the accident site was limited because he positioned his vehicle inappropriately.
• No dynamic risk assessment was conducted and sideline firefighters were moving very close to fuel tanks where there was a potential explosion hazard. Crew managers did not communicate details of the firefighting actions to the fire commander.
• The ARFFS training system did not detect the lack of knowledge, understanding, and experience in aircraft incident command and firefighting tactics. Exercises were limited to simple fire scenarios and no appropriate simulated techniques were developed to challenge the fire commanders, sector commanders, crew managers, and firefighters to assess fire dynamics and develop appropriate tactics.
• The most recent pre-accident audit carried out by the GCAA included findings that were not appropriately addressed by the airport management.
• The most recent airport emergency exercise, carried out in June 2015, revealed deficiencies that were repeated during the accident response.

Survivability

• The Captain did not initiate the evacuation until approximately one minute after the aircraft came to rest. Part of this time was used to locate the evacuation checklist amongst the items that had been scattered around the cockpit during the impact.
• The airport Passenger Evacuation Management System (PEMS) did not control the evacuated passengers.
• The Mobile Incident Command Centre (MICC) was not deployed until sometime after the accident and was not utilised as per procedure.

GCAA Safety Oversight

• The Civil Aviation Regulations, CAR-OPS 1, did not specify that (pilot) training was required for rejected landing, bounced landing recovery, go-around below 50 feet, go-around after touchdown under normal engine power, or after the loss of an engine.
• The GCAA clarified that as the Regulations are not prescriptive in nature, the Inspectors’ Audit Checklist, FOF-CHK-002, contained rejected landing as a check item option.
• The GCAA conducted annual audits on the Operator based on progressive audit and the audits were supervised by the Principal Inspector designated for oversight functions, which included the operations, safety, and flight crew training.
• A review of the records of the GCAA audits of the Operator for operations, safety and flight crew training over a 6-year period prior to the accident showed that there were no significant findings against the Operator’s B777 go-around training standards, the Online Grading System for pilot review or the Operator’s hazard identification for go-around procedures and training.
• The Operator’s OFDM program was the responsibility of the Operator’s Flight Operations post holder rather than the Safety Management System post holder as the GCAA had accepted this as an alternate means of compliance in accordance with AC OPS 1.037.
• The Civil Aviation Regulations, CAR Part VIII, Subpart 7- Meteorological Services, does not give guidance with regards to aviation meteorology including the forecasting and reporting of windshear.
• GCAA safety oversight related to aviation meteorology is performed by Air Traffic Service Inspectors as there are no trained, qualified and experienced meteorology subject matter experts employed to fill this role.

The Causes of the Accident were formally determined as:

• 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.
• The flight crew did not effectively scan and monitor the primary flight instrumentation parameters during the landing and the attempted go-around.
• 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.
• 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.

A total of 11 Contributory Factors were also identified as follows:

• 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 metres beyond the runway threshold.
• 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.
• 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 manoeuvre, 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.
• 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.
• The flight crew did not monitor the flight mode annunciations (FMA) changes after the TO/GA switch was pushed because:
  • 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 feet.
  • Callouts of FMA changes were not included in the Operator’s FCOM Go-Around and Missed Approach Procedures.
  • Callouts of FMA changes were not included in the Operator’s FCTM Go-Around and Missed Approach training.
• 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.
• The FCOM Go-Around and Missed Approach Procedure did not contain steps for verbal verification callouts of engine thrust state.
• 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.
• 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.
• 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.
• 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 First Officer 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.

Safety Action taken by Emirates whilst the GCAA Investigation was in progress was noted to have included, but not been limited to, the following:

• Liaising with IATA to develop industry guidelines on how to stabilise evacuation slides in windy conditions.
• Liaising with Dubai ATS to ensure that missed approach procedures are only modified for flight safety reasons meaning that ATC should normally refrain from contacting an aircraft during the initial phases of a go-around and wait for contact to be initiated by the flight crew.
• Liaising with the Dubai Airport authorities in order to install a low-level windshear alerting system (LLWAS).
• Working with the airport Meteorological Office and ATS to conduct a study of dynamic environmental conditions such as windshear and wind shift, wake and mechanical turbulence and how they affect the airport environment and any technological methodologies for capturing this information such as a digital ‘aircraft to tower’ data link.
• Liaising with Boeing to develop engineered defences that will alert the flight crew when a TO/GA switch is pushed at a time when switch function is intentionally inhibited.
• Liaising with Boeing and systems manufacturers to develop engineered defences that protect against insufficient aircraft energy states.
• Liaising with Boeing regarding modification of the FCOM ‘Go Around and Missed Approach Procedure’ in relation to the verification of engine thrust.

A total of 40 Safety Recommendations were issued as a result of the Investigation as follows:

• that Emirates disseminate to its pilots knowledge and information about factors affecting landing distance and flare duration, such as aircraft height and airspeed over the threshold, early flare initiation and weather conditions that may affect aircraft performance during the landing. [SR01/2020]
• that Emirates enhance the normal go-around and missed approach training standards which should include simulated scenarios for a normal go-around initiated close to the runway and after touchdown when the takeoff/go-around (TO/GA) switches are inhibited. This should also include information on engine response time to achieve go-around thrust. [SR02/2020]
• that Emirates enhance training standards regarding TO/GA switch inhibiting so that pilots are aware of the effect on FMA annunciations and the flight director, and the availability of the autothrottle after the aircraft becomes airborne during a go-around. [SR03/2020]
• that Emirates enhance the flight crew training and assessment system to include procedures for managing evaluator comments on pilot performance including pilots who have met the competency standard. [SR04/2020]
• that Emirates review and enhance the go-around training standards taking into consideration the available analytical flight monitoring data as well as the recommendations made within the industry. For example, the recommendations contained in United Kingdom Civil Aviation Authority Information Notice No. IN-2013/198 - Go-around Training for Aeroplanes may be consulted. [SR05/2020]
• that Emirates implement changes to crew resource management training taking into consideration the lessons of the EK521 Accident. [SR06/2020]
• that Emirates reiterate to flight crew the effects on aircraft performance due to wind changes that can affect landing, and the importance of effective monitoring of the flight instrumentation during a windshear warning. [SR07/2020]
• that Emirates examine the training system to assess its adequacy in enhancing the cockpit instrumentation monitoring skills of flight crew. [SR08/2020]
• that Emirates enhance the simulated training scenarios for a normal go-around before and after touchdown. The training and simulator sessions should emphasize the importance of performing and verifying each procedural step. [SR09/2020]
• that Emirates include evacuation scenarios where the escape slides are affected by wind in cabin crew training. [SR10/2020]
• that Emirates for quick access, ensure that the evacuation checklist is displayed securely in a position in the cockpit easily visible to the flight crew. [SR11/2020]
• that Dubai Air Navigation Services (DANS) ensure that best practice guidelines for the transmission of air traffic control instructions to flight crew be reviewed and included in unit procedures and continuation training for all current and future air traffic controllers. These guidelines should include, consideration of appropriate times and conditions when air traffic controllers may establish communication and issue instructions, with particular emphasis regarding critical phases of flight. Note: Further reference may be found in EASA Safety Information Bulletin 2014-06 and GCAA Safety Alert 09/2016. [SR12/2020]
• that DANS implement procedures to ensure that the air traffic control missed approach procedure in the Dubai manual of air traffic service (DMATS) is consistent and aligned with the Aeronautical Information Publication (AIP) of the United Arab Emirates. Note: Reference should be made to European Aviation Safety Agency (EASA) Safety Information Bulletin (SIB) No. 2014-06. [SR13/2020]
• that DANS implement procedures and guidance that would limit the air traffic controller, to the maximum extent, from distracting the flight crew by issuing instructions modifying the published missed approach procedures in case of a missed approach. Note: Reference should be made to European Aviation Safety Agency (EASA) Safety Information Bulletin (SIB) No. 2014-06. [SR14/2020]
• that DANS enhance the procedures, and air traffic controllers training, so that whenever windshear warnings are in effect at an aerodrome, essential safety information, such as go-arounds, long/deep landings when reported, wind gust and wind shift, is always transmitted to the flight crew at an appropriate time during the approach. [SR15/2020]
• that DANS enhance the procedures and air traffic controller training so that whenever windshear warnings are in effect at an aerodrome, the reason for an aircraft go-around, including wind conditions for aircraft that landed, should be requested by the air traffic controller if the information is not passed by the flight crew when safe to do so. [SR16/2020]
• that DANS, as the GCAA-certificated meteorological service provider at Dubai Airports, install the required meteorological equipment necessary for detection and alerting of low level windshear, that will enhance the accuracy and conciseness of the weather information provided by the National Centre of Meteorology (NCM) to aviation meteorological forecasters and air traffic controllers. [SR17/2020]
• that DANS implement changes to the procedures so that following an aircraft emergency, there are effective means of obtaining and transmitting to the search and rescue and firefighting services, information related to persons on board and dangerous goods within an acceptable time if the flight crew is not available. This should be aligned with recommended practices as stated in the International Civil Aviation Organisation (ICAO) Doc 4444 chapter on Emergency Procedures and ICAO Doc 9137 Airport Services Manual, Part 7 Airport Emergency Planning. [SR18/2020]
• that Dubai Airports enhance training for the Airport rescue and firefighting service (ARFFS) personnel to enable them to identify confined heat sources based on indicators and smoke traces. This training should enable the fire commander to understand the fire dynamic and determine the appropriate tactics, depending on the site circumstances and considering utilisation of the unique capabilities of (particular) fire vehicles. This should be supported by sufficient training in incident command. [SR19/2020]
• that Dubai Airports enhance the ARFFS personnel practical training exercises by including new scenarios based on appropriate simulated techniques, that challenge the firefighters, crew managers, and fire commanders to assess fire dynamics and develop tactics. The scenarios should replicate the circumstances of actual accidents, with various aircraft states. Different weather and environmental conditions should also be considered. [SR20/2020]
• that Dubai Airports periodically test the Airport passenger evacuation management system (PEMS) using properly-developed exercises, to ensure that the system is effective in providing a high level of safety to the evacuees from the time of evacuation to the time of assembly in the Survivors Reception Centre (SRC). [SR21/2020]
• that The Boeing Company enhance the Boeing 777 crew alerting system to include aircraft configuration inconsistency when a go-around manoeuvre is commanded and the engine thrust is insufficient for the manoeuvre. [SR22/2020]
• that The Boeing Company enhance the Boeing 777 Flight Crew Operations Manual (FCOM) and the Flight Crew Training Manual (FCTM) for consistency in TO/GA switch inhibiting information. In addition, it is recommended to appropriately highlight, in both the FCOM and FCTM, the significance of the effects on the A/T due to the TO/GA switch inhibit logic. [SR23/2020]
• that The Boeing Company include requirements for the pilot flying to give call outs for thrust setting with verbal verifications of thrust increase being made by the pilot monitoring in the Boeing 777 Go-Around and Missed Approach Procedure and amend the FCOM and FCTM accordingly. In addition, emphasis should be given to the importance of guarding the thrust levers. The existing thrust setting callout in the Takeoff Procedure could be referred to. [SR24/2020]
• that The Boeing Company study the benefits of adding callouts to Boeing 777 Flight Mode Annunciation (FMA) changes at the initiation of the Go-Around and Missed Approach Procedure, and amend the FCOM and FCTM accordingly. [SR25/2020]
• that The Boeing Company conduct a safety study to determine the benefits of developing a common procedure for the Boeing 777 normal go around and missed approach. This procedure should consider manual advancement of the thrust levers at low altitude and after touchdown, and the requirements for go-around after touchdown including flap position, aircraft rotation speed and crew awareness of associated warning/alert messages. [SR26/2020]
• that The General Civil Aviation Authority of the United Arab Emirates (GCAA) implement measures that could improve the audit program and checklist used by the inspectors so that the effectiveness of the oversight function related to flight crew training and flight operations is enhanced. [SR27/2020]
• that The GCAA establish a position within its organisation and induct a subject matter expert in aviation meteorology who is appropriately trained, qualified and experienced (as an inspector). [SR28/2020]
• that The GCAA publish recommendations for air navigation service providers:
  • to implement procedures and guidance that would limit the air traffic controller, to the maximum extent, from issuing instructions to flight crews that would modify the published missed approach procedures in case of go around with the sole exception of transmitting essential instructions to ensure air safety;
  • to emphasise the benefits of consistently applying the published missed approach procedure and the risks associated with modifications to such procedure at a time of high flight crew workload when potential for distraction must be minimised;
  • to emphasise, during all phases of air traffic controller training, the importance of correctly timed, concise and effective communication to flight crew performing a missed approach;
  • to incorporate appropriate details of the accident described in this report and the lessons learned into air traffic controller training. [SR29/2020]
• that The GCAA enhance the Civil Aviation Regulations for the provision of flight information services related to information regarding significant changes (see Note) in the meteorological conditions, in particular the latest information, if any, on windshear and/or turbulence in the final approach area or in the takeoff or climb-out area, to be transmitted to the aircraft without delay, except when it is known that the aircraft already has received the information. Note: - Significant changes in this context include those relating to surface wind direction or speed, visibility, runway visual range or air temperature and (for turbine-engined aircraft), the occurrence of thunderstorm or cumulonimbus, moderate or severe turbulence, windshear, hail, moderate or severe icing, severe squall line, freezing precipitation, severe mountain waves, sandstorm, dust storm, blowing snow, tornado or waterspout. [SR30/2020]
• that The GCAA study the benefit of specifying and incorporating changes to the Civil Aviation Regulations, the required meteorological equipment used for detection of low-level windshear and alerts; placement of anemometers along the runways; and receiving current aircraft wind information, that will enhance the accuracy and conciseness of the weather information broadcasted from the aviation meteorological forecasters and air traffic controllers. [SR31/2020]
• that The GCAA revise the CAR-OPS so that they are aligned with the requirements of ICAO Annex 2 and ICAO Doc 4444 with regard to submission of the operational flight plan and for the GCAA to specify what information is considered relevant in the flight plan. [SR32/2020]
• that The GCAA provide guidance to the air traffic service providers in the United Arab Emirates, aircraft operators and airport operators, so that following an aircraft emergency where the flight crew is not available, there are effective means of obtaining and transmitting to the search and rescue and firefighting services, information related to persons on board and dangerous goods for flights departing and arriving at United Arab Emirates airports within an acceptable time. This should be aligned with recommended practices as stated in ICAO Doc 4444 chapter on Emergency Procedures and in ICAO Doc 9137 ‘Airport Services Manual, Part 7 Airport Emergency Planning’. [SR33/2020]
• that The GCAA perform a safety study, which should include a review of the Civil Aviation Regulations, to determine the effectiveness to include the requirement that passenger safety briefings and passenger safety cards have clear instructions and illustrations that carry-on baggage must not be taken during an emergency situation and to leave carry-on baggage during an evacuation. The Investigation recommends that the GCAA refer to ICAO Doc 10086 ‘Manual on Information and Instructions for Passenger Safety’. [SR34/2020]
• that The Federal Aviation Administration of the United States (FAA) perform a safety study in consultation with the aircraft manufacturer for the purpose of enhancing the Boeing 777 windshear alerting system. This study should encompass both ‘predictive’ and ‘immediate’, (TSO-C117a/b) windshear systems. [SR35/2020]
• that The FAA perform a safety study in consultation with the aircraft manufacturer, for the purpose of enhancing the Boeing 777 autothrottle system and TO/GA switch inhibit logic to avoid pilot errors due to overreliance on automation. The study should also include improvement in crew procedures and training on the autothrottle system and TO/GA switch inhibit logic, including manual advancing of the thrust levers for a go-around initiated at low altitude or after touchdown. [SR36/2020]
• that The FAA require Essex Industries (the manufacturer of the protective breathing equipment ‘PBE’), to evaluate the current design features of the PBE container (stowage compartment) and pouch, and develop modifications to prove compliance with TSOC116a and TSO-C99a regarding easy access. [SR37/2020]
• that The FAA review the current Federal Aviation Regulations and relevant guidance material to address inadequate performance of escape slides during evacuations with collapsed landing gear. The review should consider the effect of wind on escape slide performance. [SR38/2020]
• that The International Civil Aviation Organisation (ICAO) studies the benefit of establishing a global, coordinated and structured data sharing within the industry, which derives the precursors to accidents and serious incidents. This initiative, together with participation of the aircraft manufacturers, should provide clear guidance on how these precursors can be identified through data analysis. [SR39/2020]
• that The ICAO defines Standards and Recommended Practices (SARPs) and procedures for air navigation services so that air traffic controllers, except where necessary for safety reasons, are aware as to when it is safe to initiate communication with the flight crew during a go-around. Reference should be made to European Aviation Safety Agency (EASA) Safety Information Bulletin (SIB) No. 2014-06. [SR40/2020]

The Final Report of the Investigation was issued on 20 January 2020 and published on 6 February 2020.

Related Articles

• Loss of Control
• Rejected Landings
• Go Around
• Post Crash Fires
• Cockpit Automation - Advantages and Safety Challenges
• Operational Use of Flight Path Management Systems
• Emergency Evacuation on Land
• Evacuation Slide Functional Issues
• Terrain Avoidance and Warning System (TAWS)
  • Low Level Wind Shear