EK521 Final Report

[oz_mark]

The final report on EK521 is out

https://www.gcaa.gov.ae/en/ePublication/admin/iradmin/Lists/Incidents%20Investigation%20Reports/Attachments/124/2016-Final%20Report%20AIFN-0008-2016%20UAE521%20published%20on%206-Feb-2020.pdf

 

[serfty]

For Context:

...
On 3 August 2016, at 0837:38 UTC, an Emirates Boeing 777-31H Aircraft, registration A6-EMW, operating a scheduled passenger flight UAE521, impacted runway 12L at Dubai International Airport (OMDB) during an attempted go-around, and slid on its lower fuselage along the runway surface for approximately 32 seconds before coming to rest. ...

 

[jb747]

Taken from the adjacent runway, about 12 hours after it happened.

 

[p--and--t]

That must have been a very heartening sight for nervous passengers waiting to take off (Bad humour)

 

[Mattg]

Interesting reading.

At the time of the accident, I had wondered whether the pilots had just completed a redeye turn to TRV and whether fatigue might be a factor. However the report states that they had a 30 hour layover in Trivandrum having arrived the previous day as passengers, and that there were "no signs of fatigue".

The final report still largely blames pilot actions.

This section is also interesting (and sad):

2.10.2.1 Passenger behaviour

Before the seat belt sign was turned ‘off’, passengers started to stand up. The cabin crew, who had been instructed to attend to their stations, were prevented by passengers in the aisles from moving into the cabin and addressing passengers directly. Instead, the passenger address system was used in an attempt to have the passengers remain seated.

By the time the Commander ordered the evacuation, one minute had elapsed since the Aircraft had come to a stop. During this one minute, time was spent by the flight crew in locating the emergency checklist which had been scattered with other loose items in the coughpit as a result of the impact. Before the evacuation command, some passengers left their seats to retrieve their belongings from the overhead bins. These passengers blocked the aisles and passages to the exits. It was difficult for the cabin crewmembers to keep the passengers seated before the evacuation was commanded and by that time the cabin had started to fill with smoke, the Aircraft was visibly damaged, and the external fire had started and was visible to some passengers.
...
The cabin crewmembers were challenged by a situation in which they had to decide whether to remove belongings affirmatively from passengers, which would delay the evacuation and lead to blocking of the aisles and passageways by bulky bags, or to let the evacuation continue with some passengers carrying their belongings which would risk damaging the slides and causing personal injuries. The removed carry-on bags filled the galleys and blocked access, consequently the cabin crew decided to allow the passengers who were carrying their bags to evacuate with their bags.

The Investigation believes that removing carry-on bags may increase the personal safety of the evacuee, but will increase the evacuation time and so endanger the lives of other passengers. Removing bags affirmatively may compromise the safety of cabin crewmembers positioned near the open exits.
Regulations, and the Operator’s procedures, became ineffective when more passengers arrived at the exits with their carry-on bags. The cabin crew were left with no choice but to let the passengers evacuate with their bags. The risk of damaging the two remaining useable slides was high, with potentially catastrophic consequences.

 

[Citoyen]

Interesting reading.

At the time of the accident, I had wondered whether the pilots had just completed a redeye turn to TRV and whether fatigue might be a factor. However the report states that they had a 30 hour layover in Trivandrum having arrived the previous day as passengers, and that there were "no signs of fatigue".

The final report still largely blames pilot actions.

This section is also interesting (and sad):

More than sad... This is human behaviour at its worst. What could people possibly have in carry on that couldn't/ wouldn't be replaced by airline ? (I concede many would not be insured on TRV to DXB sector )
(Reminds me of midnight boarding school fire drills - new kids always took their belongings, older kids feared the punishment for that more than losing worldly goods in a fire)

Given how little time elapsed between the exit and the fire - lucky not more fatalities.

 

[jb747]

There is discussion in the pilot and cabin crew circles about the initiation of evacuations in circumstances like these. Having just crashed the jet, it can be argued that the information coming from the pilots may well not be from the best source.

This was all pilot error. But fatigue mostly shows as pilot error, so you can’t read anything into that. And yes, they may have had 30 hours off prior to the accident, but what actual rest did they get. What were their rosters like when looked at over a longer period. There have been plenty of QF patterns over the years, that were ok individually, but when you’d done a few of them, or in concert with some other ‘harmless’ patterns, became very tiring.

There also seems to be a very large training issue here. It seems that it has become accepted in some circles to initiate a go around in some Boeings by simply pushing the TO/GA switches, and letting the autothrottle push the levers forward. If you don’t push the levers up yourself, and if you remove your hand from them, you’re asking for trouble.

 

[jb747]

The picture I posted above was taken by my SO (with my camera), as were were about to turn off the other runway, after landing. This was the fourth airliner that I’ve seen in a similar state over my career.

747 floating alongside in HK
737 (and Metro) destroyed at approximately mid-field in LA
777 next to the runway in London
777 in Dubai.

 

[p--and--t]

The picture I posted above was taken by my SO (with my camera), as were were about to turn off the other runway, after landing. This was the fourth airliner that I’ve seen in a similar state over my career.

747 floating alongside in HK
737 (and Metro) destroyed at approximately mid-field in LA
777 next to the runway in London
777 in Dubai.

... real fun "sight seeing" with you LOL.