Investigation number
AO-2009-012
Occurrence date
Location
Melbourne Airport
State
Victoria
Report release date
Report status
Final
Investigation level
Systemic
Investigation type
Occurrence Investigation
Investigation status
Completed
Aviation occurrence type
Ground strike
Occurrence category
Accident
Highest injury level
None

On the night of 20 March 2009, an Airbus A340-541, registered A6-ERG and operating as Emirates EK407, with 18 crew and 257 passengers, sustained a tailstrike and overran the end of the runway on departure from Melbourne Airport, Victoria. The investigation found that the accident resulted from the use of erroneous take-off performance parameters. Those erroneous parameters were themselves a result of an incorrect take-off weight being inadvertently entered into the electronic flight bag during the pre-departure preparation. Due to a number of factors, the incorrect data entry passed through the subsequent checks without detection. As part of its investigation of the accident, the ATSB undertook a research study titled Take-off performance calculation and entry errors: A global perspective to review the factors involved in a number of incidents and accidents in the 20 years leading to 2009. That report indicated that this accident was just one of many occurrences involving the use of erroneous take-off performance parameters across a range of aircraft types, operators, locations and types of operation. As in the accident under investigation, a consistent aspect of these occurrences was the apparent inability of flight crew to perform 'reasonableness checks' to determine when parameters were inappropriate for the flight. Equally significant was that degraded take-off performance was generally not detected by the flight crew until well into the take-off run, if at all. The investigation found that the take-off performance philosophy used in civil transport aircraft did not require the flight crew to monitor the acceleration of the aircraft or provide a reference acceleration that must be achieved. As a result of the accident, the operator and aircraft manufacturer have taken, or are taking, a number of safety actions. In addition, the Australian Transport Safety Bureau (ATSB) has issued a safety recommendation to the United States Federal Aviation Administration and a safety advisory notice to the International Air Transport Association and the Flight Safety Foundation in an effort to minimise the likelihood of future similar events.

 

Animation: [Download AVIavi: Animation 20 MB]

Aircraft Details
Departure point
Melbourne, Vic.
Destination
Dubai, United Arab Emirates
Model
A340
Serial number
608
Registration
A6-ERG
Operation type
Air Transport High Capacity
Damage
Substantial
Departure time
2232 ESuT
Aircraft Operator
Emirates
Attached Media