In-Depth Case Study: Emirates Flight 419 Incident - Safety Analysis

This case study examines the Emirates Flight 419 incident that occurred on March 22, 2007, involving a Boeing 777 with 357 passengers and crew at Auckland Airport. The incident arose from miscommunication and overlooked information regarding a temporary reduction in runway length, compounded by pilot error and controller oversights. External factors included a rubber removal truck obstructing the runway and the limited runway length, while internal factors involved the crew's failure to diligently check updated ATIS and NOTAM information. The analysis highlights the importance of clear communication, adherence to standard procedures, and thorough verification of critical information by both pilots and controllers to prevent similar incidents. The study concludes by emphasizing the need for improved ATIS effectiveness and continuous reinforcement of safety protocols within the aviation industry. Desklib provides access to similar solved assignments and past papers for further learning.

Emirates Flight 419
Incident

Description About the Incident
 The incident happened on 22nd Match
2007
 It involved Boeing 777 under the flight
name Emirates 419
 Had 357 passengers, 16 cabin crews and
2 pilots

 The pilots had a ATIS signaling the of
limited landing from Sydney
 Updated ATIS broadcast changed it to full
length runway
 It was temporary due to long-haul flight
to Singapore
 The pilots did not bother to check the
message at the middle of the updated
ATIS broadcast

 The ATIS was not significantly different
from the previous one
 Hence led the pilots to overlook checking
for changes
 They believed that the availability of full-
length runway has not changed

 Hence requested for instruction for
departure from the aerodrome controller
 They were instructed to use 05R runway
but to hold at A10
 The ground controller cleared them to
leave
 Did not bother to inform them of unusual
changes

 The pilots had acted the normal take
engine thrust
 The first officer saw an obstruction ahead
 Immediately applied the TOGA thrust
 The plane became airborne at the speed
of 163 knots
 The case can be categorized as a CFIT

External Factors that Led to
Threats
 Rubber removal truck at the close eastern
closed end
 Limited runway length with normal
engine thrust
 Engine failure upon application of abrupt
TOGA
 Not sure of achieving enough take-off
acceleration

Internal Factors that Led to
Threat The threat was caused by error made by crew
 The correct information was contained in ATIS
and NOTAM which they failed to diligently
check
 They were confused by the previous changed
instructions on availability of full length
runway
 The pilots opted to follow updated ATIS
missed instruction on reduced length

Controls, Defenses, and Threat & Error
Management Strategies
 The incident was a lesson to the airways
 Precautions should be taken by all
controllers to ensure the crew has read and
listened to all instructions and understood
them
 Standards and procedures should be
diligently followed
 Interruptions should be occur during regular
traffic

Controversies and Conclusion
 ATIS failed to serve the purpose
 It was longer than recommended by ICAO
 Although the situation was managed,
pilots have responsibility to always follow
the standards procedures
 Controllers also have a role of informing
and confirming of changes out of normal

References
 Abeyratne, R. (2013). Reinventing ICAO's Role in Economic
Regulation-A Compelling Need. Issues Aviation L. & Pol'y, 13, 9.
 Flight safety and you. (2010). Emirates 419 incidence at Auckland.
Retrieved from
http://flightsafetyandyou.blogspot.com/2010/10/emirates-419-
incident-at-auckland.html
 Shappell, S., Detwiler, C., Holcomb, K., Hackworth, C., Boquet, A., &
Wiegmann, D. A. (2017). Human error and commercial aviation
accidents: an analysis using the human factors analysis and
classification system. In Human Error in Aviation (pp. 73-88).
Routledge.