A sobering report suggests that an Emirates 777 came within 200 feet of crashing in Dubai due to pilot error. This report is not confirmed, but numerous data points suggest something went terribly wrong aboard EK231.
Did EK231 Nearly Crash Over Dubai?
First noted by God Save The Points, here’s what we know about what happened:
- The incident occurred aboard Emirates EK231 traveling from Dubai (DXB) to Washington Dulles (IAD) on December 20, 2021
- The flight was scheduled to depart at 2:25AM utilizing a Boeing 777-300ER (A6-EQI)
- Pilots failed to set the autopilot to an altitude of 4,000 feet, the initial climb altitude, instead leaving it at 0 feet (presumably set by pilots on the previous flight in order to land in Dubai)
- After takeoff, the plane’s nose pitched down
- At one point, the aircraft was traveling at 262 knots at a flight level of 175 feet (far faster than normal) over Diera City Center (near the airport)
- Pilots realized the error and corrected it, but even though the plane potentially “sustained damage” elected to continue to Washington, DC
- At IAD, the plane was checked for cracks as well as damage to the wings, flaps, and landing gear
- The return flight, EK232, departed about three hours late
- The 777-300ER sat on the ground in Dubai for two days before operating to Kuwait (KWI) earlier today and is currently in Geneva (GVA)
What Other Evidence Do We Have About EK231?
Beyond this timeline, we have both flight data from Flightradar24 suggesting the low altitude over Diera as well as the following memo Emirates sent to pilots concerning the incident:
CREWS ARE REMINDED THAT THERE ARE NO FCOM NORMAL PROCEDURE REQUIREMENTS TO CHANGE THE MCP AFTER LANDING OR SHUTDOWN. THERE HAVE BEEN TIMES WHEN THE MCP “ALTITUDE WINDOW” HAS BEEN SET TO THE AIRPORT ELEVATION WHICH MAY CAUSE ISSUES ON THE SUBSEQUENT DEPARTURE. CREWS SHALL NOT SET AIRPORT ELEVATION ON THE MCP AFTER LANDING OR SHUT DOWN.
FCOM means “Flight Crew Operating Manual” and MCP means “Mode Control Panel” which is used to instruct the autopilot to hold a specific altitude.
What Should We Make Of This?
This is really big news and I find it highly unlikely there is not some truth to this report.
It does not mean that flying is unsafe or that Emirates is unsafe. Flying remains one of the safest modes of transport and far safer, statistically, than stepping into your car and driving down the road.
But this story does show that pilot error is possible and that it goes beyond a simple autopilot vs. human error tradeoff. Here, sloppiness may have led the autopilot, also called flight director, to be improperly configured.
Still, pre-flight checklists should have prevented this and reports suggest all four pilots in the cockpit have been terminated.
I’m not about to avoid Emirates if this report is true. If anything, it will make me more likely to fly Emirates because pilots will now be extra vigilant. As horrifying as this report is, it seems that Emirates is already holding responsible parties accountable and taking steps to make sure this does not happen again.
CONCLUSION
Initial reports suggest EK231 almost crashed while departing from Dubai on December 20, 2021 due to pilot error. A deadly crash would have deeply set back Emirates and commercial aviation in general, but far importantly led to the loss of life for what were probably more than 300 souls onboard plus countless more on the ground.
If this report is accurate, hopefully Emirates and airlines around the world will learn from this incident and pilots will take extra steps to ensure that pre-flight checklists are closely followed.
Not just the passengers and crew onboard, Deira city center is extremely densely populated and a crash into the “wrong” set of residential buildings could’ve potentially killed tens of thousands on the ground as well.
So true.
Fortunately, The Scheduled departure for that flight EK231 is 2:25 AM
Where usually such malls are closed
I watched this disturbing incident on the Flight Channel and understood how it could happen just based on human nature. Training instills an element of automatic behavior, but in this case it looks like the pilots just glossed over what to them is a routine process, the preflight checklists. Even though both pilots are supposed to double check each other’s figures, it appears a scary oversight was committed and that is why these accident reviews are so important. Even with thousands of hours of experience, that is no guaranty all aspects of the flight will go like clockwork when you mix instrument readings with the human element. Going like clockwork is only as good as the pilot is at monitoring his instruments and really double checking things and not just assume figures given to him are accurate. I guess my question is a common one, how did the two pilots miss the autopilot reading? They have done this hundreds of times, but again, this incident proves humans are fallible, yet it is no excuse at the end of the day. The consequences of the plane crashing would have been horrific. As someone else chimed, why were the other two relief pilots terminated? Obviously, we don’t have the investigator’s reports and I suppose they may have played a role in the cockpit during the event in question. Nevertheless, Emirates did the right thing by sending a clear message to remind other pilots to follow procedures to a T. It’s easy to become relaxed and overlook so called routine matters, I can say that from behind the keyboard yet it amazes me that despite many of these pilots having amassed large number of flying hours, they still make mistakes and during a time of uncertainty, they will respond based on preconceived or wrong assumptions. Sometimes it’s like a state of denial, not considering the worst case scenario. However, glad as hell they didn’t crash and hopefully this doesn’t happen again. I’m sure I don’t have to repeat this, but I hope all commercial pilots spend time reviewing these accident investigations just as a reminder that human error is a primary cause in many of them.
While it won’t impact me flying them, it has cross my mind on EK 777’s that the pilots would most likely be F/O’s at best on a narrow body in the U.S or Europe. Not all of them, but I imagine a good percentage. Add as well the mix of cultures, training backgrounds, and native languages in EK cockpits and you do appreciate the symmetry of pilots and seniority one would find in comparison on an AA 777-300 for example. I am not saying EK is unsafe. But it does add a small but more difficult dynamic.
Aside from that, why fire all four? Only two would have been pilots flying so I wonder how the other two were responsible. Leads me to believe that all four were in the cockpit and the two flying did not properly work the checklist with the other two not calling them out on it. Love to hear the recordings on this.
I believe they continued to their destination despite overspeeding the aircraft in its take off configuration. They should have returned for the appropriate aircraft inspection
That would make sense in the other two being involved in that decision. Thanks. Can’t believe they all imagined it would go unnoticed. Or that the two not flying would risk their careers defending the other two.
I believe all four pilots would have been in the cockpit for takeoff, even the two non-flying. Since this incident could only have happened as described (we don’t have full confirmation yet) if the crew skipped multiple pre-takeoff checklist items, then all pilots present would have been expected to notice/raise an alarm. It appears, if the story is accurate, that no one did… in that case this would be a serious dereliction of duty by all present… If it’s true that the aircraft hit 216kts on the ground before rotating, as is now being reported, it absolutely beggars belief no one raised an alarm well before then.
Do pilots at the ME3 just switch on autopilot as soon as the wheels are off the ground? While there is nothing inherently dangerous about this, it does suggest pilots that don’t have experience and, therefore, the level of situational awareness and air sense as, say, 77W pilots at UA or BA would.
Please allow me to reply to your inappropriate comments about ME pilots. They are more situationally aware and operate their aircraft professionally and to the highest level of safety. When you make such comments and use UA or BA as reference, you would better be knowing what you are talking about because you do not seem so. Aircraft incidents/crashes do not discriminate against pilots because of their color or race but you do. Please grow up and open your eyes and mind, if you have any left in your head.
Why don’t you enlighten us?? There’s a reason why those 737 Max crashes happened where they did.
And you should learn to f*cking read before you accuse people of discriminating in a way they clearly weren’t. I never said anything about pilots FROM the Middle East, Plenty of pilots at the ME3 are white and from Europe, the US, Australia, etc, and many of them are in more senior positions much earlier in their careers than pilots in regions with longer seniority lists. It’s part of the attraction of going to one of the ME3. Maybe these pilots were white. Most of the executives responsible for problematic culture at EK and QR certainly are.
It’s not a question of race or skin color. I’m a bleeding-heart advocate for more diversity in the cockpit, as I think just logically if you’re only drawing from a pool of mostly white men with a certain profile, you are probably missing out on a large pool of excellent airmen and women.
But it is a question of experience and airmanship that comes with that experience. Clearly something is wrong with experience, operating procedures, awareness, and cockpit culture when FOUR pilots allow a flight director computer to speed through Vr, past the end of the runway, to the end of the safety runoff, and rotate 90m before they collide with the localizer antennae. If you can’t see that, then sorry I can’t help you.
I am a ME pilot, we are authorized to fly manually up to 20000ft and encourage to do it as much as we can if the conditions permit. We are also very hard trained having much more sim session than most of other airlines.
I just couldn’t pass this one by. I recently retired after 34 years as a pilot with a major U.S. airline. This incident doesn’t surprise me, especially as it concerns Emirates. In the pilot community EK has a long standing reputation as having the most toxic work environment. The bosses don’t want to hear about mistakes or bad actors. PR is paramount. In the US mistakes or deviation from operating procedures are brought up, discussed and dealt with. Not swept under the carpet. The most telling thing about this incident is that a damaged aircraft made a return flight to Dubai. Coincidence? Had the aircraft been inspected at IAD it would have been grounded and an inquiry commenced through the FAA. Bad PR. Back in Dubai the optics are better managed.
This incident happened as a result of poor airmanship plain and simple. A classic example of pilot mismanagement of the electronic flight computer and then compounding the problem with lack of basic flying skills. If this were the first such incident at EK it would be cause for raised eyebrows and hopefully remediation. Sadly it’s not the first or even the second. Sure letters were written and people were sacked. The writer seemed to be satisfied with this as the correct action. Pilots are absolutely vigilant but flying transport aircraft is a complex endeavor. History has proven fear and recrimination doesn’t work in the cockpit. Openness, discussion and reflection do. IMHO the toxic environment at EK continues.
What has puzzled me reading about this is not so much that they forgot to change the altitude setting (I assume these mistakes can happen) but how in the hell they did not rotate the aircraft after calling V1 and instead kept speeding down the runway? You would think at some point long before the end of the runway that one of the two pilots would yell, “Oh crap, fly the plane!”
Without testimony from the pilots involved it’s impossible to ascertain the “big picture “ on this incident. I did fly the 777(great airplane). Strictly my opinion but I believe the pilot flying simply fixated on the flight director in the moments before rotation (lift off). With the altitude window set to “0” the flight director was never going to “steer”the pilot toward a takeoff. Without guidance one must “fly” the airplane with other references. You are absolutely correct in your assessment. The call is Vr though not V1. The V1 call comes first meaning, we’re going not stopping, Vr means rotate. And absolutely, where was the pilot not flying? They should have been strongly advocating for pulling back on the yoke to the point of taking over because impact was indeed eminent.
Thanks for this explanation and is very informative.
So, in your opinion, do you think the pilot was just waiting for an indication from the flight director system to rotate, and because of the configuration, that direction wasn’t going to come? I just can’t imagine a pilot not having the awareness of groundspeed on takeoff, and just letting the plane speed through Vr (which s/he should know) and past the threshold of the runway.
Incidents like this do make me appreciate the experience and seniority of pilots at legacy carriers, both in the US and abroad.
Briefing let’s walk through a takeoff. The Captain lines up on the runway, if he’s the PF(pilot flying) with takeoff clearance he advances the throttles, pushes a button on the throttle quadrant advancing autothrottles to takeoff power. His hand stays on the throttles to V1 after which he removes his hand because the takeoff decision has been made(if everything is in order). Shortly thereafter the call is “rotate” representing Vr. This is the que to smoothly pull back on the yoke and transition your gaze from outside/inside to the flight director and shoot for the desired deck angle. Properly done this includes a “scan” of the other instruments, airspeed, Vertical Speed Indicater and airplane track at the very least. On the 777 all this information is on one gauge if your looking for it.
It was a long flight to IAD so they were obviously pretty heavy and used something in the vicinity of 9000’ of runway to get to Vr. Assuming a 12,000’ or so runway length they would cover that last 3000’ in a second or two. Delaying action at Vr is disastrous, delaying action when the runway is disappearing is disastrous even if you didn’t hear any of the calls. It all happens fast.
The single best way to build a safe pilot group at an airline is reduce operating parameters to numbers: flap settings,airspeeds,altitudes so everyone knows and follows these parameters faithfully. If one has this concept ingrained things go very smoothly both when things are normal or when things are abnormal. The environment must be such that any crewmember can question or call out another when there’s is a deviation. Sounds simple, it’s not, it takes very hard, relentless work to build this system. Safety must transcend ego and biases. It starts at the very top.
I am a Pilot, who is also rated on the B-777. Its a pity such an incident occurred. I do point my fingers at the situational awareness of the crew. A thorough investigation needs to be carried out, to prevent a re-occurrence. Its not a matter of wielding the big stick and firing the pilots. What was he workload of the crew in the last two weeks. What kind of indoctrination is given, and enforced in the Company Do we still remember the accident between a Russian aircraft, and a DHL Aircraft over Germany. Where there was a TCAS warning on both aircraft, and the Russian aircraft followed the erroneous ATC clearance, disregarding the TCAS RA (Resolution Alert). There is also the issue of confirmation bias. which is the tendency to search for, interpret, favor, and recall information in a way that confirms or supports one’s prior beliefs or values, in this case the flight director. What should be done is to get to the root of the problem, whether it is the training, and indoctrination, or other factors
The altitude in the MCP would be set to the missed approach altitude on the previous approach, not zero as mentioned in the article.
Missed approach altitude? Please explain.
If you cannot land you should be ready to execute a missed approach.
This is a very simplistic explanation but it goes something like this. That altitude window is very important. Every flight gets an initial altitude on their clearance which should be set upon receipt. That is your clearance limit. As you climb and get subsequent clearances you continue to set it higher. Every time you get a different clearance you reset this window. The auto flight system will not exceed this altitude. A pilot can fly through whatever is set when manually flying thus extra vigilance is need when hand flying. On descent you reverse. Setting the window lower as you get descent clearances. When you’re on approach to the runway at some point you reset the window to the published missed approach altitude on your chart. You do this to ease the work burden on a go-around. This is where the window usually is upon landing.
Every airline has different nuances on how,when,who sets this window and where it should be set when the outgoing crew leaves. You can actually make a case for setting this to “0” for the next crew. This isn’t a smoking gun or set up for this crew. They should have caught it do doubt. It’s also true it should have been a distraction on the takeoff not a near disaster. Again I’d love to hear testimony from all the crew members.
When you execute a missed approach you don’t do a go-around you go to the hold.
Brian, thank you for these incredibly detailed and informative explanations.
Can you say just a little bit for us about what, on takeoff, is automated/instrument controlled, and what is or should be manual flying? Also, what is left up to the airlines to determine re: procedures about how and when to engage autopilot (e.g. I’ve read Emirates pilots engage autopilot as low as 200 feet, while some 777 pilots on legacy US carriers have mentioned that they fly manually up to a certain altitude before engaging autopilot)?
Thank you again~
All takeoffs are done manually. Where I worked(I think it’s industry standard) an autopilot must not be engaged before 200’. The hand flying/ autoflight debate swings like a pendulum. Flying is a hand-eye coordination skill set so obviously the more you do the better you get. Really good manipulation of the automation is also a skill set. I came along when automation in the cockpit was in its infancy. Lots of Captains really struggled with it but they were awesome stick and rudder pilots. Again, I speak about this from the perspective of US carriers. Some years the focus is on using and trusting the automation and something will come along (Air France ) and the focus returns to hand flying skills. It all works out. Very few pilots I flew with engaged the autopilot until at least we were in a clean configuration me included, say 3000’. I generally flew into until it got boring. Trimmed up, climbing to altitude in smooth air and the airplane really flies itself. Approachs are a different animal. The workload is higher, traffic seems to become more critical. Anything you do to relieve the mental workload is safer. As an example whenever my flying partner decided to hand fly going into ORD,LHR or any high work situation caused me to roll my eyes. Not only are you piling on the duties you’re taking a set of eyes away from outside.
I do believe flying skills are slowly going away but the automation is getting better by leaps and bounds. The robotic cockpit probably isn’t that far off.
Brian is the best thing to come along to LALF in ages in the comments. His insight is engaging, well explained, and courteous. He gives a real perspective and cleans up a lot of misperceptions, some my own.
Thank you, Brian.
And Stuart, spot on!
Thank you for a very informative discussion by professionals.
And Thanks Matthew for your posts.
As an aside, an autopilot is not a flight director.
I try not to point fingers and try to be alert when driving a car. Look at the car to assess the tires before driving. Then listen, look, and feel if the car is ok while it is exiting the garage or parking lot. Never mindlessly hit the gas pedal and drive off, not looking for traffic.
From what I see from reading about many accidents lots of pilots don’t instinctively understand and react correctly to the basics of flight. I see basic airmanship errors made that ere ingrained in us as fledgling Navy / Marine pilots in the sixtys!
So – all you “experts” have already decided the cause of the crash was pilot error and support the sacking of the pilots. How about waiting until there has been a proper enquiry? Yet again, we see a single causal factor – pilot error – being cited as being responsible for the incident – not to mention racial comments suggesting that non-American airlines are less safe safe than American ones. This sort of attitude is about 50 years out of date. There should be a proper enquiry over this incident, which should examine not only IF the pilots made a mistake but, more importantly WHY they carried out actions which may have led to a degradation of safety. Just blaming incidents and accidents on “pilot error” is far too simplistic and omits other factors – training, fatigue, corporate philosophy, aircraft design etc. etc. which may have led to the situation where, sooner or later, a pilot somewhere in the world would have carried out the same actions. Just saying “pilot error” and sacking the pilots will not discover the other causal factors, including systemic errors, and will not lead to what is the most important justification of a full enquiry – to prevent it happening again.
You are completely right. Blaming pilots before getting any report is not journalism. It won’t help flight safety.
Each time an incident occurs, it is necessary to wait for an extensive analysis before jumping on conclusions.
I don’t think reaching any conclusions in this matter without knowing all the facts is appropriate. In other words, we don’t know the full extent of the follow-up investigation, for all we know it may have been very detailed and comprehensive, or, maybe not. Therefore, I would with hold any assumptions or cast blame based on incomplete information.
I have been an airline pilot for years and unless there is some sort os extreme extenuating circumstance I have never had the autopilot on that low on takeoff. It is always good to keep your hand flying skills on point and hand flying to 10,000 feet is rather standard where I am at. This above incident cannot happen when hand flying. In addiction I cannot count how many times before the flight we verify our initial altitude. This goes to show how poor Crew Resource Management is taught and executed in some parts of the world .
Hear, hear. This is so true.
A good example is the 737 MAX crashes of Lion Air and Ethiopian Airlines. U.S. carriers who flew the same plane for thousands of hours were apparently able to handle the problem without an accident let alone a fatality.
Question for pilots: How many pre-flight checklists would have to be performed improperly for this not to have been caught?
To respond to the comment Matthew made about this having little to do with EK safety beyond this event, I make no claim that EK has unsafe procedures or is generally unsafe to fly, but IF the crew failed to properly perform as many pre-takeoff checklists as I suspect, that would indicate a serious problem of training, safety culture, and crew discipline.
This would depend upon specific airline procedures. At my airline it would take multiple mistakes by both crew members. I’ll try to walk you through a normal work progression for pilots at the gate.
Pilots arrive at the aircraft about 1 hr prior to push back. The captain assigns who will be the flying pilot and who will be the monitoring pilot. At my airline captains and first officers generally rotate positions each flight they operate together. Eg I fly from NY to LA Switch rolls and I monitor LA to NY.
Behind the scenes at the airlines operation control center
A flight plan gets submitted to air traffic control by the dispatcher. That same flight plan would get sent to each pilot electronically, and many airlines print this at the gate.
The pilot flying would either manually load the flight plan into the FMS or have it automatically uploaded.
The loaded route would be verified independently by all pilots.
The pilot monitoring completes systems checks during this time.
Once the flight plan is loaded, the pilot monitoring would go double check the routing.
About 30 mins prior to ouch back air traffic control will issue a clearance. Sometimes that is the same as what was requested by the dispatcher and sometimes it’s different.
Once any clearance changes are input. The pilots do a challenge and response with one pilot reading the clearance from air traffic control and the other pilot reading the loaded data.
At that point the pilot flying gives a departure briefing to the other pilot. Things discussed are weather, taxi plan, expected runway, runway environment, departure procedures, any special procedures for engine failures, ect
Then a preflight checklist is accompli
During the taxi a quick departure briefing is completed. For the airline I work for this includes runway, departure, 1st fix to cross, airspeed limitations, initial altitude, and mode the flight director will be in. Eg runway 31L, score4 ranger transition, 5000’ lnav, vnav. Each item is physically pointed to during this brief., and both pilots verify.
At every point above where I wrote route, or clearance the departure procedure is discussed. Departures all have an initial altitude that pilots should expect to be cleared to. The selected altitude is viewable on each of the primary flight displays and in the altitude window on the mode control panel (center if the glare shield)
That’s a lot of looking at an altitude that is set to zero presumably. The Emirates message to crews about not setting field elevation is odd to me. Normally crews set an unusual altitude to help the next crew figure out they haven’t done something. Example settling 5100 instead of an expected 5000. Setting 0000 or field elevation would fall into setting strange altitude and would in my mind be viewed as a helpful reminder.
My biggest concern about this incident is the lack of airmanship it demonstrates. When Vr is called your eyes as the pilot flying should be alternating between inside (looking to set the target initial pitch attitude) and outside as you watch the centerline of the runway in case of an engine failure. But here is the critical thing. When Rotate is called you ease the yoke back and rotate. Under no circumstances should you just leave the airplane just racing down the runway regardless of what the flight directors are commanding. To repeat there is simply no reason whatsoever for what happened with this flight.
When the PM (pilot monitoring) called rotate the PF (pilot flying) should have rotated. When he didn’t the PM should have repeated the call and then absent an IMMEDIATE response to that call announced “I have control” and rotated the airplane. The two relief pilots in the cockpit have nothing to do but monitor what’s happening and both of them should have been firmly calling for the PF or PM to rotate the airplane. That this airplane continued the length of the runway before rotating in the overrun and then continued to its final destination is likely why all 4 pilots were fired. Its a simply astounding case of bad judgement and poor airmanship. I will also note that at least at my airline SOP is that when you get to the final 1000′ of the runway you rotate no matter what. I suspect this is pretty industry standard as its been the norm everywhere I’ve worked.
Absolute failure/lack of basic flying skills. Similar to Asiana crashing short of 28L in San Francisco. They came in 37 kts below target speed! (No more than 5 below is acceptable for most people).
Ifyou can’t turn off the autopilot, flight director, and auto throttles and comfortably fly a visual approach in perfect weather conditions, you are not a pilot and should take a desk job. And taking off is so easy (absent of any malfunctions), a kid with a few hours in a Cessna could successfully takeoff a 777 with some coaching. I talked a 12 yr old through one in a full motion sim.
Thanks for the answers by pilots, which are very illuminating.
I’m certainly not a pilot, but have watched enough cockpit videos and seen the repeated checklists that I have to wonder how it could happen.
For whatever its worth, Sam Chui had a recent video about the Emirates Flight School, which trains cadets and has them flying EK 777s immediately out of flight school! This sounds absolutely great if you are a young student pilot, but I found it a bit surprising — if not shocking — that there is no time in the minor leagues flying smaller aircraft at all. Seems to me that does not give much opportunity to weed out poor aviators before they are sitting as FO of a widebody. That is a cultural difference that I suspect wouldn’t “fly” in an established US carrier where many or most pilots are recruited from military aviation.
Seriously? You mean to tell me thesw guys go straight from ground school to biz jets (as trainers) without ever setting foot in a 172 of the like?
F–k this, the FAA needs to bar Emirates from US airspace until they start teaching basic airmanship.
“ (presumably set by pilots on the previous flight in order to land in Dubai)”
This is not true. When youre about to land the altitude set on that window would be the Go Around altitude for in case theres a go around, the altitude to fly to is already set
In this case it would probably be 5000 or something close
If the window was in 0 that was done on the ground