UAE regulators have issued a series of safety recommendations in a new report concluding the investigation of an incident in 2017 involving an Emirates A380 carrying 448 people.
On its approach to Moscow Domodedovo on 10 September 2017, flight EK131 descended to 504 feet above the ground while it was more than seven nautical miles from the runway before the crew executed a go-around.
The aircraft dipped to under 400 feet before its ground-proximity warning system activated and the crew pulled up. On its third attempt, the aircraft landed uneventfully and nobody on-board was injured.
According to the final report on the investigation, the aircraft’s instrument readings had been false. ILS data was inaccurate because the plane was at the time outside of the zone of reliability for ILS signals.
The readings caused the crew to erroneously believe the plane was too high and enter into a rapid descent.
The GCAA’s report recommends that extra information should be included in Emirates’ operations and training manuals regarding the possibility of multi-waypoint sequencing of the flight plan, and the FMS auto-reset that can occur during a missed approach.
During the investigation, the cockpit voice-recorder data was unavailable because it had been overwritten during the plane’s return flight to Dubai, with the crew not considering the event to be a “serious incident”.
Regulators recommended that Emirates re-inforce to its pilots the procedures regarding the preservation of flight recorder recordings as evidence.
According to the investigation, air traffic controllers in Russia could have transmitted a shorter urgent instruction in standard terminology to give the crew more time to react to the situation.
The report recommended that controllers should also provide a series of headings including the final vector that should result in a localiser intercept angle with a final approach track of 45 degrees or less.
The GCAA made two safety recommendations for Airbus. It detailed: “The ICAO ILS glideslope envelope elevation coverage lowest angle was not included in the Airbus FCOM. In order to ensure sufficient glideslope beam quality for a normal capture for all operators, it is recommended to include the definition of the ICAO envelope elevation coverage lowest angle in the operations manual.”
According to Airbus’ FCOM, the glide interception from above procedure should only be applied when the aircraft is established on the localiser. The term “should” in FCOM was not strong enough to emphasise the threat when the procedure was applied outside of the certified ILS envelope, according to the report.
Regulators advised: “In order to ensure that all Airbus A380 aircraft operators perform the procedure correctly, it is recommended to emphasise to pilots the necessity of ensuring that the aircraft is established on the localiser as a mandatory prerequisite action to apply the glide interception from above procedure. The manufacturer should update the procedure in the operations manual.”