The existing take-off certification standards, which were based on the attainment of the take-off reference speeds, and flight crew training that was based on monitoring of and responding to those speeds, did not provide crews a means to detect degraded take-off acceleration.
The US Federal Aviation Administration has advised that they have provided additional information to the industry that regarding the reduction of data entry errors in FMCs, as well as joining EASA on the TOPMS EUROCAE working group. Given that this level of safety action is, at least, equivalent to the EASA action, the ATSB is satisfied that adequate safety action has been taken.The issue has been identified as partially addressed because the safety action is the right people seriously looking at the issue, but no solutions have yet been implemented.
The Australian Transport Safety Bureau recommends that the United States Federal Aviation Administration take action to address the existing take-off certification standards, which are based on the attainment of the take-off reference speeds, and flight crew training that was based on the monitoring of and responding to those speeds, and do not provide crews with a means to detect degraded take-off acceleration.
The ATSB believes that the development of a take-off performance monitoring system standard in the US would support the efforts of prospective US manufacturers of those systems and optimise the efficiency of any US developmental work. In addition, it could be expected that the ongoing work to harmonise FAA and EASA certification efforts would maximise any synergies between the respective regional manufacturers’ developmental efforts, and the production of high quality, reliable take-off performance monitoring systems for use by the world’s airlines.
The ATSB is concerned that the apparent inaction in this area by the FAA is a missed opportunity to enhance the safety of scheduled transport operations throughout the world.
During the investigation, the ATSB sought an understanding from the United States Federal Aviation Administration (FAA) of whether the FAA was contemplating work similar to that by EASA to develop a standard to guide the development in the US of take-off performance monitoring systems. On 6 December 2011 the FAA advised that:
…the FAA has entertained this idea before, notably, in the aftermath of the Air Florida accident here in Washington, DC, and has found the idea of these systems, with all of their inherent complexity to be more problematical than reliance on adequate airmanship. That has been the FAA position in the past. I'm sure the FAA would be happy to entertain any recommendation to re-visit the issue in the light of new information or ideas.
The ATSB believes that the development of a take-off performance monitoring system standard in the US would support the efforts of prospective US manufacturers of those systems and optimise the efficiency of any US developmental work. In addition, it could be expected that the ongoing work to harmonise FAA and EASA certification efforts would maximise any synergies between the respective regional manufacturers’ developmental efforts, and the production of high quality, reliable take-off performance monitoring systems for use by the world’s airlines.
The ATSB is concerned that the apparent inaction in this area by the FAA is a missed opportunity to enhance the safety of scheduled transport operations throughout the world.
Previous unexpectedly poor takeoff acceleration events led to the 1987 SAE Aeronautical Standard for takeoff performance monitoring (TOPM) systems. Because adequate technology and equipment were not available at that time, no systems were completed, and the standard was never invoked.
With advances in technology and equipment, the European Organisation for Civil Aviation Equipment (EUROCAE) convened a working group to study the feasibility of developing standards for TOPM systems. The group is expected to deliver its first report in March 2013. We intend to work with the government and industry team to define modern standards for designing and using TOPM systems.
The ATSB report noted that the first contributor to the subject accident was a human data entry error in the first digit of the airplane’s takeoff weight which caused gross discrepancies in takeoff calculations and expected performance. To address this hazard, we issued policy covering weight entry methods in flight management systems that are intended to reduce exposure to the particular error that initiated the Emirates accident sequence. Future systems will include features to assist pilots during flight planning that would reduce the likelihood of hazardous preflight errors. The features will perform automatic checks on each weight component and calculation, and will alert the crew to errors. TOPM systems, if available, would provide another layer of safety and error detection.
The ATSB acknowledges that the FAA is collaboratively working towards addressing this safety issue and will continue to monitor the progress of the safety actions.
In response to the Emirates flight 407 accident, the FAA's Transport Aircraft Directorate issued policy memo ANM-111-09-006, dated March 30, 2009. This memo discusses weight entry methods in Flight Management Systems that are intended to reduce exposure to errors similar to the one that initiated this accident. Future systems will likely include features to assist pilots during flight planning that would reduce the likelihood of hazardous preflight planning errors. The features will perform automatic checks on each weight component and calculation and will alert the crew to errors.
Previous unexpectedly poor takeoff acceleration events in transport category aircraft led to the development of the 1987 Society of Automotive Engineers (ASE) Aeronautical Standard for takeoff performance monitoring systems (TOPMS). However, adequate technology and equipment were not available at that time, and no systems were completed. As a result, the Aeronautical Standard has not been utilized.
With current advances in technology and equipment, the European Organization for Civil Aviation Equipment (EUROCAE) convened a working group of experts to evaluate the state of the art of TOPMS. Both the FAA and the European Aviation Safety Agency (EASA) are participants in this working group. The group has been tasked to study the feasibility of developing guidance and standards for TOPMS and provide recommendations. The group is expected to deliver a rough draft of its recommendations in March 2014 and a final draft in December 2014. If it is determined that the state of the art has reached a point where developing standards for a TOPMS is deemed feasible, the FAA will support the development of such standards.
Through its certification policy memo and on-going participation with the EUROCAE working group, the FAA has taken action to address the existing takeoff certification standards as noted in Safety Recommendation 12.184. The FAA considers its actions complete and does not plan any additional action.
The ATSB acknowledges the technical challenges inherent in the development of a take-off performance monitoring system. The ATSB also acknowledges the Federal Aviation Administration (FAA) efforts to work with the European Aviation Safety Agency (EASA) as part of the European Organisation for Civil Aviation Equipment (EUROCAE) working group studying the feasibility of take-off performance monitoring systems. This commitment by the FAA to contribute to the development of a standard for such systems is appreciated. The ATSB anticipates that the action by the FAA will, in collaboration with the EUROCARE working group and industry and other stakeholders, maximise the likelihood of the development of a take-off performance monitoring system standard.
Given the FAA’s commitment to working with EASA and the EUROCAE led international working group, the ATSB considers this safety recommendation closed. However, the ATSB will continue to monitor the output of the EUROCAE working group, and any associated developments that will address the hazards presented by data entry errors, as part of the ATSB’s SafetyWatch program.
The ATSB also acknowledges FAA Transport Aircraft Directorate policy memo ANM‑111‑09‑006, dated 30 March 2009 in respect of improvements to the certification of future aircraft Flight Management Systems. The ATSB accepts that the inclusion of such improvements in these systems will assist in the prevention of take-off performance occurrences that result from take-off performance data entry errors.
On 21 October 2011, Emirates advised that they were assisting a major avionics company to develop of a take-off acceleration monitoring and alerting system.
The ATSB recognises the inherent technical difficulties associated with the development of a take off monitoring and alerting system, and understands that this project is in the very early stages of research into such a system. However, the ATSB believes that the equipment will, when successfully developed and installed in scheduled transport aircraft, significantly enhance the safety of operations in all aircraft with such equipment installed.
On 28 October 2011, Airbus advised that: This subject is also discussed within EUROCAE association in which Airbus is involved. The item raised by the ATSB will be covered by a future function called Take-Off Monitoring (TOM). This function will compute theoretical acceleration of the aircraft and trigger an alert (during the take-off roll) if the actual acceleration is too far from this theoretical acceleration. For the time being, this function is under feasibility study for a certification targeted to be available in 2015 for A380 and between 2015-2020 for A320 and A330/A340 families.
The ATSB is satisfied that the work by Airbus to develop the company’s take off monitoring system will, when that equipment is successfully installed and tested in Airbus aircraft, address this safety issue in those aircraft.
On 28 October 2011, the European Aviation Safety Agency (EASA) advised the ATSB that: EASA [has] already received safety recommendations on take-off performance monitoring system and, despite such system feasibility has not yet been demonstrated, is cooperating with EUROCAE to set up a group of experts who will review the state of the art options, if any, which could [be] worked out to eventually develop a standard which could then be used by the industry to develop such systems. A rulemaking action could then be envisaged by EASA to require such system based on the standard.
The ATSB acknowledges the technical challenges inherent in the development of a take-off performance monitoring system. The commitment by EASA to work with industry experts to develop a standard to guide the development of such systems is appreciated. The ATSB anticipates that the action by EASA will, in collaboration with its industry and other stakeholders, maximise the likelihood of the development of a European take-off performance monitoring system standard.
