Air Accident Investigation Sector

Accident
- Preliminary Report -
AAIS Case No AIFN/0015/2023

Severe Turbulence Encounter In-Flight

Operator: Emirates Airlines

Make and Model: Airbus A380-861
Nationality and Registration: The United Arab Emirates, A6-EEV
Place of Occurrence: Male Airspace
State of Occurrence: Republic of Maldives
Date of Occurrence: 4 December 2023
 Air Accident Investigation Sector
The United Arab Emirates

Accident Brief
AAIS Report No.: AIFN/0015/2023
Operator: Emirates
Aircraft Type and Registration: Airbus A380-861, A6-EEV
MSN: 150
Number and Type of Engines: four, General Electric − GE90
Date and Time (UTC): 4 December 2023
Location: Male Airspace (Republic of Maldives)
Type of Flight: Commercial, Scheduled Passenger
Persons Onboard: 490
Injuries to Passengers and Crew: 5 serious injuries, 23 minor injuries
Other Injuries: None
Nature of Damage: Damage to the cabin

Investigation Objective
This Investigation is conducted pursuant to the United Arab Emirates Federal Act No. 20
of 1991, promulgating the Civil Aviation Law, Chapter VII − Aircraft Accidents, Article 48. It is in
compliance with the Air Accident and Incident Investigation Regulation (AAIR), and in conformity
with Annex 13 to the Convention on International Civil Aviation.
The sole objective of this Investigation is to prevent aircraft accidents and incidents. It is
not the purpose of this activity to apportion blame or liability.
The information contained in this Preliminary Report is derived from the data collected
during the ongoing investigation of the Accident. Later Interim Statements, if any, or the Final
Report may contain altered information in case of appearance of new evidence during the ongoing
investigation.
The Final Report may contain amended information when new evidence becomes
available during the ongoing investigation.

Investigation Process
The occurrence involved an Airbus A380-861, registration marks A6-EEV, and was
notified to the Air Accident Investigation Sector (AAIS) of the United Arab Emirates by a phone
call to the Duty Investigator (DI) Hotline Number +971 50 641 4667.

Preliminary Report №. AIFN/0015/2023, issued on 7 March 2024 ii

 An Investigation team was formed in line with the Annex 13 obligations of the United Arab
Emirates being the State of Registry and State of the Operator. The Investigation was delegated
to United Arab Emirates by the Republic of Maldives, in writing, as the latter being the State of
Occurrence.
After the initial investigation phase, the occurrence was classified as an ‘Accident’.
The AAIS notified the Bureau of Enquiry and Analysis for Civil Aviation Safety (BEA) of
France as of being the State of the Manufacture and Design. The BEA assigned an accredited
representative assisted by advisers from the aircraft manufacturer.
The AAIS is leading the Investigation and will issue a Final Report when the Investigation
is completed.
This Preliminary Report is publicly available at:
http://www.gcaa.gov.ae/en/epublication/pages/investigationReport.aspx
Notes:
1
Whenever the following words are mentioned in this Report with the first letter Capitalized, it
shall mean:
− (Accident) – this investigated accident
− (Aircraft) – the aircraft involved in this accident
− (Commander) – the commander of the flight
− (Copilot) – the copilot of the flight
− (Investigation) - the investigation into this accident
− (Operator) – Emirates
− (Report) – this Preliminary Report.
2
Unless otherwise mentioned, all times in this Report are in coordinated universal times (UTC).
3
Figures used in the text of this Report are taken from different sources and are adjusted from
the original for the sole purpose to improve clarity of the Report. Modifications to images used
in this Report are limited to cropping, magnification, file compression, or enhancement of
color, brightness, contrast or insertion of text boxes, arrows or lines.

Preliminary Report №. AIFN/0015/2023, issued on 7 March 2024 iii

Abbreviations and Definitions
AAIS Air Accident Investigation Sector of the United Arab Emirates
AIFN Accident/incident file number
ATPL Air transport pilot license
BEA Bureau of Enquiry and Analysis for Civil Aviation Safety
CB Cumulonimbus
CP Control panel
CPDLC Controller pilot datalink communication
CVR Cockpit voice recorder
DFDR Digital flight data recorder
EFIS Electronic flight instrument system
FCOM Flight crew operating manual
FCTM Flight crew techniques manual
FIR Flight information region
MFD Multi-functional display
MSN Manufacturer serial number
NOAA National Oceanic and Atmospheric Administration
OM-A Operations manual – Part A
OFP Operational flight plan
OMDB Dubai International Airport
PF Pilot flying
PM Pilot monitoring
PWS Predictive wind shear system
QRH Quick reference handbook
RT Radio telephony
TURB Turbulence
SEP Safety and emergency procedures
UTC Coordinated universal time
WAFC World area forecast centers
WX Weather
WXR Weather radar system
YPPH Perth International Airport

Preliminary Report №. AIFN/0015/2023, issued on 7 March 2024 iv

Contents
Accident Brief .............................................................................................................................. ii
Investigation Objective ................................................................................................................ ii
Investigation Process .................................................................................................................. ii
Abbreviations and Definitions ..................................................................................................... iv
1. Factual Information ................................................................................................................. 1
1.1 History of the Flight ...................................................................................................... 1
1.2 Injuries to Persons ....................................................................................................... 2
1.3 Damage to Aircraft ....................................................................................................... 2
1.4 Other Damage ............................................................................................................. 2
1.5 Personnel Information.................................................................................................. 2
1.6 Aircraft Information ...................................................................................................... 3
1.6.1 Aircraft data ................................................................................................... 3
1.6.2 Airbus A380 weather radar modes ................................................................. 3
1.7 Meteorological Information .......................................................................................... 4
1.8 Aids to Navigation........................................................................................................ 5
1.9 Communications .......................................................................................................... 5
1.10 Aerodrome Information ................................................................................................ 5
1.11 Flight Recorders .......................................................................................................... 5
1.12 Wreckage and Impact Information ............................................................................... 6
1.13 Medical and Pathological Information .......................................................................... 6
1.14 Fire .............................................................................................................................. 6
1.15 Survival Aspects .......................................................................................................... 6
1.16 Tests and Research .................................................................................................... 6
1.17 Organizational and Management Information .............................................................. 6
1.18 Additional Information .................................................................................................. 6
1.18.1 Operation manual − Part A (OM-A) policies – [Operating] in Adverse and
Potentially Hazardous Atmospheric Conditions ........................................................... 6
1.18.2 Flight crew techniques manual (FCTM) − Use of Weather Radar .................. 6
1.18.3 Quick reference handbook (QRH) − Procedures during severe turbulence .... 7
1.19 Useful or Effective Investigation Techniques ............................................................... 7
2. Ongoing Investigation Activities .............................................................................................. 8

Preliminary Report №. AIFN/0015/2023, issued on 7 March 2024 v

1. Factual Information
1.1 History of the Flight
On 4 December 2023, Emirates Airbus A380-861 was scheduled to operate flight EK421,
from Perth International Airport (YPPH), Australia, to Dubai International Airport (OMDB), the
United Arab Emirates.
The flight crew consisted of the Commander, who was the pilot flying (PF), the Copliot,
who was the pilot monitoring (PM), and augmenting captain who was occupying the third occupant
seat in the cockpit behind the Commander and the Copilot.
The flight crewmembers reported to their duty fit and well-rested. As per the Commander’s
statement, he received the briefing package1 ahead of time.
According to his statement, the Commander thoroughly reviewed the information related
to the flight. He described the information provided on the day as, “not special”2 given his extensive
experience flying this particular route for long time.
The Commander stated that he conducted a briefing for the flight and cabin crew on the
way to the airport. He informed the cabin crew about the weather conditions expected during the
flight, but he did not highlight any specific instances of severe turbulence condition in flight since,
as per his statement, there was no such information indicated in the operational flight plan (OFP).
The cabin supervisor, who was in charge of the business class, confirmed in her statement
that there was no mention of the possibility of encountering severe turbulence during the briefing.
Furthermore, the Copilot mentioned that no precautionary measures were discussed regarding
severe turbulence during the flight, as the flight crew did not anticipate encountering such severe
turbulence
The Aircraft took off from YPPH at 1428:53 UTC. The takeoff was uneventful and smooth,
as per the statement of the augmenting captain. This was confirmed by the Investigation from the
data retrieved from the digital flight data recorder (DFDR).
At 2029:35 UTC, the Aircraft entered Male flight information region (FIR) from SUNAN3
waypoint. The Commander stated that there was an off-path cell forming at the 11 o’clock position.
During this time, the augmenting captain, who had taken over the PM role from the right seat as
the Copilot was on a break, observed the off-path weather on the radar approximately 10 o’clock
position, about 20 to 30 nautical miles away, and confirmed it was visually under clear skies. The
augmenting captain also stated seeing clouds below the Aircraft, noting off-path weather about 10
nautical miles ahead as a low layer of clouds significantly below the Aircraft.

1
Briefing Package: A term used to describe the informative package of information the Operator provide to their crewmembers
which includes the operational flight plan and the weather enroute.
2
When asked about the turbulence on the route, he stated that flying over Indian Ocean mostly include active weather conditions
such as Cumunulimbus formation and turbulence activity.
3
A waypoint is a specified geographical location used to define an area navigation route or the flight path of an aircraft employing
area navigation [Source: www.skybrary.com]

Preliminary Report №. AIFN/0015/2023, issued on 7 March 2024 1

 About seven hours into the flight, at 2105:03 UTC, and while flying in Male’s FIR, the
Aircraft encountered a severe turbulence, causing serious injuries and damage to the cabin
interiors. The Aircraft exited Male’s FIR at 2145:50 UTC.
As per the Commander’s statement, after consulting the flight crew and the cabin
supervisor, and considering the diagnosis of the doctors who were onboard, he decided to proceed
with the flight to OMDB. As per the augmenting captain statement, a medical emergency was
declared over Dubai airspace on radio telephony (RT).
At 0045:02 UTC, the Aircraft landed safely at OMDB.

1.2 Injuries to Persons

Table 1. Injuries to persons

Injuries Flight crew Cabin crew Other crew Passengers Total Others
onboard Onboard
Fatal 0 0 0 0 0 0
Serious 0 2 0 3 5 0
Minor 0 12 0 11 23 0
None 3 10 0 449 462 0
TOTAL 3 24 0 463 490 0

1.3 Damage to Aircraft

The Aircraft sustained damage to the cabin. This has resulted in the Aircraft going under
maintenance after arrival at OMDB. Further maintenance actions will be discussed in the Final
Report.

1.4 Other Damage

There was no other damage.

1.5 Personnel Information

Table 2 illustrates the Commander and Copilot information current at the time of the
Accident.

Table 2. Crew information

Commander Copilot
Age 47 39
Type of license ATPL (A) ATPL (A)
Valid to 9 August 2024 27 October 2027
Rating IR/MPA/A330/A340/A380 IR/MPA/A380
Total flying time (hours) 13,438.33 6,432.55
Total on this type (hours) 9,216.99 1,515.55
Total on type last 90 days (hours) 257.46 230.27
Total on type last 7 days (hours) 35.30 38.36
Total last 24 hours (hours) 10.39 10.39
Last recurrent SEP training 9 November 2023 17 October 2023

Preliminary Report №. AIFN/0015/2023, issued on 7 March 2024 2

 Last Operational Proficiency Check 21 March 2023 25 December 2023
(OPC)
Last line check 16 December 2022 25 August 2023
Medical class Class 1 Class 1
Valid to 30 June 2024 7 June 2024
Medical limitation Nil Nil

1.6 Aircraft Information

The Airbus A380 is a four-engine jetliner manufactured by Airbus Industries. The Aircraft
cabin layout is comprised of “double -deck”. The Operator is the largest operator of this type of
aircraft.
1.6.1 Aircraft data
Table 3 illustrates the general Aircraft information as of the date of the Incident

Table 3. Aircraft data

Manufacturer: Airbus Industries
Model: A380-861
MSN: 150
Date of manufacture: TBD
Nationality and registration: A6-EEV
Name of the Operator: Emirates Airlines
Certificate of airworthiness
Number: UAE-COA-0230
Issue date: 19 May 2014
Certificate of registration
Number: UAE-COR-0724
Issue date: 19 May 2014
Date of delivery 19 May 2014
Time since new (TSN) (hours) 37,845:43
Cycles since new (CSN) 4,133
Cycles since last service check 26

1.6.2 Airbus A380 weather radar modes

As per the flight crew operating manual (FCOM), the weather radar system (WXR) has
the following modes:
− weather (WX) display function
− turbulence (TURB) detection function
− weather ahead function
− predictive wind shear system (PWS) function
− ground mapping function.

Preliminary Report №. AIFN/0015/2023, issued on 7 March 2024 3

 The weather radar is armed on ground when the WXR button has been set to AUTO on
the multi-functional display (MFD) page. When armed, the WXR will start to scan the envelope
ahead of the aircraft if both of the following conditions are met (Figures 1 and 2):
− At least one engine is running; and
− The WX pushbutton is selected on at least one electronic flight instrument system
(EFIS) control panel (CP).

Figure 1. Weather radar rotating knobs Figure 2. WX (weather) button on EFIS

[Source: FCOM-Surveillance Panel]

1.7 Meteorological Information

The Investigation examined the weather information provided to the flight crew on the
day of the Accident4. The forecast for the flight segment over Male FIR indicated the presence of
Cumulonimbus (CB) cells which were expected to be associated with moderate/severe turbulence
and with icing. Additionally, the eastern part of India was impacted by the active cyclone
"Michaung," leading to heavy rainfall and flooding5.

4
The weather information was provided by world area forecast centers (WAFC). One is located in the United States of America
and operated by National Oceanic and Atmospheric Administration (NOAA) and the other one is located in the United Kingdom and
operated by the Meteorology Office. The information provided to the Operator was from the center located in the United Kingdom.
[Source: https://www.metoffice.gov.uk]
5
The rain dropped 20 centimeters of rain in many areas of Eastern coast of India [Source: https://earthobservatory.nasa.gov]

Preliminary Report №. AIFN/0015/2023, issued on 7 March 2024 4

 Figure 3. Weather information forecasting CB formation over and around Male’s FIR which was provided to the
flight crew

The Commander and augmenting captain stated that they took note of the CB formation
at their 10 to 11 o’clock position. In addition, the augmenting captain stated, “there was a layer of
clouds that is significantly under the aircraft.”
Further weather details will be discussed in the Final Report.

1.8 Aids to Navigation

Aids to navigation will be discussed in detail in the Final Report.

1.9 Communications
All communications between air traffic control and the flight crew were recorded by the
ground-based voice recording equipment and made available to the Investigation.
Entering Male FIR, and as per the Commander’s and the augmenting captain’s statements,
the communication was done by means of controller pilot data link communications (CPDLC).
The details of the communication will be further discussed in the Final Report.

1.10 Aerodrome Information

The Accident occurred in-flight.

1.11 Flight Recorders

The Aircraft was equipped with a digital flight data recorder (DFDR) and a cockpit voice
recorder (CVR) unit as mentioned in table 4.

Preliminary Report №. AIFN/0015/2023, issued on 7 March 2024 5

 Table 4. Flight data recorder
Recorder Manufacturer Model Serial Number Date Received Date Downloaded
DFDR L3-Comms 2100-4045-00 000905076 7 December 2023 11 December 2023
CVR L3-Comms 2100-1025-02 000596336 7 December 2023 11 December 2023

The DFDR was received in good condition and the downloaded data was relevant to the
flight. The data retrieved from the DFDR will be analysed and discussed in the Final Report.
The Investigation downloaded the compressed audio file from the CVR. The download file
was decompressed and converted into five readable audio files which will be analyzed and
discussed in detail in the Final Report.

1.12 Wreckage and Impact Information

The Aircraft was intact.

1.13 Medical and Pathological Information

The flight crew did not undergo any medical test post-Accident.

1.14 Fire
There were no signs of fire.

1.15 Survival Aspects

Will be discussed in the Final Report

1.16 Tests and Research

Will be discussed in the Final Report.

1.17 Organizational and Management Information

Will be discussed in the Final Report.

1.18 Additional Information

Additional Information will be discussed in the Final Report.
1.18.1 Operation manual − Part A (OM-A) policies – [Operating] in Adverse and
Potentially Hazardous Atmospheric Conditions
As per the OM-A − Operating in Adverse and Potentially Hazardous Atmospheric
Conditions, flights should not be dispatched or operated into or through areas of reported or
forecast hazardous weather conditions.
1.18.2 Flight crew techniques manual (FCTM) − Use of Weather Radar
As per the FCTM − Use of Weather Radar − General Modes, both PF and PM can
independently manage their own weather radar display.
It also states,

“…. By default, TURB (turbulence) mode should be in AUTO. The flight

crew can temporarily turn off the TURB mode to better differentiate
between precipitations and wet turbulence.”

Preliminary Report №. AIFN/0015/2023, issued on 7 March 2024 6

 In addition, it states,

“… at a long distance, ahead of the aircraft the accuracy of the weather

echo is low due to the both of the following:
− The increase of width in the weather radar beam
− Signal attenuation …”

Further discussion to the use of weather radar will be discussed in the Final Report.
1.18.3 Quick reference handbook (QRH) − Procedures during severe turbulence6
As per the QRH − Abnormal Procedures − Severe Turbulence, the following procedures
need to be implemented by the flight crew:
“…
− Seat belts: ON
− Maximum turbulence speed: 300kts/.85 Mach
− Minimum turbulence speed: Green Dot7
Adjust speed as necessary for comfort.
− Autopilot: Keep ON
− Cabin and cockpit (loose equipment): Secure
The flight and cabin crewmembers must secure all loose equipment.
Be prepared to use the speed brake, if necessary.
If excessive thrust variations:
− Auto Thrust: OFF
− Descend to or below optimum altitude: Consider…”

1.19 Useful or Effective Investigation Techniques

The techniques employed during this Investigation will be outlined in detail in the Final
Report.

6
Severe turbulence is characterized by large, abrupt changes in attitude and altitude with large variations in airspeed. There may
be brief periods where effective control of the aircraft is impossible. Loose objects may move around the cabin and damage to
aircraft structures may occur. [Source: www.skybrary.com]
7
Green Dot Speed is defined as: the engine-out operating speed in clean configuration. It provides an estimate of the speed for
best lift-to-drag ratio. [source: www.skybrary.com]

Preliminary Report №. AIFN/0015/2023, issued on 7 March 2024 7

2. Ongoing Investigation Activities
The Investigation is ongoing and will include further examination and analysis of:
− The implementation of dispatch policy as outlined in the OM-A
− Human factors including training
− Organizational factors
− The procedural aspects
− Any other safety aspects that may arise during the course of this Investigation.

This Preliminary Report is issued by:

The Air Accident Investigation Sector
The United Arab Emirates.
E-mail: aai@gcaa.gov.ae

Preliminary Report №. AIFN/0015/2023, issued on 7 March 2024 8