Air India Express B738 crash

[lomapaseo]

That sums it up in a nutshell!:D


Not really :=

Finding fault is one thing, corrective actions are what it's all about

[drive73]

I dont think the fo was being spiteful and thinking the way you speak of. He was responsible for the inintial descent and not getting the descent clearance from 37k until 77 miles, nor did he really effectively pass that along to the captain. He also seemed confused by the lack of radar vectors and stated he wasn't sure how to do the approach without radar? I think he didn't recognize the captain was mentally out of it and in tunnel vision world. The capt never responded to any of his requests or the automation giving him aural warnings. Clasic tunnel vision signs. He seemed to think the capt. Was going to save the approach. I don't think this is expat against local, stuff everybody wants it to be so badly.

[bravolima553]

According the report obviously there was no communication between the flightdeck crew, indicating they had problems with each other.
As further stated in the report, a question arouse: does the CMD Glusica knew about the written complaints of the F/O regarding to another CMD on another flight? I suppose, the fleet with 21 aircrafts is not as big that incidents like this doesn`t make the round....
As well according to the report, CMD Glusica was summonded two month earlier to his fleet commander beeing accused of a hard landing by another F/O. He felt being treated unfair at that case.

Angry men on the flightdeck?

[fireflybob]

A well known large low cost airline has the FO at 500 ft saying either "Five Hundred Continue" or "Five Hundred Go Around".

So if the FO calls "Five Hundred Go Around" the SOP is that the Captain will execute a Go Around.

Seems so simple - why can't other carriers have this system?

[Admiral346]

We do, but it's at 1000': Either stabilized or Goaround...

[Rananim]

A well known large low cost airline has the FO at 500 ft saying either "Five Hundred Continue" or "Five Hundred Go Around".

So if the FO calls "Five Hundred Go Around" the SOP is that the Captain will execute a Go Around.

Seems so simple - why can't other carriers have this system?

I dont agree with this as an SOP.I wouldnt fly with such an airline.I dont know of an airline that employs such a policy.I am not saying that under most circs,a good Captain should not listen to a good FO and heed the call.Thats fine.But the flt deck isnt a democracy even in todays pc world.In the system you describe,the gradient is totally flat and both should be wearing 4 stripes.That is as dangerous as the very steep gradient.CRM must start with the central premise that theres one Captain and work from there.FAR 91.1 is very explicit.
Of course,as related to this particular incident,your SOP works.But to dilute pilot-in-commands authority based on the actions of one bad Captain is a dangerous path to go down.Do your FO's order/execute a reject as well?

[Kenny]

Rananim,

I hate to tell you this but un-stable approaches still remain the number one reason for FOQA exceedances. Because of this the 500' call "stable" or "not stable" is being adopted by more and more airlines. My current company certainly does it as did the company I worked at before in the US.

The company I worked at in the US was probably one the only CRJ operators where the FO could call reject on the take off. Why? Because if they were PF and experienced a PCU runaway of the elevator on take off, only they would know.

Now, neither of these stop a Captain over-ruling the FO but they'd better have a damn good reason.

Unfortunately, FO's used to be seen as Captains in training. Now, with the decrease in experience levels, they're seen as more of a liability. Shame really.

[stepwilk]

the flt deck isnt a democracy even in todays pc world.

Decades of work down the drain.

[Centaurus]

So if the FO calls "Five Hundred Go Around" the SOP is that the Captain will execute a Go Around.


The captain is in charge of the flight and he decides whether or not a go-around is warranted - not the first officer. Your company SOP needs to be reviewed in terms of the Human Factors issues involved. Quite often a nervous nellie or inexperienced first officer will start yelling for a go-around when it is unwarranted. This is often seen in the simulator when a first officer is flying and decides he is going to execute a go-around when it is clear the approach is well within tolerances.

While 500 feet is standard with many operators as a decision point in terms of a stabilised approach, there are other pertinent factors to be considered. It is as bad empowering the first officer to initiate an abort during his take off rather than the captain making that vital decision and subsequent action to reject

[captjns]

In a number of carriers, it's not F/O or CAPT. that states 500 continue or G/A. It's the NFP that makes the observation as to whether or not the aircraft if on a stable approach. FR comes to mind with this "Challenge/Response" which seems to work.

Rananim... There is more than airline on the planet that may use different procedures than yours.

Perhaps Rananim, if and when your carrier establishes such a procedure, you will inform us of your resignation with immediate effect:rolleyes:?

[stealthpilot]

I dont agree with this as an SOP.I wouldnt fly with such an airline.I dont know of an airline that employs such a policy.A lot of airlines have that policy, more will embrace it.
At mine it isn't FO/Capt its PF/PNF. Stabilization criteria are laid down- 1000' or 500' depending on the approach, as Kenny pointed out unstabilized approaches are still very common.
No harm in going around, it's not a bad word anymore. How does a go around call 'dilute pilot-in-commands authority'?

Matter of fact in my company below 1000' anyone can call a go around. Above 1000' the FO can suggest it, but the captain can continue if he/she thinks they can stabilize in time. But at and below 1000' if anyone calls a go around- you go around. Can there be a few bad (for lack of a better word) calls of course!! Whats the worst that happens- the aircraft goes around and lands behind schedule and the pilot in question gets a debriefing.
Why do we have this call? No need to look further than the AI topic we are discussing.
or Incident: Air Europa B738 at Lanzarote on Oct 31st 2008, departed runway on landing (http://www.avherald.com/h?article=40f34e77/0001&opt=0)

The captain is in charge of the flight and he decides whether or not a go-around is warranted - not the first officer. Your company SOP needs to be reviewed in terms of the Human Factors issues involved. I disagree, if your company implies the captain solely decided on a go around that SOP needs to be revised. A go around is just that, a go around!!
Yes the captain is in charge of the entire flight, and he decides most things. But what have we learnt over the past few decades (even 4 years?). Pilots make mistakes, people get fixated. It could very well be an inexperienced FO, heck look at the link above it almost always involves an experienced captain. The empowerment to call a go around IS directly related to Human Factors and is in the larger interest of safety.
A go-around is not as important an event as a rejected takeoff ..... it's just a go around.

Quite often a nervous nellie or inexperienced first officer will start yelling for a go-around when it is unwarranted. Quite often?? If that's the case send the FO for extra training. Thats no excuse for ignoring an actual call.

[RAM777]

just finished reading the report,pretty informative.I just wish the first officer had takenover the controls but now its too late.RIP. i wish all fellow pilots safe flying

[BOAC]

steathpilot - thank you for correcting a strange (and somewhat historic) concept! Certainly those F/Os would need more training.

[drive73]

I think what your all missing is the pm must be able to recognize when the pf is in a tunnel. You can make all the calls you want if the pf is in the tunnel it won't matter.
This is where experience comes in, or special training in recognition of this state. One can't expect a low time pilot or one with no experience with training to recognize it. India and other countries with 250 hour new hires will always have this problem. The absence of being a flight instructor is big. When you spend 2-3 thousand hours with people trying to kill you on a daily basis, recognition of these issues and how to deal with them is much easier and quicker. This needs to be trained for in these kinds of countries. There was not one response to the go around calls or automated calls, not one. No recognition until it was too late, a good pilot probably, but no recognition of a tunnel visioned capt. I am quite sure he knew something was screwed up, but this was probably his first experience with it and this caused confusion in his mind. They should put these kinds of things in regular training.

[captplaystation]

In theory it is covered in initial & recurrent CRM training, & many companies have a policy whereby if PF does not respond to the 2nd challenge, PM is to assume he is incapacitated & take control. That would have worked here, as whatever you care to call it ( fatigue/tunnel vision/ land-itis) sitting there , fixated on landing at any cost, whilst simultaneously ignoring the exhortations of both your colleague, and the machine, is a (not very subtle) form of incapacitation ,& should be dealt with by the other crew member on that basis.

[drive73]

Talking about it and dealing with it at 6 in the morning after an all night flight for the first time at 2 miles with the captain descending at 3 thousand feet a minute with very narrow window of time are two different beasts. You can't just talk about this kind of stuff it needs to be trained regularly for guys in this part of the world. As an instructor both light and jets I can't tell you how many times I have sat and watched guys with a disconnected ap horn blasting away yelling checklist items back and forth. Never canceling landing gear warning horns stuff like that. When something like this happens the pm can be drug into it just by not comprehending it is being taken this far, which it self can cause inaction on the pm's part. Think about it, as an fo how many times did you have to physically take the controls from your capt. In my 20k plus career I can think of only 1 time from an experienced captain, and I was really surprised it happened.

[PT6A]

Drive,

The First Officer was not a 250 hour guy... He was undergoing his Command training:eek:

[MDT06]

At mine airlines the PNF makes the 500 ft Go Around call out. According to the airline, it’s reducing the amount of un-stable approaches. So it must work.

[aterpster]

The unstabilized approach is serious but the reality that the airplane would not touch down until the last 2,500 feet of a short ("table top") runway borders on insanity on the part of the captain.

In a sense this accident (crash) is similar to the OPRN Jet Blue crash. A seriously messed up captain and a fairly experienced, but too timed F/O.

At 500 feet the AIE F/O should have shoved the throttles to "radar power" rotated, then exclaimed to the captain, "Would you like the airplane back to fly a proper approach, or should I do it?"

I feel so bad for the passengers aft of the area where the 8 survivors were seated. They survived the impact to die, probably not seriously injured, of a death by fire.

The worthless piece of **** captain died a quick death by impact.

Excuse my emotions, but they come from reading a good accident report like this one.

[drive73]

Pt, just because your undergoing command training doesn't mean your experienced. When I flew in India I flew with 3000 hour guys who couldn't manually turn the airplane or land without auto brakes. When 2750 of your 3000 hours is 95 percent automated flying your not experienced. Again if he was experienced in dealing with fixation he would have gone around. Instead we are reading this report. Multiple levels of an aviation career are important in building experience, if that's not available it needs to be trained in the sim.

[Livesinafield]

Worthless peice of ****?.... Christ calm down he died aswell he has a family that would be mourning the loss, a mistake was made i agree but still please dont be disrespectful to the dead

[aterpster]

Livesinafield:

Worthless peice of ****?.... Christ calm down he died aswell he has a family that would be mourning the loss, a mistake was made i agree but still please dont be disrespectful to the dead

If you consider landing in the last 2,500 feet of such a runway in a 737-800 a mistake in nice VFR conditions, then you and I have a vastly different understanding of airline flying.

Those who die on death row have families too. They also have their victim(s).

[IcePack]

Well said livesinafield. Also as stated earlier in this thread he could also have been suffering some sort of incapitance.

[aterpster]

Ice Pack:

Well said livesinafield. Also as stated earlier in this thread he could also have been suffering some sort of incapitance. Indeed the report did mention once such possibility; that is, self inflicted incapacitation:

“In spite of availability of adequate rest period prior to the flight, the Captain was in prolonged sleep during flight, which could have led to sleep inertia. As a result of relatively short period of time between his awakening and the approach, it possibly led to impaired judgment. This aspect might have got accentuated while flying in the Window of Circadian Low (WOCL).”

That long “nap” wasn’t long on professionalism either.

[drive73]

Aterpster,

Are you even a pilot? Just because you have adequate rest time doesn't mean you get adequate rest. Early in my carrier I could sleep any time, as I got older it has become increasingly hard to sleep during the day. You can't force yourself to sleep. Don't think your above making a bone headed mistake you are human after all. The second you think your above doing something like this is the day you should leave the cockpit. Degrading the guy like he intentionally killed all those people and himself makes me think your not a pilot, very fresh ppl pilot, very immature, or arrogant, any of the above doesn't belong in the air in any capacity other than a passenger.

[BOAC]

drive - the point is valid whatever. Yes, we all get dog-tired at some point, but it behoves us to then put in place a controlled rest environment - in this case an agreed appropriate 'wake-up' point which appears to have been missing..

[Livesinafield]

i am not defending his mistakes or trying to justify them, all i am saying is like what drive said nobody is immune to them

this guy im pretty sure didnt set out that day to do this, sleep inertia is a form of incapacitation and if it did play a role would be significant, i am afraid it can happen to all of us

mistake,useless a murderer call him what you like but he is dead now and cannot defend himself the case can be investigated to the end but we will never know what was happening iside the guys head, and that is the most frightening thing about aviaition accidents

[aterpster]

drive73:

Are you even a pilot? Just because you have adequate rest time doesn't mean you get adequate rest. Early in my carrier I could sleep any time, as I got older it has become increasingly hard to sleep during the day. You can't force yourself to sleep. Don't think your above making a bone headed mistake you are human after all. The second you think your above doing something like this is the day you should leave the cockpit. Degrading the guy like he intentionally killed all those people and himself makes me think your not a pilot, very fresh ppl pilot, very immature, or arrogant, any of the above doesn't belong in the air in any capacity other than a passenger.

27 years with TWA and 20,000 hours. I flew my share of multi-leg overnight trips and horribly long duty days. My crews and I declared crew fatigue after excessively long duty days on a few occasions over those years.

I also participated in several air carrier accident investigations. I am well aware of the stress and circumstances that cause honest mistakes to be made, which in some cases result in horrible accidents.

I am also aware of the Comair 5191 crash at KLEX. I did some technical work on that one. It was similar to the crash at issue that the "mistake level" rose to gross negligence.

The late captain at issue was grossly negligent. Had he survived he would have been criminally prosecuted in many countries, as well as he should been. He isn't here to defend himself; by the same token he has been spared a trial at which he would have mostly likely been found guilty of criminal neglegence. It is a shame the F/O didn't take control before it was too late. But, apparently he had been so poorly treated by this egomaniac he just gave up. It is shockingly similar to Islamabad.

If you don't see this after a careful read of the official report, what more can I say?

Are you aware of the various criminal legal levels of taking another life?

[PJ2]

aterpster;

Re, "It was similar to the crash at issue that the "mistake level" rose to gross negligence." [referencing Lexington in re Mangalore]

Yes. Continuing an highly unstable approach after forceful, verbal interventions by one's crew member(s) does not belong to the category of "an honest mistake".

And all else being equal, the time for bombastic personalities over-ruling CRM principles is over and the matter, difficult though it may be, begs to be addressed. Fortunately there are extremely few examples of such unprofessional behaviour with which to come to terms in some form (criminal prosecution?) or another.

I don't wish to re-argue views on criminal prosecutions and aircrews involved in accidents because I know you know the arguments. However, while I do acknowledge a long (by centuries) history of English tort law and the more serious criminal jurisprudence, the circumstances in aviation are materially different, with the notion of "the greater good" lurking in the background, and the need to "find out to prevent".

We know that in extremely rare cases, accidents occur to perfectly serviceable airplanes in which crew behaviour and actions are nothing short of gross negligence.

Aviation safety is advanced by knowing and understanding accidents, yet criminal prosecution opposes such knowing by enframing the dialogue such that the law, and not human factors is the arbiter of understanding and final outcomes.

I don't disagree with your views on this captain and it is difficult to keep emotion out of it when such outlying behaviours are involved. The accident brings to mind the Garuda over-run accident in 2007 at Yogyakarta, and a couple of others.

But the backdrop to any such views and emotions is Human Factors. The quote above from your post defines the fork in the road in this ongoing argument: At what point does an accident cross over and move from the need to understand, to the need to merely prosecute? So far as society is concerned, it is not an open-shut question.

I don't know the answer of course and it wouldn't matter if I did anyway, because such judgements are in the end a societal matter and not merely a "DGCA", (or NTSB or...?) matter. It is a credit to the existing system that such seemingly-negligent causes are so rare. But we in Canada have already "gone there" and neither the aviation system nor the courts have answered the question. Despite the law against it, (TSB Act), CVRs have been played in open court.

The point is made more stark by asking, for example, questions about the captain's physical health, and considering just the possibility of, say brain disease, (cancer/stroke/latent epilepsy) which had not manifested itself in previous medicals etc. As well-written as it is, the DGCA Report does not discuss this and, likely correctly, cites sleep inertia etc.

It is very difficult to condemn a fellow airman, but it is equally difficult to accept unprofessional standards when obvious answers (go-around) are at hand and especially when fatalities are involved.

Where do we cast our nets?

[fdr]

Aterpster/livin'field

:eek:

OK... in living memory there have been only a few highly public events where an aircraft has been deliberately crashed... it is a fairly large headline, (or was when it ended up with the "Patriot Act"... and a war or two on questionably dubious grounds).

If you assume that the PIC was not either homicidal or suicidal, then he is about the same boat as the Air France FO's or the Polish Airforce Captain... and hundreds of others that given slightly different circumstances would be relating another hanger/war story rather than at best wishing for an opportunity to redo 10 seconds of their life, or at worst have their families and those of their victims wishing for that opportunity.

Being human is a double edged sword, occasionally we see the benefit of humans in the loop, ie QF32, US1549 and many more daily events that culminate in a save that doesn't rate a headline, and other times you don't.

There is a fair chance that the PIC's family in this case feels rather conflicted, with some thoughts aligned with Aterpster's but would also have all the natural grieving processes of any human loss.

A more constructive question may be why does one crew get themselves into such an out of sorts event when others (Aterpster included, naturally) can avoid it for 20,000hrs/25 years. In the cold light of day, it is often staggering to consider how risky a particular event was that a crew has on the day considered as being worth staying with. Cognitive overload, loss of AS, or pure incompetence, whatever, is far more common than is indicated in the funny pages, most stuff ups result in nothing more than embarrassment and dented ego's, and underneath it all, the group risk taking generally proceeds unabated. Every event you "get away with" assists in normalising deviation, and this is universal behaviour, exhibited in the USA, China, Korea, Europe and the Antibodies etc., civil and military.

It is harsh to attack the departed who cannot defend their own name, but then, a lot of other grieving families are invested heavily in the decisions that the PIC took... and their burden is no less severe.

[safetypee]

At/PJ, is hindsight bias is enhancing emotion?
Those who wish to prosecute ‘deviant’ crews without all of the evidence (because many cognitive aspects are not available), should consider what aspects of safety could be learnt from alternative viewpoints. Try being the defense lawyer.

There is much that we (industry / humans) do not understand about human behavior, particularly in the interactions present in modern, complex operations.
For an alternative view of LEX, see
http://ida.dk/netvaerk/fagtekniskenetvaerk/byggerioganlag/brandtekniskselskab/Documents/Erik%20Hollnagel%20040210.pdf
and
Application of Functional Resonance Accident Model (FRAM) to - rossir24-0004 (http://www.docstoc.com/docs/47002285/Application-of-Functional-Resonance-Accident-Model-%28FRAM%29-to---rossir24-0004)

Anyone care to speculate about alternative contributions to this B738 accident and possible interactions:
Pilot selection, personality (prone to deviation – done it before do it again), training, operational procedure, regulatory oversight, data monitoring, cognitive processes; … … monitoring and intervention – do these really work.
The surrounding infrastructure, organization, and operational situation probably had greater influence than any ‘legal’ human behavior.
Consider all of the successful (not necessarily safe) landings in similar circumstances, what contributed to the successful outcome, what contributes to being safe?

[aterpster]

safetypee:

Those who wish to prosecute ‘deviant’ crews without all of the evidence (because many cognitive aspects are not available), should consider what aspects of safety could be learnt from alternative viewpoints. Try being the defense lawyer.

Hindsight is indeed 20/20. The report is quite thorough and provides more than sufficient information to conclude that the captain did not conduct the flight properly.

Had the captain survived no doubt we would have been afforded the opportunity to hear the criminal case as presented by both the prosecution and defense. My experience with defense lawyers is their objective is to get their client off, not present the truth in a court of law.

As to your complex science and its criticism of the NTSB, you need to take that up with them. My simple, flight operations oriented mind agrees completely with their analysis and conclusions with Comair 5191. The papers to which you refer brush over the large amount of non-pertinent conversation between those two crew members.

[Piltdown Man]

My experience with defense lawyers is their objective is to get their client off, not present the truth in a court of law.

or that could be re-written:

My experience with prosecuting lawyers is their objective is to get their accused found guilty, not present the truth in a court of law.

Aterpster - I'd like to think that we were having a discussion about how we stop this sort of event from re-occurring. I thought we had moved on from -

The late captain at issue was grossly negligent. Had he survived he would have been criminally prosecuted in many countries, as well as he should been.

You are wrong. Here's why. Let's say the guy emerged from the smoking hole in the ground totally unscathed. And then you get your way and they guy is prosecuted by the judicial system. You just tell me why he would help with his own prosecution? If that were you, I'd suggest you'd say nothing to convict yourself. I certainly wouldn't, even if innocent lest my comments were misinterpreted by some scumbag lawyer. Yet your testimony would be the most valuable thing for the investigation team. Now let's stick him in prison until he rots. We've just punished the guy - well you can say "That's justice!" But have YOU done ANYTHING to prevent this from re-occurring? No, you've just clumsily nailed up a sign that says "Trespassers will be shot!" Now, whenever there's any sort of incident, CVR/FDR's will "malfunction", paperwork will be shredded, crews will bugger off out of the country or hide away and become "sick" etc. Redneck justice deals only with pain, there is no gain.

What the investigators who wrote this report were trying to achieve was to understand the human factors that drove this crew into doing what they did. For this they should be commended.

PM

[aterpster]

PM:

You are wrong. Here's why. Let's say the guy emerged from the smoking hole in the ground totally unscathed. And then you get your way and they guy is prosecuted by the judicial system. You just tell me why he would help with his own prosecution? If that were you, I'd suggest you'd say nothing to convict yourself. I certainly wouldn't, even if innocent lest my comments were misinterpreted by some scumbag lawyer. Yet your testimony would be the most valuable thing for the investigation team. Now let's stick him in prison until he rots. We've just punished the guy - well you can say "That's justice!" But have YOU done ANYTHING to prevent this from re-occurring? No, you've just clumsily nailed up a sign that says "Trespassers will be shot!" Now, whenever there's any sort of incident, CVR/FDR's will "malfunction", paperwork will be shredded, crews will bugger off out of the country or hide away and become "sick" etc. Redneck justice deals only with pain, there is no gain.

I've heard your argument and the contra-arguments since the first accident investigation in which I was involved; 1972.

What the investigators who wrote this report were trying to achieve was to understand the human factors that drove this crew into doing what they did. For this they should be commended.

Yes, because they were trying to set forth a possible explanation for the captain's series of bad decisions. Nonetheless, the report also tells it the way it was.

[PJ2]

safetypee;

Re your observation, "Those who wish to prosecute ‘deviant’ crews without all of the evidence (because many cognitive aspects are not available), should consider what aspects of safety could be learnt from alternative viewpoints. Try being the defense lawyer."

With respect, please re-read my contribution to the discussion. Given my history here you should be well aware that I understand both the phenomenon of hindsight bias, and the broader notions of organizational failure.

While we may not be able to discern the cognitive state of the captain in this accident such that understanding and thus prevention are possibilities, I did clearly state,

"The point is made more stark by asking, for example, questions about the captain's physical health, and considering just the possibility of, say brain disease, (cancer/stroke/latent epilepsy) which had not manifested itself in previous medicals etc. As well-written as it is, the DGCA Report does not discuss this and, likely correctly, cites sleep inertia etc."

There is already much to learn from this accident, including the issues of mandatory go-arounds by the PM even if the cognitive sources of abnormal cockpit behaviours on the part of the PF cannot be discerned in the moment.

In flight data analysis I have seen and see daily trends of long landings, some well beyond the TDZ. I see power-off, high-rate-of-descent, high-speed approaches where go-arounds are absolutely indicated yet crews press on, some on 6000ft runways. Do we investigate the cognitive states and predispositions of each PF involved? Of course not... The tools and processes for prevention are already available.

Cognitive processes are, in the end, (and as you almost certainly know) complex to the point of being serious subjects of the philosophy of mind, and if you are aware of those areas of serious academic work, you will know that strong differences of interpretations of cognitive processes exist even at these levels.

Most certainly, "prosecution" is not the answer, and I should have thought that the "but..." in my post would have made that clear.

PJ2

[safetypee]

At, I agree that legal debate does little to enhance safety, thus my question - 'what contributes to being safe'.
A Socratic debate (seeking truth) about the contributing factors in this accident, without judgement, would better benefit the industry.
What entails a “properly conducted flight”, where is this defined; - not an individual’s version, but that of the crew’s at the time, and in the circumstances of the accident. All of these aspects require definition – establishing a local ‘truth’ about them at that time, not one of an idealistic operation.

You appear to dismiss the ‘complex science’ (FRAM). I agree that the scientific outcome is not necessarily relevant, but the process or similar, might enable the identification of additional contributions or re-evaluation of the effective magnitude of the existing factors, this could enhance safety.

Re non-pertinent conversation; this appears to be a personal judgement. How can we judge (in hindsight) what was or not relevant to the human behavior in that situation, as seen (perceived and understood) by the crew. We were not there, all that we might do is surmise the human thoughts and behaviour, but even this would have some bias – our experience, culture, personality, etc, etc.

I don’t argue for right or wrong; instead I seek a wide view to identify potential contributors which any organization could consider in their safety programmes – could this happen to us.
Blaming the crew does nothing to help maintain / improve safety.

PJ, :ok:

[moon11]

aterpstar:


How old are you now? 70+? I strongly recommend that you visit doctor and check for Alzheimer's.
In your mind only Captain exist, you should understand that there was also F/O on that flight. As many colleagues wrote, if F/O took control there would be no tragedy, do you understand that?

[aterpster]

moon11:

aterpster:
How old are you now? 70+? I strongly recommend that you visit doctor and check for Alzheimer's.
In your mind only Captain exist, you should understand that there was also F/O on that flight. As many colleagues wrote, if F/O took control there would be no tragedy, do you understand that?

Probably a lot sharper than you are:

I quote myself in Post 498 on Feb 19th:

In a sense this accident (crash) is similar to the OPRN Jet Blue crash. A seriously messed up captain and a fairly experienced, but too timed F/O.

At 500 feet the AIE F/O should have shoved the throttles to "radar power" rotated, then exclaimed to the captain, "Would you like the airplane back to fly a proper approach, or should I do it?"

In more civil discourse I would expect an apology from someone of the likes of you who fails to read my previous posts then makes an inappropriate insult. I'll match wits and knowledge of instrument procedures with you any day of the week.

[Yankee Whisky]

Conflicting reporting; Bloogs states runway drenched and below's input
mentions dry runway. Keep it factual fellows and galls.



Just talked to a friend at Mangalore with ix. confirmed no MELs.
He quoted eyewitnesses as saying that the aircraft made a pretty steep approach and touched down close to half way down the runway. They heard the thrust reversers and then a loud thud which was caused by the right wing hitting the Localiser at the end of runway. part of the wing fell there and the aircraft then fell over into the valley below. Then burst into flames.
Very sad incident and may God give strength to the bereaved families in this hour of distress.

PS: no precipitation at time of crash. Runway was dry.

[stepwilk]

In more civil discourse I would expect an apology from someone of the likes of you who fails to read my previous posts then makes an inappropriate insult. I'll match wits and knowledge of instrument procedures with you any day of the week.

Wouldn't be much of a contest, Terp, I doubt he's a pilot.

[moon11]

aterpster:

I will not apologize to you, of course.
If you remember, you insulted our late colleague.
Is it civilized way to insult someone who can not defend himself??
Shame on you, over.

[aterpster]

Yankee Whiskey:


Conflicting reporting; Bloogs states runway drenched and below's input mentions dry runway. Keep it factual fellows and galls.

It's all in the official report including photographs.

Excerpts rom the report:

Despite the EGPWS warnings and calls from the First Officer to ‘Go Around’, the Captain had persisted with the approach in unstabilised conditions. The final touch down of the aircraft was at about 5200 ft from the beginning of R/W 24, leaving only about 2800 ft to the end of paved surface, to stop the aircraft.

Soon after the touchdown, the Captain had selected Thrust Reverser. But, within a very short time of applying brakes, the Captain had initiated a rather delayed ‘go around’ or an attempted take-off, in contravention to Standard Operating Procedure (SOP) laid down by the manufacturer i.e. Boeing Commercial Airplane Company, USA.

When the aircraft came in contact with Mangalore Area at 05:36 hours IST, the First Officer was given the following weather information from METAR of 05:30 hours:- “Winds - Calm, Visibility - 6km, Cloud - Few 2000 ft, Temperature - 27o, Dew Point - 26, QNH - 1006 hPa” At 06:04:19 hours IST when the aircraft was given landing clearance for R/W 24 by ATC, Mangalore, the winds were reported to be calm.

No significant weather had been either forecasted or reported en-route from Dubai to Mangalore. The visibility at Mangalore was 6 km at the time of accident. As such the prevailing weather conditions did not contribute towards the accident.

[misd-agin]

Things you can't defend -

On an ILS(!) approach being 625' AGL at 1 mile or crossing the threshold at 200' AGL.

Landing 5200' past the threshold.

Landing with 2800' remaining.

[drive73]

Aterpter,

I have just over 24000 hours and flew at united until they decided to steal my money, I finished my career in India, and assume if you have 20000 hours we are of similar age. I am amazed by your arrogance and attitude. You had a lot of luck which helped you finish your career without bending any metal. Remember no weather radars, no microburst detection, no deicing programs, just to name a few. I lost a few good friends who were not so lucky. Hell I remember when guys could have a drink in the cockpit. You can't tell me you were always fit to fly in your career or you called in fatigued every time you were in that state, fatigue wasn't even addressed when we started flying. You would have been laughed out of the building. You were lucky, just like the rest of us. Nowhere is it ever stated this captain was bad to his fo that flight. You should apologize for that blatant lie. There were no responses other than to the atc inquiry. As stated several times this was a complete breakdown in crm between the captain and fo. No communication to captain about late descent, no recognition by captain of late descent until 3 miles, no response by captain to calls from fo or jet, no recognition by fo of captains state and finally no action to go around until on ground after reverser deployment and long landing. Poor communication from before captain went to sleep, as stated by another poster they should have set a wake up time. All easy to see after spending hours investigating, the crew didn't have that liberty and never do. Funny thing about being a pilot, when you screw up your the first to appreciate the gravity of that mistake and for the most part don't need to be prosecuted. But mr. Perfect keep thinking your stellar career at twa was all your doing and that you were immune to mistakes that could of killed you if things hadn't linked up just a little differently, you will be the only one who believes it. You remind me of an ex pilot who joins the Feds and thinks he can do no wrong, maliciously destroying good pilots careers because of his god complex.

[aterpster]

drive73:

I have just over 24000 hours and flew at united until they decided to steal my money, I finished my career in India, and assume if you have 20000 hours we are of similar age. I am amazed by your arrogance and attitude. You had a lot of luck which helped you finish your career without bending any metal. Remember no weather radars, no microburst detection, no deicing programs, just to name a few. I lost a few good friends who were not so lucky. Hell I remember when guys could have a drink in the cockpit. You can't tell me you were always fit to fly in your career or you called in fatigued every time you were in that state, fatigue wasn't even addressed when we started flying. You would have been laughed out of the building. You were lucky, just like the rest of us. Nowhere is it ever stated this captain was bad to his fo that flight. You should apologize for that blatant lie. There were no responses other than to the atc inquiry. As stated several times this was a complete breakdown in crm between the captain and fo. No communication to captain about late descent, no recognition by captain of late descent until 3 miles, no response by captain to calls from fo or jet, no recognition by fo of captains state and finally no action to go around until on ground after reverser deployment and long landing. Poor communication from before captain went to sleep, as stated by another poster they should have set a wake up time. All easy to see after spending hours investigating, the crew didn't have that liberty and never do. Funny thing about being a pilot, when you screw up your the first to appreciate the gravity of that mistake and for the most part don't need to be prosecuted. But mr. Perfect keep thinking your stellar career at twa was all your doing and that you were immune to mistakes that could of killed you if things hadn't linked up just a little differently, you will be the only one who believes it. You remind me of an ex pilot who joins the Feds and thinks he can do no wrong, maliciously destroying good pilots careers because of his god complex.

In addition to your obvious bitterness you really to go off on a a tangent.

Unlike you, I suspect, I participated in several accident investigations. Most, if not all, were the classic chain of events that finally broke and were usually because of lack of knowledge in a particular circumstance coupled with honest mistakes.

That is not the case here nor was it at OPRN. If you fail to see the difference then I must say you were the lucky one that made it out the other end alive.

[captplaystation]

aterpster,

I don't know if you try to be so abrasive as part of your internet "persona", or if you really are so bitter & blinkered, I hope, for you too, it is the former.

In the 1st instance,I have to agree wholeheartedly that this approach was so royally screwed up, that I cannot fathom anyone with experience somehow thinking they could get away with it.
On the other hand, I find it difficult to believe that the PIC truly wished to end his life, in a smouldering heap, off the end of a runway in the god forsaken hole that he was forced to seek work.

Do you see where I am coming from ?
We must assume therefore that he was either such a "devil may care" risk taker that he decided , "what the hell, lets go for it" . . OR, he didn't, at that moment in time, appreciate how much sh1t he had dropped himself in.
In a former life I flew in a company with a fair few Serbs. Yes, they were known to push the boat out a bit further than some other nationalities, perhaps an inevitable consequence of living in a country ravaged by civil war, but, they were generally competent switched -on guys who would normally know when to REALLY call it a day.

I have flown approaches after spending a very long night flying UK/Europe to the Canaries/Cyprus & back, where I was physically falling asleep on final, I was that feckin tired ! ! Sometimes, this woke me with such a bloody start that I landed, feeling Tom Cruise like, convinced I could probably loop the space shuttle if needed. On other occasions, it took all my physical & mental strength to somehow figure out how to gracelessly flare/plonk it down, & subsequently taxy half way round the world (in particular CDG) without falling asleep at the wheel. On the odd occasion I have messed it up (or had it messed up for me by ATC) the Tom Cruise mode has usually kicked in . . . . . what if it hadn't ? & what if, on that day, the guy sitting next to me had been more worried about cultural issues/face-saving or whatever than saying "Hey mate, you are going to kill us all ".
Having spent some time with a Turkish carrier, I have seen situations where RHS would prefer to be killed by LHS than open his mouth ( & believe me it was 1000% easier for him to do so with me, than with Capt Turk! )

The unfortunate Capt in this accident was making his 1st flt following his 2 weeks OFF , after his 6wks ON . . . in :mad: India ! !
How rested was he ? how able was he to be "more" rested than he was? how much sh1t was he maybe taking whilst at home, for his "rest", from "her indoors", who, whilst no doubt grateful for the pay-check , possibly also made her feelings well known about running the family home unaided/unsupported (except financially) for 6 weeks ?
I am sorry to say it, but just bad-mouthing somebody who royally screwed up an approach, without acknowledging that there are 1001 factors (visible & invisible) which have contributed to that mental abberation , is both heartless & very closed-minded.
You keep trumpeting your accident investigation skills. . . as far as I can see from this report, at least the remit /scope of this investigation (even in a country like India) appears to have moved on a tad with respect to your , frankly blinkered, viewpoint.
YES YES YES, PIC cocked up so horribly badly that we cannot imagine how. . . it is however, much more important/relevant to try & figure out why, lest we are not the next, in preference to merely bad-mouthing a fellow pilot, whom , I have no doubt, wished to get to the end of the next 6 weeks, & then go back to his family/civilisation.
Sorry Sir, but you are a heartless blinkered individual . . . . nonetheless, I am happy that you have made it to retirement, as others have said though, maybe you should give thanks occassionaly to lady luck, rather than retreating so far up your own sphincter that you think it was ALL down to you.

[drive73]

At,

I defiantly am not bitter, other than having a large amount of money stolen, but I suspect most people would be. I had a great career and have no regrets. I do however understand that luck plays a large roll in an uneventful career, especially in aviation and certainly back before good work rules and equipment.

You however seem to think your career success, if true is due to your own godly skills. If you investigated accidents I am amazed you made up the captain was autocratic and uncaring of his fo's concerns. The fact you seem to miss, mr investigator, is why this captain was so fixated on this approach he never responded to his fo or the calls from the jet or why he didn't recognize he was on the false slope for so long or even why he didn't recognize the descent wasn't initiated until much to late. Why with his experience he tried a go around after reverser deployment. As an instructor for many years those are the things I as an investigator would want to find out. Why did a captain with no history of unstable approaches do this? The answer is far more important than assigning blame, which is what you choose to do. We all know the Crew screwed up, it's why that is important. Investigating cause of an accident is only a part of correcting a problem, determining why the cause happened is another part and correcting it is the final part. Your much to happy to make up a story about a drunk on power captain who ignored and ridiculed his fo as the cause. To you it is the simple answer easy and easy to correct, but there is much more going on here than that. As an investigator you should know this by reading the report, even I as a pilot can see human factors were a big factor in this accident.

[aterpster]

captplaystation:

aterpster,

I don't know if you try to be so abrasive as part of your internet "persona", or if you really are so bitter & blinkered, I hope, for you too, it is the former.

In the 1st instance,I have to agree wholeheartedly that this approach was so royally screwed up, that I cannot fathom anyone with experience somehow thinking they could get away with it.

On the other hand, I find it difficult to believe that the PIC truly wished to end his life, in a smouldering heap, off the end of a runway in the god forsaken hole that he was forced to seek work.

I have never suggested he willfully murdered all aboard. What I did suggest is criminal negligence. There is a legal distinction there. I said the same about the Air Blue captain.

This captain was flying an advanced airplane on a nice day that is capable of flying the DME ARC onto the ILS quite easy. But, not only did he screw that up (rather than using the boards sooner or perhaps a 360 prior to entering the DME ARC) he was operating into a familiar, company-imposed "special quals" airport where being on speed and touching down in the company-designated TDZ was crucial. I don't consider a guy like this a fellow pilot.

Again, I feel sorry for the cultural environment that kept a competent F/O from taking over when they are still aloft well beyond the TDZ. That cultural environment was exacerbated by a berating captain.
Sure there are human-factors; there are always human-factors in every incident or accident. But, human-factors does not equate to a "get out of jail free card."

If I am considered abbrasive becuase of my profound comptempt for this captain, then color me abbrasive.:ooh:

[Machinbird]

Aterpster,
I too have investigated accidents (as a military aviator) but I have a different take on this captain's performance.
Have you ever considered the possibility that he never actually awakened? If you are tired enough, it is a distinct possibility.

I have personal experience with sleep driving which is a related concept.
I was young and driving a long distance under time pressure. On the second night of the trip in the middle of Kansas, I pulled off into a rest area (From the Interstate highway) for a quick nap. I set the alarm for 20 minutes into the future and laid down across the seats. Next thing I was aware of, I was driving down a two lane road with the oncoming driver flashing his lights. But where was the Interstate?
In the moonlight, there was another parallel strip of concrete off to the side!

To make a long story short, I had pulled out of the parking spot, reversed travel direction in the parking lot, and gone out the parking area Entry ramp! The car had no extra paint on it from the maneuver so it was not a "drive by braille" exercise. All this while asleep.:eek:
This was a manual transmission car too!!!

[newday]

Machinbird: Good point!
There is interesting discussion going on:

http://www.pprune.org/rumours-news/477991-over-tired-pilots-falling-asleep-duty-balpa-survey.html
“The MPs heard that 43% of pilots said they had fallen asleep in the cockpit, based on a survey of 500 members of the British Airline Pilots' Association (BAPA).”


I have a good friend and colleague (744 driver for 15 years) who admitted that he fell asleep many times, the funniest one: during flare! He was lucky that F/O pulled the control column.
I was in similar situation many times also, especially after landing at CDG or Narita 34R.
I only wanted to pull the parking brake in the middle of my taxi route and have a nap.

[safetypee]

Machinbird, an interesting theory (#529). Is there any science which support this, or with such science, anything which links it with the events of this accident.
I can relate to similar symptoms but in the sense of ‘automatic’ skillful behavior – activities without conscious awareness.

We conduct many tasks at the subconscious level, but not normally with the conscious mind being ‘unconscious’, i.e. asleep.
Distraction or lack of attention – wandering mind, or even complacency can contribute to these types of situation, but generally if a non-normal situation is encountered we expect people to ‘wake-up’ – become aware of the situation.
In flight operations, procedures and check-calls provide opportunity (even for subconscious behavior) to realize that the normal – ‘on the rails’ – type of operation is not progressing according to the ‘skilled’ plan; something jerks you back to reality.

In this accident, this type of input was either not present (poor SOPs, calls, etc) or not effective (FO did make some calls), the latter may represent a failure to hear, which is often associated with being maxed-out with some other task – attention deficiency.
If the Captain was asleep (unconscious) we might expect that crew calls or other actions would wake him, but if the conscious process was maxed out or ‘stalled’ by some other process (inappropriate task, task overload), then the apparent state of normality might remain.
Unfortunately we cannot tell in this accident, but perhaps this line of speculative thought will act as a reminder for the need for well-considered procedures (stabilized approach) and check points (approach gates), with crew intervention, as a possible defense against this type of behaviour.

[drive73]

At,

You continue to lie about the aex capt. He never berated the fo. This is slander and absolutely false. No way you ever have investigated accidents with your history of making completly false statements. Investigators deal with facts they don't make sh@& up to make themselves look better.

[Livesinafield]

wow aterpster... i wish i was as good a pilot as you, and completely immune to mistakes...

[aterpster]

Livesinafield:

wow aterpster... i wish i was as good a pilot as you, and completely immune to mistakes...

First, you have to be a pilot before you can be either a good, fair, or bad pilot. I have no idea about you.

As far as I am concerned you are putting words in my mouth. I never said I was a great pilot. I was a careful pilot, knew my company's procedures, and flew the airplanes they owned in accordance with their directives.

I made my share of mistakes, some of which I caught and some of which my cooperative fellow crewmembers caught.

[aterpster]

Machinbird:

Aterpster,
I too have investigated accidents (as a military aviator) but I have a different take on this captain's performance.
Have you ever considered the possibility that he never actually awakened? If you are tired enough, it is a distinct possibility.

I have personal experience with sleep driving which is a related concept.
I was young and driving a long distance under time pressure. On the second night of the trip in the middle of Kansas, I pulled off into a rest area (From the Interstate highway) for a quick nap. I set the alarm for 20 minutes into the future and laid down across the seats. Next thing I was aware of, I was driving down a two lane road with the oncoming driver flashing his lights. But where was the Interstate?
In the moonlight, there was another parallel strip of concrete off to the side!

To make a long story short, I had pulled out of the parking spot, reversed travel direction in the parking lot, and gone out the parking area Entry ramp! The car had no extra paint on it from the maneuver so it was not a "drive by braille" exercise. All this while asleep.http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/eek.gif
This was a manual transmission car too!!!

I fail to see the comparison. You were probably dead tired and certainly weren't operating under a structured environment. Stuff like that happens.

OTOH, the subject captain had just come off a rest period and was apparently on-duty for less than 5:00 hours, some 3:15 or so in flight. I don't accept that he suffered from extreme fatigue like you did. I do accept the possibility that he was suffering from what the accident reporters called sleep inertia. If so, that was his own fault. He could have scheduled a reasonable wakeup time with his F/O, but that would have required both cooperation and professionalism. Further, it is doubtful he was so groggy that he didn't hear any of the cautions issued by the F/O, for which he apparently had nothing but contempt.

I have no doubt this guy thought he was "the ace of the base."

[aterpster]

The real human-factors issue that needs to be taken apart bit by bit is the inaction of this apparently competent F/O as well as his apparently competent fellow F/O at Islamabad.

Both of them should have seized control of their respective airplanes before it was too late. But, apparently both of them were so brow-beaten they entered a state of disbelief about what the old man was (or was not) doing.

That is truly the sad aspect of both accidents.

[misd-agin]

aterpster - "I have no doubt this guy thought he was "the ace of the base." "


It's comment's like these that completely undermine your posting. Why don't you try explaining how you came to that conclusion?

[drive73]

At, you continue to completly lie! Where does it state in the crash report these two pilots had conflict. Where is cvr data that backs up your berating captain claim. I believe you were one of his fo's and must of had a conflict with him. You continue to slander without evidence. Your credibility is completly ruined, I believe nothing you say.

[stepwilk]

I believe you were one of his fo's and must of had a conflict with him.

Brilliant deduction, since the man logged 27,000 hours with TWA. Hard to understand all the hate being thrown his way, since Aterpster makes far more sense than do all the hysterical rants directed at him--"liar," "completely false statements," "bitter and blinkered," "you continue to lie..."

[Machinbird]

Machinbird, an interesting theory (#529). Is there any science which support this, or with such science, anything which links it with the events of this accident.
Reasonable question. Did a little digging on the subject. It fits the category, Parasomnia.
parasomnia /para·som·nia/ (-som´ne-ah) a category of sleep disorders in which abnormal events occur during sleep, such as sleepwalking or talking; due to inappropriately timed activation of physiological systems.
The best briefing on the subject I found was here:Parasomnia (Insomnia & Sleep Disorders) (http://www.videojug.com/interview/parasomnia-2?autoredirect#are-parasomnias-harmful) (Wait for the advertisement to run its course.)

From what I have learned, it would not be at all surprising to find unconscious skilled behavior in a parasomnia event. If sleeping women can cook a meal and eat it without actually waking, I pilot should be able to make a semblance of an approach and landing while unconscious.

I have not yet gone through the accident report with a fine tooth comb looking for evidence of parasomnia, but in a brief read earlier, the Captain was not interacting much after he was 'awakened'. If parasomnia was involved, it is all the more reason for a PM not being bashful about taking charge when he sees the Fit about to hit the Shan.

OK465, I spent a few months at Miramar, but was mostly an East Coast flyer.

[Stick_Rudder]

Machinbird,

I have gone through the accident report and there's no mention of Parasomnia like activities anywhere.
I think the family members would have known, if at all the captain had issues related to Parasomnia, and let the investigators know about it.
What do you think...?

[safetypee]

at, ref #536; the HF issues with the FO in this and other accidents is very important and warrants some speculative discussion (Machinbird also, #540). However, without evidence the assertion about the crew’s mental state (belief) and the reasons for it cannot be justified.

The apparent failure of the ‘monitoring’ crew member to intervene is often cited as a factor in accidents. If considered in isolation and with hindsight, this could be labeled as a root cause - as ‘deviant behavior’, which is not necessarily appropriate.
To continue discussion on this aspect, but independently of this accident and the emotion associated with this thread, I have started a new thread - http://www.pprune.org/safety-crm-qa-emergency-response-planning/478368-monitoring-intervention.html#post7050481

[Machinbird]

Stick_Rudder, I'm not an authority on the subject, but family members might not know of its significance if Parasomnia events had occurred, and that would only be an indicator of a tendency. My own event has not been repeated to the best of my knowledge in a span of almost 50 years.

As to whether it was possible to have a pilot function to that level of performance that the Captain exhibited, I guess if you can have a nightmare about an event, you can have a parasomnia event given the right circumstances. The Captain exhibited way too much focus on a single path of action. The conscious mind is exploring alternatives.

[drive73]

Step,

He can say he's logged 50000 hours in the space shuttle, doesn't mean it's true.

He has slandered the dead captain multiple times in his posts with zero evidence in the accident report of any berating during this flight. Why would somebody who didn't have an emotional connection with this event or person outright lie and have high enough emotions to contradict the accident report? More than meets they eye hear. Hence my jilted first officer deductions. Unless you believe this capt willfully caused this accident during a power driven, screaming at the fo, extremely high fast approach. But the accident report refutes that premises.

[cyrilroy21]

Air India Ltd did not provide mandatory cockpit training to most of its international flight crew for over two years, violating regulatory norms and which could have potentially led to the Air India Express crash in 2010, according to an internal email. The inquiry into the flight IX-812 crash in Mangalore, on May 2010 which killed 158 people, pointed to poor crew resource management (CRM) as a key reason for the worst crash India had seen in a decade.

CRM training for pilots is primarily meant to improve air safety and focuses on interpersonal communication, leadership and decision making. It was started in 1979 internationally after it was found that most aviation accidents occurred because of human error. In India, CRM training is to be done for all pilots every year, according to the Directorate General of Civil Aviation (DGCA), according to a Mint report by Tarun Shukla.

“The court of inquiry into the Mangalore accident has published its report, wherein inadequate CRM has played a significant role,” AS Soman, Executive Director of Operations and Customer Service, Air India, wrote in a June 3, 2011 email to then airline chairman Arvind Jadhav. “A comparison of the tables in the report forwarded herewith clearly indicates that practically no CRM training was conducted in the operations department between 2007 and 2010.”

The court of inquiry report directly attributes the crash to poor CRM and a lack of “assertive training” for the first officer of flight IX-812, who did not challenge any of the errors made by the commanding pilot. “...the CVR (cockpit voice recorder) recordings reveal low standards of CRM by both pilots... The pilots were not working in harmony...” the email said, quoting the crash report.

Air India Express, the low-cost international arm of Air India, did not have a safety or a training department, and used Air India’s facilities, calling into question if the crew that operated the IX-812 flight complied with all the requirements of the aviation regulator, said Mohan Ranganathan, an Air Safety Expert and Member of the government-appointed Civil Aviation Safety Advisory Council, which was established after the Mangalore crash to review air safety.

“None of the mandatory training has ever been stopped,” an Air India spokesman said.

Ranganathan said the email points out that DGCA’s rules for scheduled transportation was not followed. “How did this also pass muster with the IATA-certified audits?” the international benchmark for safety among airlines, he asked.

The email also said there were indications that records were potentially fudged to portray better results. “Use of registers with no control over entries show instances of mismatching signatures (especially for training captains and senior executives), overwritten dates, altered entries and logging of navigation classes as CRM classes,” the email said. “No CRM manuals were issued to crew. One manual with (outdated) first generation CRM material (was) maintained only for audit purposes.”

International and local audits were conducted recently and “we have not been found wanting in any training”, the Air India spokesman said.

“This is another example of a farce being played out by DGCA when they do safety audits. Every accident India has witnessed since 2000 has identified CRM failure as a major factor,” Ranganathan added. “The two fatal crashes involved the Air India family—Alliance Air (in 2000) and Air India Express. Stating that DGCA has given them (Air India) a clean chit cuts no ice.” He said he was curious why Soman, as the head of operations and safety, allowed such a serious lapse to take place during his tenure.

An Air India official said that the airline was not inferior in any training aspect and dismissed the CRM findings as “petty political bickering between two factions within the airline”.

Air India Express flies typically to West Asia from southern Indian states. It is a subsidiary of Air India run under Air India Charters Ltd and operates 175 international flights and 15 domestic flights every week. The carrier ferried 2.5 million passengers in the year ended March 2011. An audit done last year by DGCA had found that Air India Express did not have a human resources department and needed to lean upon parent Air India for nearly everything, even in situations that required quick decisions, resulting in operational handicaps, Mint reported on 5 December.

“It was surprising to note that even (for) the photocopier, (Air India Express) was dependent on Air India,” the DGCA report said, warning that letters exchanged between Air India and Air India Express indicated “total interference in the working of Air India Charters, which is detrimental to the overall progress and directly infringes on air safety”.

The carrier did not have either a DGCA-approved chief of safety or deputy chief of safety. “The airline seems to have purposely overlooked some deficiencies,” the report had said, citing at least three instances where a pilot made grave errors but was promoted to fly bigger aircraft instead of being penalised.



Travel Biz Monitor :: Air India evaded mandatory cockpit training for pilots (http://www.travelbizmonitor.com/air-india-evaded-mandatory-cockpit-training-for-pilots-15833)

[cyrilroy21]

Top brass from the aviation industry have been named as accused in a complaint filed in the court of the Judicial Magistrate First Class (JMFC) II at Mangalore in connection with the crash of flight IX 812 from Dubai on May 22, 2010 in which 158 lives were lost.


The complaint filed by the 812 Foundation, a trust formed by advocates Yeshwanth Shenoy and Nayana Pai with Triveni Kodkany who lost her mother and husband in the crash to help the victims and bring the guilty to book, names top officials of Air India Limited, Airport Authority of India (AAI) and the Directorate General of Civil Aviation (DGCA).

It alleges that Capt Glusica, who was the commander of flight IX 812, did not meet the eligibility criteria for a Foreign Air Crew Temporary Authorisation (FATA) licence. The DGCA, which is primarily responsible for issuing licences, allegedly failed to verify the Airline Transport Pilot Licence (ATPL) and log book of the pilot-in-command before issuing the FATA licence.

Capt Glusica obtained his B-737-800/900 endorsement on May 22, 2008 and joined Air India Express (AIE) (AIE) on December 15, 2008 during which period he did not fly this type of aircraft. When AIE applied for his FATA, he did not have the 100 hrs on type (B-737-800). Despite this, the DGCA approved the FATA violating section 6, Part V & Schedule II of Aircraft Rules, 1937.

The complaint also maintains that Air India did not provide mandatory cockpit training to most of its international flight crew for over two years, violating regulatory norms. DGCA circular No. 8 of 2009 and CAR mandates Crew Resource Management (CRM) training every year. The Court of Inquiry (COI) report clearly points out inadequate CRM as having played a significant role in the accident. This is acknowledged in an e-mail dated June 3, 2011, written by A S Soman, executive director (operations and customer service) addressed to Arvind Jadhav, former CMD, Air India Express.


Lapses at bajpe airport
The complaint quotes a writ petition filed in the Karnataka High Court in 1997 in which it was stated, “Minimum area for stop way is clearly insufficient. The runway distance itself is about 2,400 metres, and even if the area left is most cautiously utilised, what is left is only about 300 metres on each end of the runway. By the prescribed standard, this is far below the required distance needed for an emergency stop way.

“Therefore, the chances of an aircraft that has achieved the decision speed forcing an emergency stop are critically minimised, and the inevitable consequence could be that the plane would come crashing down the hill side from a height of 80-100 metres on either side of the proposed runway.” The Mangalore crash replicated this pattern.

It is further alleged that markings on the runway are wrong. The markings show the availability of 2000 feet of runway when there was actually none available. It is exactly at this point that the pilot made the decision to take off again


M (http://www.bangaloremirror.com/article/73/20120309201203092119318588a76db8/M%E2%80%99lore-crash-pilot-didn%E2%80%99t-meet-licence-criteria-Complaint.html)

[the_idealist]

Hello gentlemen, I accidentally started reading this thread lately. I'm posting this for those who have not read the report yet. These are just a bunch of organized facts that I put together from the report which may or maynot be of significance.
- Take-off, climb and cruise were normal. No briefing was heard in the CVR apart from the normal run through checklists, etc.
- The a/c etablished contact with the local ATC at reporting point IGAMA. At about 130 miles from the destination, the f/o contacted ATC requesting descent clearance from FL370, but was initially denied to ensure separation b/w other a/c (higher workload on ATC b/c of radar unfunctionality).
- The f/o reported position once they were on 80 DME, radial 287 MML, and the controller cleared the a/c to descend to 7000'. The descent was promptly initiated at 77 DME. Speedbrakes were deployed while descending through (approx.) FL290. When the f/o reported 25 DME MML, and the approach controller cleared the a/c to 2900', handling them over to the tower.
- At FL184, f/o requested to proceed directly to radial 338 MML, though there wasn't any established procedure to join the same, approaching MML from IGAMA on a radial 287, and the ATC agreed.
- They were later advised to join the VOR 10 DME arc for ILS rwy 24. A few seconds after setting QNH while passing 9500', the PF commands gear down.
- The a/c crossed the locliser, and recaptured it with a 'S' turn, possibly due to a higher speed, staying at flap 1. (SOP's state that localiser capture should be done at flaps 5 and appropriate speed).
- The a/c was fully established on the localiser and passed 5150' with an ROD of 1641 fpm.
- Attempting to capture the glideslope at 9.7 DME, the captain requested flap 10, but they were well above the speed limit for 10. They went for flap 15 at 4630' at 6.7 DME.
- At 3465' 4.3 ILS DME, they selected flap 25 at 167kts, retracting the speedbrakes to 'armed'.
-F/o: "It's too high" at 2.2 DME 2570' and 143 kt and ROD 1438 fpm and in a couple of seconds, the GPWS sounded: "TWENTY FIVE HUNDRED"
- At 2.0 DME 142 kt 2365', ROD was 1671 fpm when the f/o said "runway straight down".
- At 2300', the captain disengaged the a/p and took over controls, chasing the glideslope. In a few seconds, EGPWS aural "sink rate" warnings sound repeatedly.
- The captain had once again fully deployed the speedbrakes (at flaps 40 configuration) and at 1420' 1.0 ILS DME, the a/c was approaching rwy 24 at 155 kts with a ROD 3208 fpm, the pitch attitude being 9 degrees below the horizon. Repeated iterations of "sink rate" "pull up".
- At 550', 0.2 ILS DME, at a speed of 165 kts and ROD 2535 fpm, the speedbrakes were retracted.
- They passed the rwy threshold at 200' and 164 kt(the normal Vref being 144 kt for this configuration). The Flap Load Relief ran the flaps to 30, and then back to 40 when the speed decayed below 158 kt; this extension during the flare, led to a prolonged float on the runway delaying the touchdown.
- The right wheel touched and bounced at 4500', then finally touching down at about 5200' from the beginning of rwy 24 which has a length of 8033' paved surface.
- The autobrake was set 2 and the captain had opened the reversers. Not happy with the gradual braking, the captain applied manual braking, after which the aircraft started decelerating much faster. The reversers remained fully deployed upto about 10 seconds, and N1 on both engines 75.8%.
- After that, the captain stowed the reversers and advanced the thrust levers to take-off position. The engines chased the TL position and raced to take off power, but at this point, only about 800' of the rwy length was remaining. The configuration horn goes off, upto the end of the CVR recording.
- At the end of the paved surface of rwy 24, there is a downward slope which they call a sand arrerstor bed that lies b/w the rwy 06 threshold and the rwy 06 localiser antennae. To balance the height of the antennae to that of the rwy, they are mounted on a concrete structure. Spotting this, the crew tried to maneuver the a/c away from the structure by veering off a bit to the left of the centerine, but the right starboard wing impacted the structure and a part of the wing along with engine no.2 was ripped off the a/c.
- EGPWS sounded repeatedly "sink rate" "pull up".
- The last aural warning was "bank angle".

Conclusion was that had the maximum manual braking pressure inputs commanded along with the reversers fully deployed, the a/c could have been brought to a full stop on the paved surface.

[captjns]

Conclusion was that had the maximum manual braking pressure inputs commanded along with the reversers fully deployed, the a/c could have been brought to a full stop on the paved surface.

I guess the point is being missed here. It's not the auto-brake setting that would have saved the day, but alternative actions that could have been taken to prevent this unnecessary disaster.

Here's a better conclusion. A 360 or delayed vectors to lose altitude to regain the proper descent profile.

Here's another better conclusion. Break off the approach when unstable.

[BOAC]

Assuming QNH, and the airport is around 400'

flap 15 at 4630' at 6.7 DME.

At 3465' 4.3 ILS DME,

at 2.2 DME 2570' and 143 kt and ROD 1438 fpm

At 2.0 DME 142 kt 2365', ROD was 1671 fpm

at 1420' 1.0 ILS DME, the a/c was approaching rwy 24 at 155 kts with a ROD 3208 fpm,

At 550', 0.2 ILS DME, at a speed of 165 kts and ROD 2535 fpm,

Here's another better conclusion. Break off the approach when unstable. "OK Blogs - need any more clues"? How on earth do you prevent this? This is so basic.

[the_idealist]

Actually, by using the word 'conclusion', maybe I gave you the wrong message. Ofcourse, the report is very, very clear about the cause as "the Captain had continued with the faulty approach and landing, possibly due to incorrect assessment of his own ability to pull off a safe landing."

Direct cause stated in the report:
The Court of Inquiry determines that cause of this accident was the
Captain’s failure to discontinue the ‘unstabilised approach’ and his
persistence in continuing with the landing, despite three calls from the First
Officer to ‘go around’ and a number of warnings from EGPWS.

The point was that, even after touching down halfaway after a highly unstablised final approach, there was one last good chance that could have
averted the fatal overshoot plunging down the hill, that is, max manual braking plus detent reverse thrust all the way to a full stop. In no way does that justify not executing a go around.

[Lonewolf_50]

The Court of Inquiry determines that cause of this accident was
the Captain’s failure to discontinue the ‘unstabilised approach’ and his persistence in continuing with the landing, despite three calls from the First Officer to ‘go around’ and a number of warnings from EGPWS.
...
In no way does that justify not executing a go around.
While this has been mentioned before, for the benefit of our non pilot readers it might be worth reviewing a "back to basics" imperative.

Way back when dirt was more or less recent, and I taught folks who had never flown before how to fly and how to land, we first taught them the "waveoff" (go around) procedure before we taught them landing.

Standard teaching point, and point of discussion in a few of the briefings, was roughly as follows:

"No approach, made by your or by me, is so good that it can't be waved off. Many approaches or runway conditions call for a wave off at some point. So, do it and take another shot at that perfect approach and landing.

If you wave it off, you get another chance at a good landing. If you don't, one day you'll wish you had."

The only approach you can't wave off that I can think of is a dead stick approach with no engine(s), or an engine (or set of engines) with rollback/restricted power.

Somewhere in his early training, I suspect the Captain on this flight was likewise taught and trained. One forgets this basic lesson at one's peril. It makes me ill to see that the FO called for go around three times and the Captain still made the play for the runway from an unstabilized approach.

Two issues that the organization has to address:

1. Cockpit gradient (and a few other CRM bits) and
2. Corporate culture.

Will the company peel back the layers of the onion far enough to understand why the Captain believed he had to make a "varsity play" for the runway?