Air India Runway Excursion

[vilas]

DaveReidUK

If you're talking about B737 my point is it is a compromised aircraft. It always had some problem or the other and needed work arounds. Like the STS, MCAS, higher speeds. That makes it not an easy aircraft to fly.

[Airbubba]

It's been a long time but it seems like the legacy Airbus aircraft like the A306 and A310 also will not allow the reversers to deploy if the throttles are out of idle. Isn't this the case with most transport aircraft with moving throttles and reversers?

[vilas]

The design in A300b4 and A310 being wide body cockpit was not cramped like B737. That makes all the difference. There was never an issue.

[Stick Flying]

If you're talking about B737 my point is it is a compromised aircraft. It always had some problem or the other and needed work arounds. Like the STS, MCAS, higher speeds. That makes it not an easy aircraft to fly.
Rubbish again. The B737 MAX variants had a design oversight that allowed faulty component's to put the aircraft into a compromised situation. There is in fact a QRH procedure for all 737 variants that could possibly have prevented both accidents. But that is it. The aircraft is in no way compromised as an entity. The higher speeds issue you spout off about are laughable.

[Airbubba]

The design in A300b4 and A310 being wide body cockpit was not cramped like B737. That makes all the difference.

Huh? Needing the throttles in idle before using reverse is not an issue in a widebody but it is on a 737? You've lost me there... :confused:

[Stick Flying]

Airbubba,
I think vilas is off on some harebrained conspiracy theory. Nothing in the Air India Express accident (currently available as fact) backs up their theory but that doesn't stop the constant whining.

[parkfell]

Vilas

Are you, or have you ever been type rated on the B737-800 & flown this particular -800NG variant as a line flying pilot?

[FlyingStone]

If you're talking about B737 my point is it is a compromised aircraft. It always had some problem or the other and needed work arounds. Like the STS, MCAS, higher speeds. That makes it not an easy aircraft to fly.

Every aircraft is a compromise in some way.

Airbus didn't have the technology to have interconnected sidesticks in 1980s when A320 was developed, but Gulfstream has proven the technology is here today. So why does a training captain on the state-of-the-art A350 have to shift their view almost 90 degrees left/right and slightly down to see what inputs the student is making with their sidestick? Surely it has nothing to do with compromise and type rating/CCQ fleet commonality​​​​​​?
​

[gottofly]

Once the thrust levers are in idle, you kind of slide your hand down and pull up the reverser levers.

If you remove your hand without having aft pressure and try to just pull up reverser levers, there is a small possibility of not being able to deploy if thrust lever moves ahead. That can be a disadvantage as reverse thrust is most effective at higher speeds but again we don’t know if that has any relevance (yet) in this accident.

[Airbubba]

Reported Covid-19 outbreak among the officials responding to the scene.

Kerala Chief Minister In Self-Isolation After 22 Officials Test Positive Kerala plane crash: The Air India Express plane came with 184 passengers from Dubai under the centre's Vande Bharat Mission that expatriates Indians stranded abroad amid the COVID-19 pandemic
Reported by Sneha Mary Koshy (https://www.ndtv.com/topic/sneha-mary-koshy), Edited by Debanish Achom (https://www.ndtv.com/topic/debanish-achom) (with inputs from PTI)Updated: August 14, 2020 5:16 pm IST

Thiruvananthapuram: Twenty-two officials who responded to the plane crash in Kerala last week have tested positive for coronavirus, the Malappuram medical officer told NDTV. The Air India Express plane came with 184 passengers from Dubai under the centre's Vande Bharat Mission that expatriates Indians stranded abroad amid the COVID-19 pandemic.

"They were quarantined after the rescue operations at the plane crash site ended. Most of them were on location," the district medical officer said. Some 600 people including locals were asked to go into quarantine the very next day by health officials.

The district medical officer's team is undertaking risk assessment and more details are awaited.

Kerala Governor Arif Mohammed Khan, Chief Minister Pinarayi Vijayan, senior ministers including state Health Minister KK Shailaja and senior bureaucrats had visited the crash site on August 8. Civil Aviation Minister Hardeep Singh Puri and junior foreign minister V Muraleedharan had also visited the crash site and held meetings.

"At the airport, I hardly had any direct contact with the officials concerned. However, I have been in self-isolation since I returned to Delhi, primarily because I also visited Munnar, the area affected by landslide and there social distancing was not possible," Mr Muraleedharan told NDTV.

The Chief Minister and eight others have gone into self-quarantine. The others include EP Jayarajan, KK Shailaja, VS Sunilkumar, Ramachandran Kadannappalli, AK Saseendran, TP Ramakrishnan, Vishwas Mehta and Loknath Behra. The Local Self Government Minister AC Moideen and Minorities Welfare Minister KT Jaleel were already present in the area.

All on board the crashed aircraft were evacuated after a nearly three-hour operation. Eighteen people including both the pilots died in the crash and more than 150 were injured. All survivors were admitted to various hospitals and were also tested for COVID-19.


https://www.ndtv.com/india-news/kerala-malappuram-officials-involved-in-rescue-ops-after-kozhikode-plane-crash-test-positive-for-coronavirus-2279468

[C310driver]

Airbubba,
I think vilas is off on some harebrained conspiracy theory. Nothing in the Air India Express accident (currently available as fact) backs up their theory but that doesn't stop the constant whining.

Spot on! Trying to fault a MAX for MCAS is one thing, but trying to fault the NG for what is potentially a non issue is something else. As far as I know, even the Airbus family requires the thrust levers to be in idle before the reverse thrust levers can be raised. I seem to vaguely recall that the cause of the above safety report was to due the pilot wearing long sleeved shirts, where the cuff would potentially push the thrust lever/s forward while reaching for the reverse thrust levers. It is really a non event, because I’ve flown with a lot of guys who wear long sleeved clothing, but never have I ever had someone inadvertently do that.

The lack of a proper technique in operating the controls or a wrong seat position is not Boeing’s fault. Especially as the 737 rated guys here never have had issues with this.

Stop trying to find problems where there are none. That thrust lever design has been used since the original 737.

[George Glass]

DaveReidUK

If you're talking about B737 my point is it is a compromised aircraft. It always had some problem or the other and needed work arounds. Like the STS, MCAS, higher speeds. That makes it not an easy aircraft to fly.

Absolute drivel.
There has been more nonsense written about the B737 since the MCAS incidents than there has about the faking of the landing on the Moon.
The B737NG is one of the safest aircraft ever built. Period.
Accidents like these keep happening for reasons completely unrelated to any hypothetical design flaws in the aircraft. See previous post.
Why people feel compelled to comment on issues they clearly know nothing about is a mystery.

[tdracer]

Stop trying to find problems where there are none. That thrust lever design has been used since the original 737.

Actually, the mechanical interlock requiring the throttle to be at idle before you can raise the reverse piggyback lever is a design feature on every Boeing Commercial airliner ever built - 707 to 787 all have the same feature (although the detailed implementation varies a bit).
The motion to deploy the reversers is to pull back and up - how much brain power does it take to make the 'pull back' part to insure the lever is at the idle stop?

As for the vilas contention that the 737NG is an inherently unsafe "compromised" aircraft - as of 2018 (the latest stats I can find on-line), the 737NG hull loss and fatal hull loss rates are marginally better than the A320 series - probably not enough to be statistically significant, but reading some of the drivel that gets posted here you'd think the 737NG was an order of magnitude worse than the A320.

[George Glass]

Actually, the mechanical interlock requiring the throttle to be at idle before you can raise the reverse piggyback lever is a design feature on every Boeing Commercial airliner ever built - 707 to 787 all have the same feature (although the detailed implementation varies a bit).
The motion to deploy the reversers is to pull back and up - how much brain power does it take to make the 'pull back' part to insure the lever is at the idle stop?

In 29 years of flying Boeing aircraft I’ve never heard of or seen anybody have a problem.

[C310driver]

In addition to slacks, he probably needs a military grade helmet to protect himself from the backlash he’s receiving from all the BS that’s he’s constantly spewing on this thread.

Don't you love it when somebody tries to post ‘homemade facts’ about something they don’t have a clue about?

[vilas]

Hey guys! The discussion is in in the aftermath of an accident but not in defence of the accident or even the earlier accident or some conspiracy theory. I was a training Capt on B747 and I enjoyed every minute of it. I have not flown B737 but after the MAX fiasco what I read about 737 from it's evolution to MAX series didn't inspire much confidence. Well some people will like what they fly and it's their right. Some may defend Max also. But the aircraft has created a dubious history. If a QRH procedure was the solution then it doesn't take so long to print a QRH and it won't undergo such a massive look over and still not able to get in the air. So thank you for the information. I am not emotionally involved one way or the other.

[Porto Pete]

I have a decent amount of time on the NG. I have never seen or heard of this "problem" either. Close thrust levers during touch down, it's pretty much basics of flying any type is it not?

I did very occasionally, I think twice in ten years, have one thrust reverser fail to deploy during landing but then operate normally when recycled during taxi. Which is something I can't say I have seen on the A320 which has the same engine type.

[arf23]

There are similarities between this crash and the Pakistan Intl Airlines A320, which is pilots doing non-stabilised landings. The problem is most likely airline pressure and a small element of SkyGod mentality - if they get away with it, and they do 99.9% of the time, they are heroes for getting the job done.

The only solution really is for the insurers to insist on flight safety monitoring (FDM) by a Safety Department, and re-training for crews that do not follow SOPs, especially stabilzed approaches. This would also have caught the Indian(?) pilot who always landed on the nose landing gear. In addition EASA and others shouldn't allow carriers to operate until they have a totally functional FDM program.

[maddog2872]

Isn't the visibility requirement for VOR 28 more than 2km? Why even attempt the first approach? They could have entered a hold, or did the straight in ILS10.

[gottofly]

That is correct, 2400 mts required. Reported in Metal was 2000 -RA, tempo 1500 TSRA.
Before starting the VOR 28 approach, possibly ATC advised above 2400 mts vis and due to favorable winds the pilots maybe decided to shoot the VOR 28 .Thereafter vis reduced again and they must have discontinued to try the ILS 10 . Also possible ATC advised them about the ATR which landed 10 after the 28 approach..
We will know more once the DFDR is decoded. Till then it’s all speculation.

[gearlever]

The AAIB.
Why is BOEING not involved or any other non Indian partner?

Air Safety Experts Think Investigation Is A Cover-up Exercise (https://www.outlookindia.com/website/story/india-news-air-india-express-plane-crash-air-safety-experts-think-the-investigation-is-a-cover-up-exercise/358707)

Five-member committee to investigate Air India (https://www.cnbctv18.com/aviation/five-member-committee-to-investigate-air-india-express-accident-submit-report-in-5-months-6631411.htm)

[vilas]

There was news that someone from Boeing would be coming.

[vilas]

Isn't the visibility requirement for VOR 28 more than 2km? Why even attempt the first approach? They could have entered a hold, or did the straight in ILS10.
RW28 has an ILS.

[RetiredBA/BY]

Please explain these problems. In 7000 hours on type, -200s and 300s I never noticed them.
What did I miss ?

[vilas]

Well whatever I said was based on articles like the one I posted it's by NASA ASRS. you can read it. B737 is made from B707 fuselage to use same dyes, casts etc. to save cost it has a low wing which helped that time for loading/unloading, Engine maintenance without ladder etc but it was misfit for high bypass bigger fan engine era. It's main problem. It had uncommanded rudder problem Boeing knew there's a problem but like MAX.only reacted after two fatal accidents in the US. Then why was STS required? I didn't find any in A300, A310 or B747. So there's an issue of instability at high pitch. Then continuous stretch from 100 series so to keep tail clearence takeoff and approach speeds are higher than say A320. To cater for high bypass bigger fan Engines hamster shaped intakes. Then it was not enough for max Engines. Boeing wanted to make a new aircaft but not to lose customers like SW and AA they launched Max and rest is history. Boeing had 757 perhaps they would have been better off modifying that. I have posted video of 737 max10 where on the takeoff run the main gear has to extend. So these are not exactly innovations but work arounds. Max has been severely criticized by people working on it as designed by monkeys and made by donkeys something like that. It's an aircraft to which only FAA certification may not be enough other authorities will do their own. It has threatened the credibility of both Boeing and FAA. I am not sure if it ever happened before.

[DaveReidUK]

There was news that someone from Boeing would be coming.

As the State of Manufacture, the USA will as a matter of course be accredited to the investigation, and that role will be delegated to the NTSB.

An accredited State is in turn entitled to appoint one or more advisers, which will almost inevitably include the manufacturer.

[Airbubba]

Max has been severely criticized by people working on it as designed by monkeys and made by donkeys something like that.

Traditionally the Boeings are designed by geniuses to be flown by idiots and the Airbuses, well, vice versa.

Boeing pilots break ground and fly into the wind. Airbus pilots do the opposite.

Like you and a couple of other folks here, I've flown both brands.

[AuroraAustralis]

The recent PIA A320 accident. Why wasn't that caused by the aircraft vs pilots? That's your theory right? Aircraft type causes accidents...
That's the only crash involving the A320 in 4 years. If the A320 had 8 fatal accidents and 7 landing hull losses in the past 2 years (like the 737), even if all were blatant pilot error, it would not be illogical for some people to raise concerns.

Absolute drivel. There has been more nonsense written about the B737 since the MCAS incidents than there has about the faking of the landing on the Moon.
Seems like anytime after these recent accidents (UTAir, Xiamen Air, Miami Air, Pegasus, India Express, etc), if someone remotely raises questions on the 737 they are met with automatic rage at the mere suggestion; this attitude is not compatible with aviation safety. Reminds me of US427 in which Boeing, before the final report, blamed wake turbulence from a 727 as the cause, reality was different. People who bring airplane type into discussion are instantly labeled as "fanboys" (fanboys of who? Embraer? Airbus? McDonnell Douglas? non-737 Boeings? because none of those combined had any overrun hull losses in the past year).

Then someone will bring up the stats from 2018, which correctly states that the NG and the 320's hull loss rate was roughly equal at the time. But since 2018, the NG has had more major runway excursions than the 320 has had in its entire 32 year service; yes I realize most/all of them are pilot error and stats can "lie", it doesn't mean we should automatically dismiss those that bring aircraft type into the discussion.

Someone always brings up "the NG is the safest aircraft", which is demonstrably false. Yes, I'll take 0.08 per million over a car anyday, but there are types out there with 20+ million flight hours without a single fatal accident, operating in much more challenging conditions (E145, A319), repeating a statement over and over does not make it true.

Now regarding the accident, if it turns out to be true that a go around was attempted at the last moment, it would sadly be an exact repeat of the 2010 Air India Express accident. A tragic loss for all involved, and best wishes to the first responders and families.

[gearlever]

Airbubba

Me too, but don't understand your comment.:rolleyes:

[maddog2872]

RW28 has an ILS.
I believe it was inoperative.

​​​

[George Glass]

AuroraAustralis

If you look at the stats for the US , Europe, Canada Japan, Australia, New Zealand etc the accident rate for the B737NG is approximately zero.
Now why would that be?

[Lookleft]

Just off the top of my head: overrun in the Caribbean by a US airline, fatal in Amsterdaqm due to RA failure, overrun in the Mediterranean in similar circumstances to Air India. Or are you referring to Anglo-Saxon never made mistake because of eugenics pilots?

[George Glass]

I have flown with just about every race , religion, gender ( including transgender) and never had a problem with any of them. That’s because I have had the good fortune of only flying for First World airlines with competent training systems, strong regulators and a long history of a serious commitment to safety. I’ve flown in so-called “developing” countries and the reasons for their poor safety records is pretty obvious. Nothing to do with race. And very little to do with the aircraft either. An investigation that seeks to shift blame onto a fabricated problem with the B737NG will be futile. But it will probably happen. To save face. And round and round we go......

[vilas]

If you are trying to suggest Europeans and Americans have better flying skills if for arguments sake we agree then it proves what I said "It doesn't make it an easy aircaft to fly". ​​​​​​ There was a documentary by Al Zajeera on making of B737 800 in which Boeing workers had made serious allegations on NG fuselage which breaks on RW excursions. As you can see All I have said about 737 is not cooked up by me but said or written by US citizens. Pilots who feels MAX just needed QRH procedure need to tell it to the US congressional committee. It's valuable evidence.
​

[George Glass]

OK

Sometimes you just have back away in the face of stupidity. According to Wikipedia 10580 B737s have been built. 7061 NGs. The most popular, reliable and profitable aircraft ever built. I , like thousands of others , have flown the aircraft in horrendous conditions with complete confidence. With a HUD you can fly zero visibility approaches ,perfectly on slope ,with airspeed fluctuating by only a couple of knots because of the very effective speed carnet.

[FlyingStone]

If you are trying to suggest Europeans and Americans have better flying skills if for arguments sake we agree then it proves what I said "It doesn't make it an easy aircaft to fly".

If airlines in Europe can safely operate the 737s day in and day out with 150/200h cadets in the RHS, then there's really no excuse.

Look at the UTAir 737-800 overrun in Sochi in 2018. Crew (13,000 hours each) disregarded both predictive and reactive windshear warnings, crossed the threshold at Vref+23. Aircraft touched down 1285m from runway threshold and reverser were deployed about 20s later when the aircraft was 2690m from the threshold (LDA 2895m).

How can any manufacturer improve their aircraft to prevent this kind of events, which is how a lot of 737-800 overruns look like?

[vilas]

George Glass

You didn't answer any of the points raised by non Asians except calling them stupid and instead provided sales figures. MAX had orders of almost half of all 737 sales before it was grounded. 737 when it came was better than what was available and once airlines go for a brand they are reluctant to change Boeing kept offering tinkered versions which suited any requirement and nothing much was available till the entry of A320. Then they had to plan for the future but the buying MD, 787 initial losses prevented that. Instead they tried to drag 737 for one last time which delivered Boeing a body blow. How can MCAS be fitted without redundancy when another AOA sensor was available beats me.

[tdracer]

There was a documentary by Al Zajeera on making of B737 800 in which Boeing workers had made serious allegations on NG fuselage which breaks on RW excursions.
​
You do know that the 737 fuselage isn't actually made by Boeing, right? Hasn't been for about 20 years (it's made by Spirit in Wichita).
I wonder how many aircraft flying around today can go down a 50 ft. embankment without breaking the fuselage...

Hull loss accident rates (through 2018):
737NG (-6/7/8/900) - hull loss 0.19, fatal hull loss 0.08
A320 series (A318/19/20/21) - hull loss 0.19, fatal hull loss 0.09
(numbers are per million departures)
Now, those numbers have probably changed in the last couple years, but are you honestly suggesting that an aircraft that has been in service for over two decades somehow became inherently unsafe in the last two years?

[vilas]

I consider you as authority on Boeing. The subject I am discussing is not my personal crusade. Also it's not in relation to the recent AI crash. By 50ft embankment if you are referring to the Indian crash then it may be a late go around attempt that failed in that case it's going to break up. But the Bali and one more sea landing also it broke up. As you know in Hudson incident it was very hard impact but aircaft remained in one piece off course was written off later. Outsourcing is ok but who bears the overall responsibility? Al Jazeera documentary if true was bad reflection. There again below why only Boeing? You are the best person to explain.
https://www.google.com/amp/s/www.cnbc.com/amp/2020/07/24/faa-warns-of-possible-engine-shutdowns-in-safety-directive-on-older-boeing-737-jets.html

[parkfell]

If pilots operate iaw the way in which the manufactures suggests
[do what it says on the tin], the accident rate historically would be far less.
Just put the 737MAX to one side for the moment, and think about two accidents below:

Would the Air France 447 accident have occurred if it had been a Boeing : would the Turkish 1951 have stalled at Amsterdam had it been an Airbus?

Each type has its strong points, the weak points are invariably the pilots....

[vilas]

tdracer

The words I used was not unsafe but compromised and not an easy aircaft to handle.

[Chris2303]

You do know that the 737 fuselage isn't actually made by Boeing, right? Hasn't been for about 20 years (it's made by Spirit in Wichita).

Designed by ?????

[DaveReidUK]

It's becoming increasingly hard to avoid the conclusion that this thread has run its course ...

[AuroraAustralis]

There was a documentary by Al Zajeera on making of B737 800 in which Boeing workers had made serious allegations on NG fuselage which breaks on RW excursions. ​

I've seen the documentary. It alleges that manufacturing defects are to blame to the break ups; I don't think that is the case, although those complaints should be heard and investigated, but it may be simply the way the 737 fuselage was designed in an era of different standards. I agree with the other posters that it is not fair to expect IX1344 to survive in one piece after going off the "cliff" (see TACA in 2008 or Pegasus this year). But take a look at history and there is an apparent trend. Compare the photos of CFIT short of runway accidents: AIRES 8250 (737-700, hit 260ft short, broke into 3), with Air Canada 624 (A320, hit 740ft short, smashed through ILS equipment and powerline, traveled up embankment, remained intact). Or ditching accidents: Lion Air 904 (737-800, broke into 2), Air Niugini 73 (737-800, broke into 2), with US Airways 1549 (A320, remained intact). Or hard impact on grass: Turkish 1951 (737-800, broke into 3) with Ural 178 (A321, remained intact). This is not to mention American 331, Caribbean 523, and UTair 579, all 737-800s which broke into 2 or 3 after traveling over relatively flat ground. The 777 also seems to fare well. BA38, OZ214, and EK521 all remained intact despite hard impacts. So perhaps its not Boeing to blame, but grandfathering of older design standards. But enough with anecdotal evidence; I've read somewhere (don't remember the source) that the 737 is a 5G fuselage, while the A320 is a 16G fuselage, can someone with expertise in this area shed light on this claim?

If you look at the stats for the US , Europe, Canada Japan, Australia, New Zealand etc the accident rate for the B737NG is approximately zero.
7 (in the region listed, 6 if IST is not counted as Europe) does not equal 0. But you have a good point; that developed countries indeed have a lower accident rate. Sadly, passengers around the world don't get to cherry pick 6 countries to fly out of. Passengers in India can't simply decide to fly Ryanair or ANA on a domestic flight, and in a country with 0 A320 overruns, despite vastly outnumbering 737s; would a nervous flier pick Air India Express, or Indigo/GoAir/Vistara, looking at the accident history? Same goes for China, where there has never been a A320 hull loss, I believe, despite the type being almost half the fleet. We can't just cherry pick the "best" countries; after the MAX accidents, so many people stated that SWA, UAL, and AAL never had a problem, the MAX must be fine, not realizing that the 3 airlines only adds up to 16% of the fleet (not to mention some pilots of SWA and AAL weren't happy with it either); and that no other mainline commercial jet designed in the 21st century has yet to have fatal accident. PS: the instant dismissal of ASRS reports in this thread is alarming.

[George Glass]

Ever flown in Indonesia?
If you have I doubt you would think that.

[FlightDetent]

Same goes for China, where there has never been a A320 hull loss, I believe, despite the type being almost half the fleet. The aviation and piloting in China are strongly regulated and because discipline goes a long way, the results show. The people are failable in a similar fashion to anywhere else (already witnessed despite my short exposure pre-COVID) and thus procedures had been designed to guard against our own selves.

Enter stage: A punitive non-go-around policy. As opposed to a non-punitive go-around policy. Self-explanatory if you read its name right.

I also feel the -800 has an eyebrowraisingly high cover page presence with overruns. But any overrun could have been avoided by going around. More detail from a recommended reading Why and When to Perform a Go-Around Maneuver (page 5, Boeing's AERO 2014-II) (https://www.boeing.com/commercial/aeromagazine/articles/2014_q2/pdf/AERO_2014q2.pdf) Do not blame the airplane for being less pilot-proof, before evaluating properly the picture in the mirror.

https://cimg3.ibsrv.net/gimg/pprune.org-vbulletin/672x833/smippet_aero_e08bf4493cfec756daa17b7bddf221fbc10a4fcc.png

Some old thread here: https://www.pprune.org/tech-log/599762-737-runway-overruns-3.html#post9922361

[WHBM]

If you look at the stats for the US , Europe, Canada Japan, Australia, New Zealand etc the accident rate for the B737NG is approximately zero.
Let's hand pick our countries shall we ? Including New Zealand, where they gave up the few they had a while back.

In the last two years alone Aug 2018 to Aug 2020 there have been on average three 737-800 aircraft destroyed, departing the runway on landing, PER YEAR. That's one every 18 weeks. I'm not counting any other phase of flight, or things like the Ukrainian shoot-down, or the Max. Let's list them.

Aug 2018. Xiamen at Manila
Sep 2018. UTAir at Sochi
Sep 2018. Air Niugini in New Guinea
May 2019. Miami Air at Jacksonville
Feb 2020. Pegasus at Izmir
Aug 2020. Air India at Kozhikode

If I was an hull loss insurance agent, working on averages, I would be very alerted. It's more than an outlier.

[vilas]

https://news.aviation-safety.net/2020/03/07/faa-proposes-19-68-million-civil-penalty-against-boeing/#:~:text=The%20U.S.%20Department%20of%20Transportation's,not %20approved%20for%20that%20equipment.
Here B737 again as latest as this year. FAA fined Boeing 19.68million for fitting unsuitable equipment but settled for 1.25 million.

[DaveReidUK]

FAA fined Boeing 19.68million for fitting unsuitable equipment but settled for 1.25 million.

So was this "unsuitable" equipment subsequently removed from those hundreds of 737NGs ?

[misd-agin]

WHBM

Six A320's in the last 2.5 years. Four vs six isn't a huge difference. Yes, it's 50%. No, it's not that significant as to avoid one airplane vs. another.

[kiers]

I note that many small town airports in India don't have ATC radar ( you can check the article at economic times (.com) newspaper headline: "Many airports don't have approach radars" )

SO given that this runway excursion/overshoot was likely due to overshooting the landing touchdown by a significant distance, shouldn't Calicut ATC have done a verbal altitude check with the pilot to make sure the plane was properly tracking the right glide path at an proper altitude at a given DME reading? I think (having read the Indian DGCA report on the Mangalore Tabletop runway crash from 2010) i deduce that the Mangalore ATC were silent on altitude correction advisement many miles before even the pilot got near the tabletop. It's not like Calicut ATC would be burdened by too many flights, (probably handling 3-4 or 5 flights per day tops) and they know their own tabletop better than others so it seems feasible that they could've talked the pilot to a proper altitude and thereby avoid altitude errors despite having no radar.

PS this thread is SO big it scares me, so if i'm a little late to this thread or in a different area excuse me..

[Gordomac]

Not waded through all 16 pages but does AI have an "Imminent Over-run" drill ? Way back, on the tripots at LHR we did. Handling pilot called for it & non HP carried it out. Just involved shutting off fuel supply and pulling the fire handles & discharging. Worked if you recognised the imminency , called correctly and got what you wanted done, correctly.

[FlyingStone]

I note that many small town airports in India don't have ATC radar ( you can check the article at economic times (.com) newspaper: 5967775.cms );

A lot of regional airports in Europe don't have it as well.

SO given that this runway excursion/overshoot was likely due to overshooting the landing touchdown by a significant distance, shouldn't Calicut ATC have done a verbal altitude check with the pilot to make sure the plane was properly tracking the right glide path at an proper altitude at a given DME reading?

Most runway overruns tend to happen because the aircraft is too fast on approach and then bleeds the energy in a float over the runway as opposed to a firm touchdown in the touchdown zone (beginning of the runway). So the aircraft could be perfectly on profile for the entire approach and still overrun the runway.

[vilas]

True to some extent. Excess speed and long float has been the reason in most 737 overruns in India. But that wasn't the case in Mangalore accident which was never on profile.

[Herod]

If the crew can't work out altitude versus distance-to-go, it's not ATC's responsibility to monitor and warn them.

[parkfell]

.....given that this runway excursion/overshoot was likely due to overshooting the landing touchdown by a significant distance, shouldn't Calicut ATC have done a verbal altitude check with the pilot to make sure the plane was properly tracking the right glide path at an proper altitude at a given DME reading? ..

Unless the Airport Authority specifically ban landing with a tailwind on RW10, it was not the function in these particular circumstances for ATC to ‘interfere’ in the way you describe.

ATC could not foresee that the landing would be deep. They might well have expected a touchdown at the start of the touchdown zone given the prevailing circumstances.

So in a nutshell, NO.

[maddog2872]

Atc gives traffic separation. If a pilot can't navigate to a runway in 3d its not atcs fault, not one bit, radar or no radar.

[vilas]

Landing on RW10 with tailwind is pilot's decision. He is supposed to calculate the FLD before undertaking it. That's why you must only do what was briefed and not switch runways or type of approach unless in emergency situation.

[parkfell]

How do you know yet that a new briefing did not occur for RW10 ?
The CVR will reveal all, and hopefully a transcript of the salient aspects will be revealed.

Was diversion ever mentioned / discussed?

It could be of course that a “SKYGOD style” briefing in which case the FO was is “catch up” and simply was more or less a passenger for the second approach RW10.

[vilas]

I mentioned it in connection with ATC role.

[Roj approved]

Not waded through all 16 pages but does AI have an "Imminent Over-run" drill ? Way back, on the tripots at LHR we did. Handling pilot called for it & non HP carried it out. Just involved shutting off fuel supply and pulling the fire handles & discharging. Worked if you recognised the imminency , called correctly and got what you wanted done, correctly.

In these modern times the “Imminent Over-run” drill should be negated by SOP’s, the on board LDR Calculations, Stabilised Approaches and correct touch down zone at the correct speed, if you get over the runway and it’s not working out, a Go-Around should be initiated.

Lots of “Should’s”. Unfortunately, we see a little to often, that something has gone amiss, the approach/landing is pushed beyond the limits and we see this type of accident occur again.

If a crew finds themselves in this predicament, they are a little off script so what they do now, while it may be a good idea, is uncharted territory.

The drill as you describe it sounds like the actions of the “Evacuation” Checklist

[FlightDetent]

In an effort to prevent re-occurrence, the investigators will need to answer why no G/A from a misadjusted approach and what can be done in the future to ensure the landing is not continued. A neighbouring country realized some time ago and enforced a punitive non-go-around policy (as opposed to a non-punitive go-around one).

And I'd vote in favour. What else there is, TEM and CRM training does not seem to deliver since people keep crashing airworthy aeroplanes under the impression they are performing alright and the dark side of HF does not apply to them. Which itself is one of the HF dark sides. The prospect of dying and killing everyone seems too distant and severe so that it gets suppressed by the unconscious and does not enter the decision making when needed. The OLD / FLD concept fails to save lives, since when rushed pilots just do not run the numbers.

https://aviation-safety.net/wikibase/wiki.php?id=219098
https://aviation-safety.net/database/record.php?id=20091222-0

Then let it be FDM and HR. Give the pilots a railing they can hold on to and not fall over the cliff of their own importance. Otherwise, as very respectable non-pilot contributor posted elsewhere in the forums the last week(my re-phrase): As long as pilots keep crashing airworthy aeroplanes, future of that profession is deservedly grim.

[Uplinker]

Very good post, Flightdetent :ok:

Not saying it applies here, but I have been in CRM courses where a Captain lounges back arrogantly and tells the young cabin crew how difficult it is to fly the plane, and by implication what a hero the Captain is. Completely missing the point that CRM is mainly to tell Captains to : Use their team, Listen to their team, and Don't be autocratic.

[vilas]

As long as pilots keep crashing airworthy aeroplanes, future of that profession is deservedly grim. Piloting errors along with the human factor which only seems to serve as an obituary is the biggest incentive to replace humans. Everyone knows about Somatogravic illusion and yet now and then we loose an aircraft because someone tried to fly by his ears and not instruments.

[parkfell]

Would Fix Based Simulators reinforce that message better about using the instruments and not other senses?
RTO probably best in a FFS.....?

[FlightDetent]

Questionable. Training against the overwhelming effect of a physiological phenomena at its absence.

The number of pure SGI crashes after a failed upset recovery is not overwhelming compared to the usual suspects of illegaly executed landings and CFITs.

You train for C at the expense of having to train less for B. More training has its upper limits too, you can only learn certain much and actively keep the skill on the line.

Besides the economical cap on training amount is coming down with more and more automation to claim its role in the upcoming aircraft design.

[Tee Emm]

In an effort to prevent re-occurrence, the investigators will need to answer why no G/A from a misadjusted approach and what can be done in the future to ensure the landing is not continued.

In another era I was a simulator instructor training students who in their own country were strongly subject to cultural mores. One of which was unquestioning obedience to authority or higher status. One of the questions I asked of them was how would they take over control from a captain when it was obvious the approach was so badly unstable that an over-run was inevitable.

I explained I was asking the question for a good reason and that was sometime in their career as a pilot there was a good chance they would be faced with such an event. The universal reply, apart from a verbal warning, was along the lines of they would never attempt to take physical control from the captain - that it was unthinkable in their culture.

There had to be a way of changing that cultural mindset. I asked them to watch me demonstrate an example of a typical badly unstable approach and to note the end result. The simulator was placed n the landing configuration on a five mile ILS final in fully visual conditions. I then deliberately flew 30 knots above Vref and that was after I had entered a tailwind of 20 knots. Inevitably we got very high on glide slope and attempted to regain glide slope by 200 feet AFE by closing the throttles and .
increasing the rate of descent. All the time I pattered the approach including saying aloud " We are badly unstable but we can make this OK".

Ignoring sink rate GPWS auto warnings, we passed high over the fence at 25 knots beyond Vref plus the tailwind so that we had an impressive ground speed which was duly pointed out. We then deliberately floated a long way to achieve a smooth touch down on the wet runway.

It doesn't take much imagination to guess what happened next. With full reverse thrust and maximum manual braking we went off the far end of the runway at 60 knots. I had "arranged" a gear collapse and the noise was impressive.

I then pointed out that what they had witnessed was the result of a grossly unstable approach even though I had said "We can make it OK." The whole demonstration took five minutes. Opinions will vary but as far as I was concerned it was good value for money.

A picture is worth a thousand words and simulator instructors should have the confidence to walk the walk as well as talk the talk. They need to cut through political correctness and not be afraid to where necessary demonstrate a sequence to get a point across to the student. The students I was teaching were rote learners and they could recall perfectly all the elements of an unstable approach. But to actually witness these elements right through to its logical conclusion I hoped would fixate the result in their mind, regardless of cultural mores.

Apart from timorously warning the captain the approach is unstable, most culturally afflicted students would have no idea how to physically take over control from a captain intent on "making it OK". . As a last resort the PM could call "GO-AROUND - GEAR UP" and select the gear up without waiting for a reply from the captain. That should really focus his attention and force a go-around without the dangers inherent in a physical intervention.

[fdr]

https://cimg6.ibsrv.net/gimg/pprune.org-vbulletin/750x512/india_express_b738_vt_ash_kozhikode_200807_9a_9465ebddb8cbdb 031db12170cc83fa55e541db7e.jpg
From AVHerald. Not on plan B myself, so don't want to guess what the pilots were doing based on this.

That is a sad image to see. Perhaps the resultant cross country ride resulted in the repositioning of some levers through mechanical linkage feedback, but the speed brake is in the down detent, which is not going to happen all by itself. The auto stow doesn't get it to the detent.

Indian conditions in the monsoon are interesting, and the runways are singularly compromised in heavy rain conditions. The lack of RESA/EMAS makes any off catastrophic.

[fdr]

Originally Posted by vilas View Post (https://www.pprune.org/showthread.php?p=10862918#post10862918)
There was a documentary by Al Zajeera on making of B737 800 in which Boeing workers had made serious allegations on NG fuselage which breaks on RW excursions. ​

I've seen the documentary. It alleges that manufacturing defects are to blame to the break ups; I don't think that is the case, although those complaints should be heard and investigated, but it may be simply the way the 737 fuselage was designed in an era of different standards. I agree with the other posters that it is not fair to expect IX1344 to survive in one piece after going off the "cliff" (see TACA in 2008 or Pegasus this year). But take a look at history and there is an apparent trend.

The NG AMM was predicated on the application of CNC machining of critical parts, which happened to include the joints of the fuselage barrels, which were expected to reduce stress and cracking, giving improved maintenance overhead. 3 Boeing QA engineers audited the supplier of the joints, to find they were not using the CNC, there was none in the plant, and the units were being formed by hand. Boeing ended up sacking the QA engineers who reported the non-conforming manufacturing practice. FAA did nothing much. The litigation for unfair dismissal was about as effective as one would assume from individuals taking on a giant run by lawyers. About as effective as Roger Boisjoily trying to get justice for Challenger. That is the world we have, and under the pumpkin king, it is not getting better anytime soon.

a number of the fuselage breakups on impact have occurred in the area of the joint, a correlation of the supplier's non-compliant parts with MSN and bingles and tube integrity would be interesting, but as the WAWKI fell off a cliff this year, not sure it makes much difference in the end.

[George Glass]

Tee Emm

Garuda GA200 in 2007 is a favourite.
As a sim exercise on unstable approaches, we were put at 2000’ in the configuration they were at and asked to continue. It made the hair stand up on the back of your neck. The CVR is gobsmacking.

[parkfell]

GA200 ~ Just reread the report.

A question I raised on the PIA 8303 thread ~ the lack of involvement by the Aerodrome Controller.

A recent UK AAIB report on an unstable approach at Bristol revealed that the Aerodrome Controller instructed the B737 to Go Around as he assessed that the ‘profile’ on final was unsafe.

No mention in the GA200 report of ATC saying anything to prevent the impending disaster, even though eye witnesses on page 41 comments on the excessive speed [210kts]. The final hole in the ‘Swiss Cheese’?

Is / was the role of ATC at a legal variance in Indonesia
or is it a ‘Cultural’ matter that you don’t question a pilot even when you know that it “doesn’t look right”.

The ATC involvement with IX 1344 might also be revealing....

[Uplinker]

In another era I was a simulator instructor training students who in their own country were strongly subject to cultural mores. One of which was unquestioning obedience to authority or higher status. One of the questions I asked of them was how would they take over control from a captain...............they would never attempt to take physical control from the captain - that it was unthinkable in their culture.

Apart from timorously warning the captain the approach is unstable, most culturally afflicted students would have no idea how to physically take over control from a captain intent on "making it OK". .......

(my bold)
A general point, since we don't yet know what went wrong in this crash:-

I have often said that taking control needs to be actually trained. It is written in the books that the F/O is supposed to challenge the Captain three times and then take control. But is this ever actually taught or practised. Flying a plane or landing a plane is not left to a written description in the FCOM. We spend weeks having it explained, being examined on it, having our understanding checked and our ability to do it by practising it in a simulator, and finally having to pass a 4 hour LPC/OPC exam in a FFS.

Yet one of the most important safety barriers to accidents - taking control from an errant Captain - is reduced to merely a few lines written in the books somewhere and rarely referred to, and never actually practised for real or tested, (in my 20yr commercial flying experience with 4 UK airlines).

Taking control from a Captain is a big deal - especially if they are also management or very senior. It therefore needs to be taught and play-acted. By everybody. F/Os need to be coached and practise saying the words to a Captain in a 'real' situation. Captains need to experience being taken over from. That way, all members on a flight deck will have been through that process. The F/Os will have more confidence to take control because they will have practised doing so. Captains will have experienced the feeling of losing face and having their authority taken from them. So if it ever has to happen for real, it won't be the first time for anyone.

This will improve F/Os confidence and make Captains better Captains because they will know that if they stray and don't correct errant decisions, they will have their control taken away.

It's not limited to some cultures either. I have sat on (UK) flight decks thinking this guy is doing something questionable. Should I take over or will it be alright.

[vilas]

In another era I was a simulator instructor training students who in their own country were strongly subject to cultural mores. One of which was unquestioning obedience to authority or higher status. One of the questions I asked of them was how would they take over control from a captain when it was obvious the approach was so badly unstable that an over-run was inevitable. In present case it's a bit early too say anything because it's not yet confirmed whether the aircraft overran during landing or during attempted late GA. Culture alone is not the cause. How well the FO was trained has a lot to do with the confidence he exudes in the execution of his duties. In the same airline in the Mangalore accident the FO who himself was upgrading to Capt(not in that flight) didn't provide any input about badly out of profile descent and approach till the RW was right under them but couldn't enforce the GA. The airline did make some changes to their CRM training because one year later a repeat of similar act after touchdown was overridden by the FO. In Australia in an A320 incident the FO was PF had more experience on type and when he messed up an approach the Capt due to his lesser experience on type felt diffident to interfere that led to a GA. In the present case FO could have interfered if approach was unstable in any parameter or the float was appreciable. But that could only happen if FLD was examined critically taking into consideration the margin if any they had with TW and worse than wet condition on a RW that would not permit overrun.

[Centaurus]

Taking control from a Captain is a big deal - especially if they are also management or very senior.
Readers may recall the crash of Silk Air Flight 185 in 1997. See: https://en.wikipedia.org/wiki/SilkAir_Flight_185

On an earlier flight some weeks before that accident the same captain was trying to lose height on short final by applying full aileron in both directions to activate the spoilers. The F/O who was not culturally bound called for the captain to go around as the 737 was badly unstable. The gyrations of the aircraft were alarming but despite this the captain was intent on landing.

When the captain ignored all the usual SOP warnings, as a last resort the F/O pushed the throttles open under the captains hand leaving the captain with no choice but to go-around. The actions by the F/O saved a sure accident. In this case the F/O did not try to take over control from the captain as he knew this would only exacerbate an already dangerous situation.

training students who in their own country were strongly subject to cultural mores. One of which was unquestioning obedience to authority or higher status.
So true. In the following instance both students were undergoing 737 type rating training in the simulator. The PM was a powerfully built chap from SE Asia with an aggressive personality.
The briefing included a multiple bird strike immediately after airborne causing the failure of one engine. The aim being to return to land at the same airport.

The engine failure was well handled by the PF. After all applicable checklist items had been completed the PF joined the circuit. A fire warning then occurred on the remaining engine. The aim of that exercise was to continue with the planned landing and deal with the fire warning once on the ground, In other words how to deal with priorities.

The PM immediately called for the engine with the fire warning to be shut down; which of course would have been disastrous. The PF wisely disagreed for obvious reasons. This is where culture came to play. The PM flourished the QRH in front of the PF who already had his hands full, demanding the PF follow its instructions which was to close down the engine. Despite protestations by the PF the PM closed down the live engine and fired the bottle. The result was predictable. Afterwards the PM was suitably debriefed by the instructor in no uncertain terms.

[Uplinker]

Thanks for pm, parkfell. Perhaps we are slowly moving in the right direction.

In the SIM we practise pilot incapacitation, which is easy because the other pilot does not interfere or argue. CAA should add an exercise to the D3 LPC/OPC form where, instead of passing out, Cap is secretly told to deliberately fly over limits or recklessly to see what F/O does. This is where F/O should question Cap and eventually take control, and would be a very useful exercise - in fact much better than doing it in a CRM classroom.

[Judd]

instead of passing out, Cap is told to deliberately fly over limits or recklessly to see what F/O does. This is where F/O should question Cap and eventually take control. That would be a very useful exercise - in fact much better than doing it in a CRM classroom.

In one airline I was with we had an excitable checkie with a short fuse. The simulator session included captain incapacitation at some point in the session. Just before one takeoff the checkie whispered to the captain to be incapacitated during the takeoff run. The F/O was unaware of the plan,

Half way down the runway, the captain suddenly gasped loudly and fell over the controls with admirable acting. The F/O was shocked and genuinely alarmed and reached over to try and help the captain whom he thought was having a real "event." With no one on the controls the aircraft veered off the runway at full power heading towards the control tower. The checkie immediately froze the simulator. The captain miraculously came alive while the F/O wondered what the hell was going on as he thought the captain was a goner real time.

The checke got stuck into the F/O for not taking over control from the simulated incapacitated captain. The F/O protested and said he thought the captain had suffered a heart attack for real. The checkie then ticked the FAIL box on the F/O's records. Naturally this upset the F/O who was a former RAF pilot with real life operational experience during the Cold War days.

After the tea break the F/O became PF. Keep in mind in the company training syllabus incapacitation only ever applied to the captain. Half way down the take off run the F/O without warning suddenly collapsed with a loud groan at the same time stiffening one leg to full rudder.

This was not a briefed exercise and the captain was immediately alarmed and leaned over the pedestal to try and comfort the F/O who by now was making anguished cries. Meanwhile under the influence of full rudder the aircraft headed towards the control tower. The checkie clicked what had happened and froze the simulator and berated the F/O calling him a smart-arse for doing something not in the syllabus. The F/O showed admirable restraint in not snapping back at his unfair treatment.

Interestingly the checkie chose not to criticise the captain for not taking over control when the F/O had his "event.". Rank obviously has its privileges..

[FlightDetent]

Wise thoughts and insightful stories above. Need to point out all of them for the plan B. Still appreciated, really.

Back to plan A? For the PIC to be lucid enough and discontinue on his/her own? That is what I had in mind when mentioning the responsibilities of the investigation body.

As mentioned above, I personally see quite some sense in a punitive rule for landing de-stabilized.

E. g. for continuously hot or high profiles, assuming 1000 ft OM-A policy:

g/a before 1000 ft - ignored
descend through 1000 ft: FDM event
descend through 500: SOP violation that goes onto the file, this can be avoided by a g/a below 1000 but before 500.
​​​​​​land from unstable at 500: demotion, this can be avoided by a g/a below 500 but before the touchdown
landing past the markers or Vapp+25 - termination

Surely it can be tuned, possibly adding the DA as a gate. These days pilots are properly trained to take the landing decision (evaluation) at that moment.

Suggestions for other methods greatly welcome.

[vilas]

In 2019 Indian DGCA suspended 40 pilot's licenses for overruns and other incidents for a period of 6 to 12 months.

[safetypee]

'In 2019 Indian DGCA suspended 40 pilot's licenses for overruns and other incidents for a period of 6 to 12 months.'

That action does not appear to have improved safety in 2020; what next ?

Its difficult to change the human condition, but you can influence behaviour by changing the place of work (James Reason); place of work includes the operational situation, runways, overrun areas, weather and runway condition reporting, …

[George Glass]

I can only speak for the operator I work for but continuing an unstable approach in IFR below 1000’ is a career altering experience. One incident will get you tea and bickies and a please explain, or worse if you didn’t self report. A second will get you busted back to the right hand seat.
QARs have been around for years. There really are no excuses. Repeat offences in a particular environment represent a comprehensive failure of safety culture and regulatory oversight.
As result of personal experience there some countries in which I simply will not fly in domestically.

[vilas]

From 500ft if the flight path and thrust is maintained the speed should not change. The problem is if at 1000ft if speed is+15 and GS half a dot above it fits into stable approach but can end up in overrun if not handled correctly.

[Judd]

I don't know how true this is but understand that a few years ago China Airlines (Taiwan) captains were continually getting the blame for QAR reports of unstable approaches into Taipei when the PF's were inexperienced cadet F/O's. The QAR's were used as a Big Brother punishment tool. That trend changed when the captains refused to give their F/O's any landings.

[FullWings]

I think you’ve got to have some disciplinary bottom lines for reckless behaviour, but at the same time you need some “carrot” as well as some “stick”. Actively praising/rewarding discontinuing an approach that is getting out of hand is very important important part of safety culture, IMO. This should be emphasised in training, checking, line operations and FOQA.

When the chimp is sitting on your shoulder giving directions, if it understands that one path leads to a reward and the other to a smack, it might lean more towards the reward.

I think that's the case for many Western airlines but I fear in many overrun incidents, sanctions and dire warnings for busting the gate at 500/1000' miss their mark, because often the excessive speed is at the threshold/in the flare, not at the gate, and that comes down to poor technique, not high energy further back in the approach.
Agreed. The aircraft state needs to be continuously assessed until you stop/vacate. I would differ in that not everything undesirable happens because of poor technique; gusts/shears, etc. at critical moments are part of normal operation but you do have to have a clear idea about what you can/can’t accept and what you’re going to do if it gets out of limits.

[Uplinker]

.......Actively praising/rewarding discontinuing an approach that is getting out of hand is very important important part of safety culture, IMO. This should be emphasised in training, checking, line operations and FOQA.
Reminds me of the Lenny Henry sketch, where he says that traffic police always pull you over if you have done something wrong, but never if you have done something well...."the way you took that corner, man, that was wicked...." ! :)


Perhaps one snag is the 1000'/500' thing.

Pilots all know they should be stable by 1000', but they also know that if they are nearly stable at 1000' there is leeway to continue to 500' (technically only if positively correcting and visual, but definitions vary).

This tells a pilot that if they are near enough at the correct speed and correcting, they can continue through 1000' - but each pilot will have their own personal definition of 'near enough', and 'correcting'. Having continued through 1000' too fast, when they get to 500', the subconscious thinks, 'well I am still near enough, and anyway, look, there is the runway; plenty of length, so we might as well land, and I won't have to write a report or waste 15mins more fuel and the chief pilot will never know'.

Perhaps the 1000' criteria needs to be tightened, so as not to allow any over-speed at that gate?

I am wondering how FDM software would automatically pick up a long landing ? I guess you could set a flag for the time from closing the thrust levers to WoW? Or perhaps from a RA of, say, 50' to WoW.

[Gizm0]

FDM systems vary considerably depending upon their age & complexity (cost!) - and also the capabilities (mainly amount & rate of data capture from the recorder). A simple one will indeed measure time from point A to point B. It can also then work with the g/speed to reach a fairly accurate t/down point. A very modern sophisticated system will use GPS to ascertain the exact t/down point (very accurately) and if then associated with the runway used (& airport) can build up an extremely useful database about long landings vs airports. If you factor in the wind as well it can be a really, really useful safety tool - just depends upon how much the airline really wants such a system......

[safetypee]

George, #333, as per the issue above #332, the QAR view in isolation might at best only provide a small improvement, but never a guarantee.

Again from James Reason ' even the very best people make the worst mistakes ', which has to be considered in context - the actual situations; accidents generally have several contributing factors, which come together at a particular time. '… the chance and largely unforeseeable concatenation of many different causal factors, none of them sufficient or even especially remarkable by themselves, but each necessary to bring about the outcome.'

The need of defence in depth.

Operators should reduce landing distance available by the amount of an unsuitable overrun area.

Airports should inspect runways more frequently in monsoon conditions; have time delay landing restrictions for poorly drained surfaces, check and publish rubber contamination (slippery when wet).

National authorities should require grooved runways, for those airfields without then reduce landing distance available to compensate for reduced braking / drainage.

Governments should allocate funding for improvements, act to instigate the above.

"Should, could, must, but who does"

[George Glass]

The recruitment criteria for most Western airlines is strongly biased towards not just technical competence but also ability to operate without direct supervision, acceptance of ,and compliance with , a rules based operational environment and high personal standards. Plus an ability to work with and listen to others. The ability to send a crew off on a multi day mission in charge of a multi million dollar asset is an achievement that I still am awe struck by. How you replicate that is the problem.

[safetypee]

vilas, #335 '… if at 1000ft if speed is +15 and GS half a dot above it fits into stable approach but can end up in overrun if not handled correctly.' :ok:

Landing distance required must be calculated (considered) for foreseeable error situations, planned for situations - approach speed increase for wind, or 'near enough'.
The approach speed must be adjusted during final approach to achieve the expected landing performance, but that would be 'unstable' - the clash of reality with procedural requirement, requiring a balanced judgement influenced by rules, interpretation, safety culture.

Uplinker, GizmO, re touch down position from FDR.
This is relatively easy to measure, even the most basic recordings provides a reasonable indication.
A key issue is the use of the data; view the human as the threat, or learn from aggregated data about influencing conditions, specific runways, airport restrictions.

I recall one analysis, many years ago, which identified a correlation between the point of touchdown and runway length; the study ranged many airports in a large operational system, and aircraft types according to long haul / short haul.
Thus with all other things being equal, if pilots can touchdown within a suitable distance on a short runway, then why not on a longer runway; a lengthy and repetitive discussion - because its human.

The operator published the findings for awareness and recurrent training comparison - the training results on all runway lengths was acceptable - we can do it, we can choose to do it, but not always.

[Uplinker]

Yes, it does not have to be a big deal, we only have to change pilot's attitude and judgement - a bit like changing drivers' attitudes to wearing seat belts or drink-driving.

Most pilots already accept the real need to be stable on approach - the days of 240kts to 4dme etc are well behind us, Being unstable should lead to a go-around without punitive consequences, and this message is slowly getting through.

On landing, none of us want to slam the aircraft in every time, but a long float is a bad habit. (I am sometimes guilty). Chief pilots could mandate that a long float should lead to a baulked landing. A baulked landing should be seen as a lesson learned and a positive contribution to safety, in the same way that other go-arounds are seen by most enlightened chief pilots.

If it was freely publicised that FDM would be used to flag touchdowns outside the touchdown zone, standards would gradually improve.

Another way to introduce incentives to change behaviour would be to publish league tables, (or even offer modest bonus payments), for stable approaches, touchdowns within the touchdown zone, and, say, three manually flown approaches every six months. Pilots' standards would improve !

[Gizm0]

League tables - of any sort - are a highly contentious subject in just about every airline. Even if they are, nominally, in the name of safety. Someone will always be "put out" or feel unfairly treated and that will ultimately lead to trouble.........

[Bergerie1]

Uplinker,

An interesting idea, but when incentivising behaviour, beware of the unintended consequences which can sometimes be totally unexpected.

[FullWings]

Definitely. I remember when they first brought in excess fuel carriage tables in my company. You had two groups who tried to get to opposite ends of the table, treating it like a competition, while the rest of us just took what we deemed appropriate on the day. The dangerous bit, IMO, was when some individuals vying for the top spot started returning negative excesses - they were using get-outs in our fuel policy designed to be used on rare occasions every time they flew...

[rb14]

As the CEO of a failing multinational (I'm not), I always get​​ bonus payments for, erm, doing my job. And, as it happens, invariably when I fail to do my job as well. I thought we had this bonus payment sector tied down, but it seems there are whispers that pilots should have a slice of the pie too. Not on my watch, no siree.

Seriously though, where does this stop? Should our cloakroom attendant be rewarded for not losing any coats? Or draping them properly on a hanger? If you find it impossible to track every coat you get, or can't hang them properly, you can have some more training. If that doesn't work, perhaps cloakrooms aren't for you.

"Stable approaches, touchdowns within the touchdown zone, and, say, three manually flown approaches every six months" shouldn't these be minimum requirements? If this isn't happening, or it's not being measured and recorded, surely something has gone seriously wrong?

[Uplinker]

@rb14, yes, I know it sounds counterintuitive, but humans need incentives. In the 1970's we should have all worn seatbelts, but we didn't. Now we do, because it became socially unacceptable not to.

Pilots should do everything right, but quite clearly they don't. You could use a stick and prosecute all errors. Or you could use a carrot and reward, or otherwise incentivise safe behaviour.

League tables for fuel is frankly xxxxxx dangerous. I have heard of really stupid and dangerous behaviour, such as one moron who flew back to a partially SNOWTAM ed UK with just 300kg extra fuel..............:mad:

So, never for fuel, I agree.

But if we had league tables or part of our pay was, say, £2.50 for every approach we flew that was fully stable at 1000', and a touchdown within the touchdown zone, it might start to change attitudes to risk taking and provide an incentive to encourage safe behaviour; it could work.

[Bergerie1]

And how do you measure safe behaviour in a fair and objective way?

FDR readouts? CVR readouts? Cockpit videos? Fellow cockpit crew member reports? ATC reports? Cabin crew reports? Check rides? Passenger satisfaction?

No thank you.

[vilas]

Uplinker

It may start a trend to duck under. Financial incentives may not be what they appear. That's why salaries are rarely have one fixed figure per month. Basic salary can be reduced and then made up by giving a little for this and a little for that. Basically it's motivation to do a job well. It could be financial or appreciation of sincere effort some other way.

[FlyingStone]

League tables for fuel is frankly xxxxxx dangerous. I have heard of really stupid and dangerous behaviour, such as one moron who flew back to a partially SNOWTAM ed UK with just 300kg extra fuel..............:mad:

So, never for fuel, I agree.

On the other hand of spectrum, you have people taking more than half an hour of extra fuel to an almost deserted 2-runway airport in severe CAVOK, just because 15 years ago they had to fly one turn in a hold one day. There's extreme cases on both sides.

But if we had league tables or part of our pay was, say, £2.50 for every approach we flew that was fully stable at 1000', and a touchdown within the touchdown zone, it might start to change attitudes to risk taking and provide an incentive to encourage safe behaviour; it could work.

If you're not stable at your gate and have not touched down in the touchdown zone or at the point that you should have for a safe landing (those two might not co-incide), you should go-around. We shouldn't reward people for doing what's expected of them.

What's next, a fiver for lifting your bottom off the seat and doing a walkaround when it's raining?

[parkfell]

.....If it was freely publicised that FDM would be used to flag touchdowns outside the touchdown zone, standards would gradually improve..... !

Where this might come into its own would be on training days, where the ‘spread’ of touchdowns were shown.
The analogy are the graphics shown as to where the ball pitches on the wicket during Test Matches etc. Analysed into various ‘zones’ as percentages and groupings. [Apologies to our American friends talking about a cricket match that can last 5 days]

AND / OR

Anonymous monthly publications of the ‘spread’, together with CP tea and biscuits, or sometimes without, as necessary.
Perhaps even individual performances sent confidentially. The difficulty then comes as to the impact caused by ‘inexperienced’ FOs learning their trade.

On balance UPLINKER’s idea is worth a closer look.

[Uplinker]

Some interesting reactions !

How can we incentivise pilots not to continue unstable approaches or long floats?

"Well pilots are paid to do their jobs properly". Yes, of course, but we have recently had two fatal crashes where unstable approaches, and in one case, a very long float ended in disaster. And this is in today's modern piloting, with CRM and SEPs etc. I am merely thinking aloud about possible ways chief pilots might push the balance towards a safer mindset.

Being both properly stable at 1000' and touching within the touchdown zone, would apparently be easy to program into FDM, and some way of incentivising these twin goals might start to reinforce the message to all?

[Herod]

Be wary of league tables; they can be a two-edged sword. Many years ago, a colleague on an annual assessment. "fewer days off sick; that's good" then "You tend to carry more fuel than most". His reply; "Yep, more fuel, less stress, fewer days off sick"

[FlyingStone]

I was under impression most sensible airlines already have that in their FDM, and for me personally, not having to go and see the chief pilot for tea with no biscuits, is a great incentive to not bust the gate or land long.

[safetypee]

Whilst the side discussion on monitoring, margins, etc, covers many aspects, how would this be applied to the accident situation. What additional distance would be expected to be added, and what is the origin of the baseline data.

Most regulatory agencies and operators require an additional distance safety margin to over baseline landing data; e.g. using OLD the minimum recommended addition is 15% (FAA, EASA), in some manuals this is listed as FOLD Factored Operational Distances (Airbus) - a significantly different concept from 'actual' distances or AFM distances with other factors.

What landing distance safety margin keeps you out of the office ?

What is this operators policy, national policy, is it recommended or mandated ?

[wiggy]

I was under impression most sensible airlines already have that in their FDM.

So was I...Long landing/excessive time in the flare/Float, whatever you want to call it, is certainly analysed in our FDM and occasionally the more extreme events receive some suitably redacted publicity..

[Judd]

While "real men don't go around" or loss of face is ingrained in the brains of some culturally afflicted pilots, clearly this sort of insane mindset is here to stay. All the lectures on CRM, TEM or whatever is the latest ICAO buzzword (invariably paid lip service by the company), won't change a thing.

We have to live with it because history has shown us these sort of accident contributory causes will continue to feature in accident reports. Unfortunately the strong possibility of a crash being caused by a cultural bent is never mentioned in accident reports possibly due to a subtle application of political correctness. Also, the nature of this type of mindset usually means it cannot be proved beyond doubt.

Flight safety technical advances may reduce the number of accidents but they cannot erase 2000 years of culture.

[safetypee]

'Long landing/excessive time in the flare/Float, … is certainly analysed in our FDM' # 357

That is an important aspect, but not the only one. Of greater importance is where the aircraft stopped - sufficiently slow, vs where it could have stopped; from this a comparison between the planned safety margin and actual available in the conditions, a check both on human contribution and the reported runway conditions.

Re several contributing factors - how many in this accident ?
The info-graphic on slide 20, 'Overrun Characteristics' https://www.icao.int/EURNAT/Other%20Meetings%20Seminars%20and%20Workshops/GRF%20Workshop%20(Frankfurt)/GRF%20Wkshp%20FR%20PPT01.pdf (slow loading file) shows the issues, indicating the relative frequency or overall significance.

* GRF - Global Reporting Format - for runway condition; to be introduced this year together with revised landing distance performance which can be related to the reported conditions.
Also:- https://www.icao.int/EURNAT/Other%20Meetings%20Seminars%20and%20Workshops/GRF%20Workshop%20(Paris)/GRF%20Wkshp%20PPT06.pdf
and
https://www.icao.int/Meetings/grf2019/Documents/Presentations/GRF2019%20S2%20Lars%20Kornstaedt%20-%20Airbus.pdf

[goeasy]

a lot of thread creep here. A great discussion for elsewhere!

Anyone have any updates on the subject of this thread?
Any developments in the investigation?

[gearlever]

"On Aug 25th 2020 the NTSB announced, they have appointed an accredited representative to assist the AAIB of India with the investigation according to ICAO Annex 13."

India Express B738 at Kozhikode on Aug 7th 2020, overran runway and fell into valley (http://avherald.com/h?article=4daf960f&opt=0)

[JumpJumpJump]

Before being misunderstood, misquoted, called an idiot etc... Calculated, briefed and carried out within limits there should be (Is?) no issue with a tailwind landing. Fact... Moving on...

... there appears to be a relatively high percentage of over runs during this period of massively reduced traffic in the global skies. I am currently camping out waiting for the aircraft to arrive at Curitiba in the South south of Brazil, the terminal is tucked up at the beginning of runway 33. the tendency here during this period of fewer movements is to take off on 33 and land on 15 to reduce taxiing times. Does anybody else play the following thought game: that we are spending more time these days performing tailwind landing (takeoffs too) to save on taxi time as it is much more likely for reciprocal operations to be granted and as such, there is still the same percentage of pilots willing to push the limits which is contributing to this?

or am I overthonking this and talking utter muffjank?

[PEI_3721]

In case I am mistaken, the issue with tailwind landings involves flare judgement at higher ground speeds. The aircraft feels the same - same airspeed, but visual feed back differs due to the 'unusual' ground and vertical speeds, thus can be misjudged, such that the variability in flare time and distance are much larger (certification speed allowance is 150% wind speed), i.e. the aircraft is more likely to float - a long landing.
Many pilots will have operated in moderate tailwinds, the industry seems to depend on the capability re changing runways or not. However, with increasing tailwinds, beyond normal ATC changeover limits, pilots lack experience and practice.

The risks in tailwinds above 10 kts increase rapidly.

Many years ago the recommended maximum was 10 kts (ICAO), this has been systematically allowed to drift to up to 15 kts. e.g. aircraft had 10 kt tail limit, customer request for 15 kts (night noise abatement) was reluctantly agreed providing that the AFM specifically limited to that operator and airport, and with additional training; 10 yrs later the AFM clearance for 15 kts was standard without limits or warnings - we forget, then fail to relearn hard lessons from accidents.

Risk during landing has increased - drift into failure - for convenience, noise, weather (particularly if wet or gusting wind), without due regard to mitigations - runway grooving, overrun area, runway condition reporting, accuracy / interpretation of landing data.

Neither 'overthonking or utter muffjank'; the reality of operations, which continually surprise us.

"What we observe is not nature herself, but nature exposed to our method of questioning."

[Stan Woolley]

FlyingStone

Which ‘extreme’ would you rather have when flying as a passenger? I know which one I’d prefer.

[C310driver]

Is there any update on this accident? Any preliminary report? Anything?

[DaveReidUK]

No sign of a preliminary report, but the final report is promised by mid-January 2021, which seems more than a tad ambitious: https://www.civilaviation.gov.in/sites/default/files/IIC_Order_VT_AXH_13_Aug_2020.pdf

[mayam13]

Any pilot who has landed in Kozhikode knows that the runway will have standing water during monsoon From this forum I understand that the Captn. has done over 20 landings inthis runway. This being so going to alternate airport would have been safer

[Maninthebar]

Final Report AXH.pdf (aaib.gov.in) (https://aaib.gov.in/Reports/2020/accident/Final%20Report%20AXH.pdf)

[DaveReidUK]

3.2.1 PROBABLE CAUSE

The probable cause of the accident was the non adherence to SOP by the PF, wherein, he continued an unstabilized approach and landed beyond the touchdown zone, half way down the runway, in spite of ‘Go Around’ call by PM which warranted a mandatory ‘Go Around’ and the failure of the PM to take over controls and execute a ‘Go Around’.

3.2.2 CONTRIBUTORY FACTORS

The investigation team is of the opinion that the role of systemic failures as a contributory factor cannot be overlooked in this accident. A large number of similar accidents/incidents that have continued to take place, more so in AIXL, reinforce existing systemic failures within the aviation sector. These usually occur due to prevailing safety culture that give rise to errors, mistakes and violation of routine tasks performed by people operating within the system. Hence, the contributory factors enumerated below include both the immediate causes and the deeper or systemic causes.

(i) The actions and decisions of the PIC were steered by a misplaced motivation to land back at Kozhikode to operate next day morning flight AXB 1373. The unavailability of sufficient number of Captains at Kozhikode was the result of faulty AIXL HR policy which does not take into account operational requirement while assigning permanent base to its Captains. There was only 01 Captain against 26 First Officers on the posted strength at Kozhikode.

(ii) The PIC had vast experience of landing at Kozhikode under similar weather conditions. This experience might have led to over confidence leading to complacency and a state of reduced conscious attention that would have seriously affected his actions, decision making as well as CRM. 209

(iii) The PIC was taking multiple un-prescribed anti-diabetic drugs that could have probably caused subtle cognitive deficits due to mild hypoglycaemia which probably contributed to errors in complex decision making as well as susceptibility to perceptual errors.

(iv) The possibility of visual illusions causing errors in distance and depth perception (like black hole approach and up-sloping runway) cannot be ruled out due to degraded visual cues of orientation due to low visibility and suboptimal performance of the PIC’s windshield wiper in rain.

(v) Poor CRM was a major contributory factor in this crash. As a consequence of lack of assertiveness and the steep authority gradient in the cockpit, the First Officer did not take over the controls in spite of being well aware of the grave situation. The lack of effective CRM training of AIXL resulted in poor CRM and steep cockpit gradient.

(vi) AIXL policies of upper level management have led to a lack of supervision in training, operations and safety practices, resulting in deficiencies at various levels causing repeated human error accidents in AIXL

(vii) The AIXL pilot training program lacked effectiveness and did not impart the requisite skills for performance enhancement. One of the drawbacks in training was inadequate maintenance and lack of periodic system upgrades of the simulator. Frequently recurring major snags resulted in negative training. Further, pilots were often not checked for all the mandatory flying exercises during simulator check sessions by the Examiners.

(viii) The non availability of OPT made it very difficult for the pilots to quickly calculate accurate landing data in the adverse weather conditions. The quick and accurate calculations would have helped the pilots to foresee the extremely low margin for error, enabling them to opt for other safer alternative.

(ix) The scrutiny of Tech Logs and Maintenance Record showed evidence of nonstandard practice of reporting of certain snags through verbal briefing rather than in writing. There was no entry of windshield wiper snag in the Tech log of VT-AXH. Though it could not be verified, but a verbal briefing regarding this issue is highly probable.

(x) The DATCO changed the runway in use in a hurry to accommodate the departure of AIC 425 without understanding the repercussions on recovery of AXB 1344 in tail winds on a wet runway in rain. He did not caution AXB 1344 of prevailing strong tail winds and also did not convey the updated QNH settings.

(xi) Accuracy of reported surface winds for runway 10 was affected by installation of wind sensor in contravention to the laid down criteria in CAR. This was aggravated by frequent breakdown due to poor maintenance.

(xii) The Tower Met Officer (TMO) was not available in the ATC tower at the time of the accident. The airfield was under two concurrent weather warnings and it is mandatory for the TMO to be present to update and inform the fast changing weather variations to enhance air safety. During adverse weather conditions the presence of the TMO in the ATC tower was even more critical.

(xiii) The AAI has managed to fulfil ICAO and DGCA certification requirements at Kozhikode aerodrome for certain critical areas like RESA, runway lights and approach lights. Each of these, in isolation fulfils the safety criteria however, when considered in totality, this left the aircrew of AXB 1344 with little or no margin for error. Although not directly contributory to the accident causation, availability of runway centreline lights would have certainly enhanced the spatial orientation of the PIC.

(xiv) The absence of a detailed proactive policy and clear cut guidelines by the Regulator on monitoring of Long Landings at the time of the accident was another contributory factor in such runway overrun accidents. Long Landing has been major factor in various accidents and incidents involving runway excursion since 2010 and has not been addressed in CAR Section 5, Series F, Part II.

(xv) DGCA did not comprehensively revise CAR Section 5, Series F, Part II Issue I, dated 30 Sep 99 (Rev. on 26 Jul 2017) on ‘Monitoring of DFDR/QAR/PMR Data for Accident/Incident Prevention’ to address the recommendations of the COI of 2010 AIXL Managlore Crash regarding the exceedance limits, resulting in the persisting ambiguities in this matter.

(xvi) DFDR data monitoring for prevention of accidents/incidents is done by AIXL. However 100% DFDR monitoring is not being done, in spite of the provisions laid down in the relevant CAR and repeated audit observations by DGCA. DFDR data monitoring is the most effective tool to identify exceedance and provide suitable corrective training in order to prevent runway accidents like the crash of AXB 1344. However, ATR submitted by AIXL on the said findings were accepted by DGCA year after year without ascertaining its implementation or giving due importance to its adverse implications.

[bucoops]

Wow, just wow. What a mess.

[Skywards747]

Both chrome and edge browsers warn that this website (Indian AAIB) is unsafe due to expiry of its security certificate. How embarrassing it is for an Indian government agency to have an unsafe website?

[Skywards747]

The aircraft departed from Dubai for Kozhikode at 10:00 UTC as flight AXB 1344 carrying 184 passengers and six crew members.

AXB 1344 made two approaches for landing at Kozhikode. The aircraft carried out a missed approach on the first attempt while coming into land on runway 28. The second approach was on runway 10 and the aircraft landed at 14:10:25 UTC. The aircraft touched down approximately at 4,438 ft on 8,858 ft long runway, in light rain with tailwind component of 15 knots and a ground speed of 165 knots. The aircraft could not be stopped on the runway and this ended in runway overrun. The aircraft exited the runway 10 end at a ground speed of 84 knots and then overshot the RESA, breaking the ILS antennae and a fence before plummeting down the tabletop runway. The aircraft fell to a depth of approximately 110 ft below the runway elevation and impacted the perimeter road that runs just below the tabletop runway, at a ground speed of 41 knots and then came to an abrupt halt on the airport perimeter road just short of the perimeter wall.

There was fuel leak from both the wing tanks; however, there was no postcrash fire. The aircraft was destroyed and its fuselage broke into three sections. Both engines were completely separated from the wings.

The rescue operations were carried out by the ARFF crew on duty with
help of Central Industrial Security Force (CISF) personnel stationed at the airport and several civilians who rushed to the crash site when the accident occurred. Upon receipt of the information about the aircraft crash the district administration immediately despatched fire tenders and ambulances to the crash site. Nineteen passengers were fatally injured and Seventy Five passengers suffered serious injuries in the accident while Ninety passengers suffered minor or no injuries. Both Pilots suffered fatal injuries while one cabin crew was seriously injured and three cabin crew received minor injuries. The rescue operation was completed at 16:45 UTC (22:15 IST).

The captain (59, ATPL, 10,848 hours total, 4,612 hours on type) was pilot flying, the first officer (32, CPL, 1,989 hours total, 1,723 hours on type) was pilot monitoring.

In detail the AAIB described the sequence of events on the overrun:

At 14:07:59 UTC, aircraft captured the glideslope. At 14:08 UTC, ATC cleared AXB 1344 to land on runway 10 reporting latest weather update as visibility of 2000 m in light rain, runway surface wet and winds 250°/08 Kt. At 14:08:29 UTC the crew discussed Landing Flap selections and decided to go for Flap 30 selection instead of the initially discussed Flap 40 due to expected turbulence. Thereafter flap 30 was selected and Landing Checklist was completed at PA 1667 ft.

At 14:09:41 UTC, the aircraft was established on ILS with autopilot and auto throttle engaged at a PA of 633 ft with a CAS of 150 kt, the ground speed was approximately 175 kt with a calculated descent rate of 750 fpm. .

At 500 ft AGL the autopilot was disengaged while the autothrottle remained engaged, the pitch attitude was reduced and the descent rate began to increase, momentarily reaching 1500 fpm. The PM cautioned PF twice for high ROD, which was acknowledged by the PF for ‘correction’. The approach soon became unstabilized, wherein the ROD and glideslope deviation increased beyond the stabilized approach criteria. The aircraft deviated 1.7 dots below the glideslope. This was followed by two EGPWS alerts (caution) for glideslope ‘glideslope... glideslope’. The PF increased the pitch attitude and the descent rate began to decrease, reaching 300 fpm before increasing again to 1000 fpm.

The aircraft crossed the runway threshold at RA of 92 ft and was moving left of centre line with an actual tail wind component of slightly more than 14 Kt and a cross wind component of 6 knots. At this point speed began to gradually increase towards 160 kt CAS and sink rate was gradually arrested as additional thrust was being manually added despite autothrottle command to reduce thrust. The engine power was continuously increased and reached 83% N1. This happened when the aircraft had already gone past the runway threshold by approximately 1363 ft and was at a height of 20 ft RA. The aircraft continued to float above the runway and moved towards the centreline as its lateral deviation was corrected. The engine thrust was reduced and at 3000 ft beyond the threshold, CAS began to decrease towards the approach speed at approximately 15 ft RA. During this time, 07 seconds before touchdown, while the aircraft was at 16 ft RA, the PM tried to catch the attention of the PF by giving a non standard call “Just check it”. At this point, the aircraft was at 2500 ft beyond threshold, 500 ft short of end of touchdown zone. At Kozhikode, end of touchdown zone is marked at a distance of 3000 ft from the threshold by the simple touchdown zone lights on either side of the centre line.

05 seconds before touchdown, the sink rate began to increase gradually towards 12 fps (720 fpm) as the nose was lowered and thrust was reduced. 03 seconds before touchdown, PM again tried to catch the attention of the PF by giving a feeble, uncomfortable call “...Captain” when the aircraft had crossed the end of touchdown zone (3600 ft beyond the threshold). During this time the engine thrust levers reached idle power setting.

Approximately 1 second before touchdown, while the aircraft was crossing 10 ft RA, at 4200 ft beyond the threshold the PM gave a call of “Go around”. There was no response from PF to the “Go-Around” call and he continued with landing. During the flare, the aircraft floated, which resulted in a long landing along with an extended flare of 16 seconds. The aircraft touched down at 4438 ft on the 8858 ft long runway with a CAS of approximately 150 kt and a GS of 165 kt. It was raining at the time of touchdown and the runway condition reported by DATCO was wet.

PF immediately resorted to max manual braking overriding the auto brake selection, auto speed brakes were fully deployed 1.2 seconds after touchdown extending the spoilers. PM gave the standard calls for “SPEED BRAKE UP” and “AUTOBRAKE DISARM” there was no response from the PF to the standard calls given by the PM as per SOP. Autothrottle disengaged automatically 03 seconds after touchdown. The thrust reversers were commanded to deploy 03 seconds after touchdown. They were deployed within 02 seconds after initiating the command and remained in that state for a brief period of approximately 02 seconds with both engines power increasing to 59%N1. There was no call from PM of “REVERSERS NORMAL” as per SOP. None of the standard calls given by PM were acknowledged by the PF.

Before the thrust reversers could take any effect, they were stowed back. While the reversers were being stowed, the aircraft brake pressure was momentarily reduced, decreasing the longitudinal deceleration. This action by the PF coincides with a call by him of “****”.

Thrust reversers were deployed for the second time 15 seconds after touchdown, when the aircraft was at 8200 ft beyond the threshold, max reverse thrust was commanded and the engine began to spool up. Thrust reversers remained deployed for a period of approximately 07 seconds and by 9100 ft beyond the threshold (paved portion of RESA) as the CAS approached 60 kt, they were stowed back with the engine fan speed (N1) still high.

Two distinct calls from the PF and PM of “****” were recorded within a gap of one second on the CVR, when the thrust reversers were stowed again and the aircraft was about to leave the runway surface (paved portion of RESA) and enter soft ground.

Speed brakes were stowed back shortly after ‘SPEED BRAKE DO NOT ARM’
light came on. At this time, aircraft had travelled 105 ft in to RESA (soft ground). However, the commanded brake pressure was recorded on the DFDR till the recording stopped. At no stage, after touchdown, were the thrust levers moved forward at any time on the landing roll.

The aircraft did not stop on the runway and this resulted in runway overrun. The aircraft exited the designated end of runway 10 (8858 ft) at a ground speed of 84.5 Kt and then overshot the RESA, broke the ILS antennae and a fence before plummeting down the tabletop runway. The aircraft fell to a depth of approximately 110 ft below the runway elevation and impacted the perimeter road that runs just below the tabletop runway, at a ground speed of 42 Kt. Aircraft came to an abrupt halt on the airport perimeter road, close to the perimeter wall. There was no post accident fire. The impact caused the aircraft to separate into three sections and resulted in 21 fatalities including both pilots.

The AAIB analysed that whatever possible landing scenario they were looking into, it was not possible to stop the aircraft within the runway remaining with the aircraft touching down 4438 feet past the runway threshold. However, had thrust reversers been applied at maximum reverse thrust, a runway friction coefficient of 0.15, the speedbrakes been extended within 1 second after touchdown and brakes engaging within 2 seconds after touch down, the aircraft could have stopped past the runway end, about 9383 feet past the runway threshold, but before the downslope.

The analysis also showed that even a balked landing, a go around being initiated after touchdown yet before thrust reversers being selected, would not resulted in the aircraft reaching lift off height before the runway end.

The AAIB analysed that the aircraft performed the first approach to runway 28. During final approach the captain's windscreen wiper failed about 27 seconds after it was selected on. Nonetheless the captain continued the approach to decision height, then a go around was initiated. The AAIB annotated that the reason for the go around could not be worked out from the evidence available. When the aircraft climbed out, ATC changed the active runway from 28 to 10 in order to accomodate the departure of another aircraft. This changed the headwinds on approach for runway 28 into tailwinds for the approach to runway 10 however. The crew failed to prepare the approach to runway 10 and in particular compute the landing performance. According to FDR data the aircraft experienced a 16 knots tailwind at 30 feet AGL on final approach to runway 10. In addition the crew had selected flaps 30 rather than flaps 40 for the approach due to expected turbulence, the approach speed thus was 8 knots higher than it would have been with flaps 40, in addition additional drag during the roll out was lost. The AAIB wrote:

Landing with Tailwinds on a Wet Runway

AXB 1344 accepted to land on runway 10 in haste without taking into account the implications of their decision. The cockpit crew did not have a discussion or briefing with regard to landing with tailwinds on a wet runway. Lack of importance given to correct landing technique, compounded by massive increase of thrust up to 83% N1, after crossing the threshold, resulted in extended flare and a long landing.

Further the AAIB wrote: "The crew did not consider the unserviceability of the windshield wiper that warranted a diversion to an alternate airfield as mandated by the SOP."

The AAIB analysed the short final:

At time 60 seconds before touchdown, descent rate increased to approximately 1000 fpm. At time 40 seconds before touchdown, the Autopilot was disengaged as the airplane descended through 800 ft PA while the Autothrottle remained engaged. At time 35 seconds before touchdown, the average pitch attitude was reduced and the descent rate began to increase, momentarily reaching 1500 fpm. At time 31 seconds before touchdown (9 seconds after Autopilot was disengaged), the PM also gave a call for “Rate of Descent” and PF acknowledged this call with “Check”. Realising that the PF had not reduced the ROD sufficiently, the PM again gave a call “Rate of Descent... Captain”. At this stage, they were 0.5 NM from touch-down and were still below the GS. The PF responded to the PM’s second call with “Yeah, Yeah...Correcting... Correcting...Correcting”. 29 seconds before touchdown, the crew increased the pitch attitude and the descent rate began to decrease, reaching 300 fpm by time 23 seconds before touchdown, before increasing once again towards 1000 fpm. Simultaneously, glideslope alert (caution) from EGPWS “Glideslope...Glideslope” was heard twice at 14:09:58 UTC. This indicates that the aircraft had deviated from the glideslope by more than 1.3 dot. At this point, the DFDR data revealed that the aircraft had deviated by 1.7 dot below the glideslope. The PM attracted the PF’s attention to this, by a call of “Check”. This was immediately followed by a worried and strained PM’s call of “uh..um”. Thereafter, the descent was arrested and the aircraft came slightly above the glideslope as both engine thrust increased to around 60% N1. While the aircraft was at 92 ft RA, it crossed the threshold of runway 10 with a ground speed of 169 kt and thrust on both engines was just above 61% N1.

At time 16 seconds before touchdown, the sink rate (negative vertical speed about the CG) was arrested. Flare initiation was difficult to discern due to variations in column deflection. By time 10 seconds before touchdown, while the aircraft was at 1363 ft from threshold, sink rate had decreased to nearly 02 fps (120 fpm) after thrust was increased manually by the crew up to 83% N1 despite autothrottle commands to reduce thrust. The manual throttle inputs were verified by comparing throttle resolver angle inputs and conflicting throttle rate commands. For the following 05 seconds, sink rate remained between 02 and 03 fps (120/180 fpm). During this period, radio altitude decreased from approximately 20 ft to 12 ft, indicating that the aircraft floated. At 07 seconds before touchdown, while the aircraft was at 16 ft RA, the PM once again tried to catch the attention of the PF by calling “Just check it”. At this point the aircraft was at 2500 ft beyond the threshold and 500 ft short of end of touchdown zone which at Kozhikode runway is marked by the lights on either side of the centre line. At time 05 seconds before touchdown, the sink rate began to increase gradually towards 12 fps (720 fpm) as the nose was lowered and thrust was reduced. This was followed by a feeble, uncomfortable call of “...Captain” by the PM when the aircraft had crossed the end of touchdown zone (3600 ft beyond the threshold). While the aircraft was crossing 10 ft RA, he gave a definite call of “Go around”, to which there was no response from the PF. The aircraft touched down in less than 01 second after this call.

The PF continued on unstabilized approach to land in spite of caution from PM and EGPWS. Starting from 35 seconds before touchdown (approximately 700 ft PA on approach) till touch down on the runway the stabilised approach criteria as mentioned in Para 25.4 of company OM part A Chapter 25 mandated a Go Around. On crossing the end of touchdown zone, which is clearly marked he once again continued with a long landing. Even after a clear Go-around call, where it was imperative on the part of PF to initiate a missed approach, he did not go-around. This was a gross violation of the SOP. On seeing no response from the PF, it was mandatory for the PM to take over controls and initiate missed approach. The PM did not take over the controls and initiate a missed approach when required to do so.

The AAIB analysed that the captain was suffering from diabeters typ II Mellitus, which was acceptable for flying duties with a proper prescription of medication, which had been issued to the captain. However, the captain not only possessed these prescribed drugs, but also carried 4 other types of diabetes medication. It was obvious he was not following his prescription, all types of drugs found in his possession were also found in his blood sample. These drugs had a serious risk of causing hypoglycaemia (blood sugar levels below required levels). The AAIB wrote this hypoglyaemia could result in "unconsciousness/coma, palpitation, anxiety, sweating, excessive fatigue, nausea, tingling lips, blurred vision, slurred speech or tremors. It may result in only cognitive effects like mental confusion, light headedness and sluggish psychomotor responses. All this can result in decrement of flying performance, which deteriorates further with the complexity of the task at hand."

The AAIB analysed that when the first officer called for a go around, the captain still continued the landing and concluded this indicates the captain completely lost situational awareness. In addition, "Get-Home-Itis" may have contributed to the desire to complete the landing, the AAIB wrote: "The PF was rostered for a scheduled flight for the following day. Any diversion of AXB 1344 flight would have placed the PF in FDTL and he would not have been available to operate the next day’s flight. PF was aware that there were no additional Captains at that base, other than himself to operate that flight. Hence, the PF created a misplaced motivation for himself (to be available for next day’s flight) and did not divert after the wiper was found unserviceable during the first approach and pressed on to land during the second approach (as another ‘missed approach’ would have left him with no option but to divert). According to the statement of the cabin crew, the PIC seemed anxious to return to Kozhikode in time and hence his actions and decisions were steered by a ‘misplaced’ motivation to land back at Kozhikode as scheduled."

In addition the AAIB analysed: "The ‘Steep Authority gradient’ in the cockpit of AXB 1344 acted as a barrier to the crew involvement, restricting the flow of feedback from FO especially with regard to threat analysis and problem solving. Only the most assertive and confident FOs would be able to challenge the authority of PIC. "

[MPN11]

Skywards747

Likewise Mac/Safari. Sums it all up, really. :=

[Big Pistons Forever]

There is good news here. The accident report clearly did not pull any punches' which certainly has not been the been the case for other reports from non Western airline accidents

BUT, has anything changed with respect to DGCA oversight ? The regulator was enviously not paying any attention to this airline.