Air India Express B738 crash

[Stick_Rudder]

Machinbird,

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

[safetypee]

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

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

[Machinbird]

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

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

[drive73]

Step,

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

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

[cyrilroy21]

Air India evaded mandatory cockpit training for pilots

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Travel Biz Monitor :: Air India evaded mandatory cockpit training for pilots

[cyrilroy21]

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


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

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

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

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


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

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

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

M

[the_idealist]

Facts based on the report

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

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

[captjns]

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

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

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

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

[BOAC]

Assuming QNH, and the airport is around 400'

flap 15 at 4630' at 6.7 DME.

At 3465' 4.3 ILS DME,

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

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

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

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

Originally Posted by captjns

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

"OK Blogs - need any more clues"? How on earth do you prevent this? This is so basic.

[the_idealist]

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

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

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

[Lonewolf_50]

The Court of Inquiry determines that cause of this accident was
the Captain’s failure to discontinue the ‘unstabilised approach’ and his persistence in continuing with the landing, despite three calls from the First Officer to ‘go around’ and a number of warnings from EGPWS.
...
In no way does that justify not executing a go around.

While this has been mentioned before, for the benefit of our non pilot readers it might be worth reviewing a "back to basics" imperative.

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

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

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

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

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

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

Two issues that the organization has to address:

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

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