Air India Near Death Incident

[Coireall]

"Alpha floor to protect against stupidity ???
Well this would have been where the Bus might have been more useful than the Boeing , Alpha floor would have been nice to have in these circumstances."
The B777 autothrottle will wake up provided the A/T arming switches are left in the ARM position.

[A37575]

Though I think is a good idea, from time to time, to turn off all automation on a clear day, low traffic and go as a Cessna 150.

Reading the above I swore I would not get involved in the never-ending debate between pilots and automatic pilot status monitors. Clear day - low traffic? Stone the bloody crows chum - are you that blindly dependant on the crutch of automation that you need a CAVOk condition to (shudder in fright) turn off the automatics and actually take control of the aeroplane and fly it.

Can't you see the obvious? It is because blind reliance on automation at all costs degrades pure airmanship and flying ability that these pilots are incompetent to seamlessly switch from automation to manual flying when the circumstances demand. And you say that even more automation is safer? I don't think so.

[A37575]

if it appears to be malfunctioning turn it off and revert to basic flying skills

Which few airline pilots seem to have nowadays judging by incidents and accidents over the past 20 years or so of superb automation systems...

[7x7]

Reading the above I swore I would not get involved in the never-ending debate between pilots and automatic pilot status monitors. Clear day - low traffic? Stone the bloody crows chum - are you that blindly dependant on the crutch of automation that you need a CAVOk condition to (shudder in fright) turn off the automatics and actually take control of the aeroplane and fly it.

Can't you see the obvious? It is because blind reliance on automation at all costs degrades pure airmanship and flying ability that these pilots are incompetent to seamlessly switch from automation to manual flying when the circumstances demand. And you say that even more automation is safer? I don't think so.

There are major airlines out there, based not too far away from India, which have SOPS demanding that pilots use maximum levels of automation available at all times on the line. There are some among that airline's line pilots who do see the obvious you refer to, (and have said so), but not a one among the management who have brought in that rule (some years ago now).

[PENKO]

b. I think the ‘voice recorder’ data is gone. It was a 15+ hour flight. I don’t know how long the flight recorder data stays in the system. It would have the most information regarding this event.

c. I do not know if the aircraft reports the event automatically by ACARS or other means.

Maybe it's something I don't understand about non-Western airlines, but surely as a captain or a pilot for Air India, you would know if your flight information was recorded and downloaded by ACARS/datalink/QAR? Or is there no such thing in India?

[DozyWannabe]

Originally Posted by 7x7

There are major airlines out there, based not too far away from India, which have SOPS demanding that pilots use maximum levels of automation available at all times on the line.

Then there is a serious problem with those airlines. I don't know how many times one can repeat that automation was developed as a back-stop to allow flight crew to manage the flight more effectively - *not* as a substitute for airmanship period!

Even Bernard Ziegler in full flow never said "See? the aircraft is flying herself. Now you don't even have to monitor the instruments or maintain the situational awareness!".

Huck - 727 crews had serious problems with airspeed in the early days of the type. In that situation, had the monitoring come unglued as it appeared to here, the 727 would have ended up a smoking hole in the ground as the engines would not have been able to produce the required thrust in time.

[leftseatview]

i smell a rat

this "story" doesnt ring true...at least in as far as the projected consequences of reporting said "incident"
Delhi elevation is 777' and the lowest level that is cleared after Take-Off is 2600'.(ie 1900agl)
Though i drive the bus,i dont beleive the the 777 cant meet this requirement by simple use of the automation.
Assuming the crew made a complete hash of things(and 777 drivrers seem to imply that the A/T would have saved the day even if it was off)their actions can be very easily verified by the DVDR(the CVR would not be the primary source of info)
Air India(and other indian operaters) are audited by IATA, and definatly have a FOCA prog.( 100% DVDR monitering and, definetly preserved if reported)
Both the airline and the regulator(DGCA) have annonomous reporting systems.
There has been no instance of any expat(or Indian national)being harmed as a result of reporting any incident.
This old friend of Jetstars2 sounds rather alarmist...with a rather crude agenda of promoting "manual" vs "automation" in flying as also the "expats" vs "indians" debate.
He might have reason to complain if he reported the matter and was ignored,but not to bother even an anonomous report and use this forum instead dosent exactly project good professionalism

[jstars2]

A little more information

Just received email replies from India:

PJ2

Q. Does Air India maintain and use a flight data analysis program on the B777 fleet or any fleet?

A. Random sampling of QAR data takes place. Data link/ACARS real time download of engine/flight data is thought to be implemented but the resource to process fleet wide data is not available. Also of interest is that neither CPDLC or EFB is used on the B777 – separate issues but indicative, perhaps, of a particular corporate mindset.

Q. Does Air India maintain a system of Air Safety Reports which can provide for anonymous input if so desired?

A. There is one but not at all trusted as the established procedure is: identify culprit, rigorously interview, belittle, apportion full blame, excoriate, punish.

Q. Does Air India have a Safety Reporting Policy which holds harmless anyone who experiences an incident and self-reports?

A. You’re kidding, right? You’d then never have a suitable culprit to be punished

Q. Is the fear of being fired or of "death in a hotel room" for reporting a serious incident a distinct possibility at Air India which one must guard him/herself against?

A. Being fired at any time for a small transgression is a distinct possibility at Air India. Second point concerning "death in a hotel room" – anything can happen in India, especially in “Maximum City” (BOM).

Nikon744

Just before I left, nearly a year ago, I do recall insane low altitude clearances at DEL off new runway 29/11, despite there being perfectly reasonable SIDs published. My friends tell me these idiotic clearances continue and that the cover-up of this incident contributes to their continuance. From memory the easily flown published SID north/westbound off R/W11 calls for a right turn at altitude 1,700 feet, climbing to altitude 3,600 feet. Off R/W29 it is a left turn, heading 170 and climbing to, I think, FL60 (Transition 4,000 feet, MSA 2,600 feet). I will, of course, stand corrected, as memory is a tricky thing. The point is that I am told that these SIDs are still not in use as of this date and, hence, life is made a lot more difficult as a result (indeed, as events appear to have shown).

From information passed to me, the AI noise abate SOP out of DEL is to select Page 2 of Takeoff in the FMC and insert Accel Ht - 1,500 (altitude 2,277 feet) and Thrust Reduction - Flap1.

My information is that the Auto Throttle Arming Switches were turned off by the handling pilot (aircraft commander).

[TopTup]

For those of you WITHOUT experience of aviation in India, namely Air India...

Can't believe CRM is as bad as that? Trust me, it is and worse. "Commanders" render themselves God-like characters and FO's are submissive "yes men/women" who fear the Commander's wrath.

Not long after I left AI the latest 777 First Officer recruits had between 175-250 hrs total aeronautical experience. Yes. C152 one day, B777 the next. Twin training / knowledge? Don't make me laugh! Question asked of me from a B777 FO: "What exactly is V1?" (See other thread on the Sth E Asia forum on twin engine credentials many of the AI FO's do not have or need to gain employment via the illustrious DGCA and AI system).

Reporting system? Despicably corrupt and humiliating to witness the cheapness of safety, let alone life. For a long time they were fixated on heavy landings. True story: Expat Capt gives FO the landing. Automatic reporting indicated a heavy landing. Expat Capt called into Safety Dept to be abused, belittled, yelled at by between 2 and 4 "managers". "Who are you do 'give flying' to FO's!??

Some here question what they cannot believe because they are privileged to never experience such a disgrace as is AI. I saw Capts (not only FO's) unable to fly straight & level with AP and FD's off, let alone fly a raw data ILS with 15 kt xwind. They were passed / checked to line. When I failed someone for doing the same I was called into the Safety Dept and ordered to change the fail to a pass. I refused. I resigned. Said Capt was given a line flight to DXB soon after and checked to line by his "batch-mate".

That airline is a disgrace and if the ICAO, FAA or least of all the corrupt as all hell DGCA had any spine that airline would be grounded. They do not WANT to look for what those of us who experienced it saw and see day in and day out. Blood on their hands in my opinion.

Go back and read the thread on the Mangalore Crash again. Lessons leant?Hell no.

AI survives on luck, not safety, but for the remotely few truly professional airmen there (both local and expat).

[PJ2]

Heathrow Director,

Thanks for the correction. I can't believe I got it wrong after having done it for so long, but there it is, wrong. Memory is the second thing to go after retirement...

jstars2;

Thanks for getting back on my questions. On Q.3, no, I'm not kidding. Sometimes these things need saying even though we suspect what the answer will be. Your comments on flight data analysis and safety reporting don't surprise me at all.

PJ2

[fdr]

Circuit Breakers

remarks: - I understand this person is a 777 commander since he states he is second in command. However he has not the common sense to pull the CVR breaker so it halts recording and maintains the incident recording. - d105

Before bitching about his knowledge, suggest you refer to the location of the CVR Cb on a B777, which is fully in compliance with the criteria of FAR25, CS25, in that it is remote to the flight deck.

[jstars2]

PJ2

Gets better. A few months back, another expat captain was riding as P2 (of a double crewed Ultra LH flight) on the jump seat for TO, on the daily Air India BOM-JFK (16+ hours flight). TOGA was selected to begin the TO run on R/W 27 but Auto Throttle (A/T) did not engage so instead of setting thrust manually, the commander as PF selected A/T on the MCP as he rolled down the runway. Only thing was, he inadvertently selected Autopilot, which duly engaged (the industry was going through a spate of these events at the time) and as both he and the 250 hour ace in the RH seat failed to check their FMAs, the Max AUW aircraft, with 112 tons of gas on board, now thundered down the runway with no means of rotating and hence getting safely airborne.

Expat captain had noticed the above events as they unfolded (easily done from the jump seat) and had started out conversationally pointing the situation out. On getting no response, his cries became louder (and shriller) to the effect that Autopilot should be disengaged until in the end, in mortal peril, he found himself shouting at the top of his voice to disengage the Autopilot and un-strapping to reach over and do the damned thing himself. Commander then seemed to wake up, hastily disengaged the Autopilot and snatch rotated near the end of the runway, narrowly avoiding smashing through the boundary fence as a flaming fireball, carving across the traffic choked main road and exploding amidst the dense residential housing beyond.

During the subsequent uneventful cruise, an extremely shaken expat captain eventually pointed out that an Incident Report had to be filed so that the airline and the industry could learn the lessons available but the commander remained evasive and non-committal, presumably not wishing to go through an upcoming Safety Department session of “identify culprit, rigorously interview, belittle, apportion full blame, excoriate, punish”. In the event no report was made but the expat captain reportedly made a confidential FAA/NASA submission back in the US.

I think that we can all draw our own conclusions on the current AI Safety philosophy.

[fdr]

JStars:

If your friend is able to avoid operating to India, I would think that he has two choices available.

1. Do nothing further, you have vented his complaint in this forum

or

2. Raise the matter with DGCA-I. I think without having the data to support your allegation that the authorities would not act further, and if they did a white wash would be in order form the DGCA and AI anyway.

Suggest he thoroughly enjoys life in a different location, and forgets the past.

As to the issues of a low alt level off, I have investigated at least one wide body accident where the events you indicate resulted in a hull loss. Interestingly, the manufacturer of that particular airframe modified the ATR logic about 9 months after the accident, to mitigate the effects of a capture of an altitude at a ROC of climb that exceeded the steady state energy available to the aircraft.

To the concerns in relation to safety programs, I would think that they are well founded. In my case, I reported a serious event to a major world leader in safety, to be personally threatened by their management. I departed and reported at the same time. In a later company, I reported as a foreigner a serious safety matter, which eventually was responded to as a serious matter by the management, but of course left subsequently. As a contract pilot, foreigner, Ferringhi/Gaijin/Weikukin etc, you ned to be prepared to move if your conscience and the law dictate that you report an issue. Wish the world was different. Equally, placing faith in the oversight and integrity of the safety institutions to retain confidentiality, or even to do their own legislated duty is potentially harmful to you as the reporter. In the first case, having had data for 120 days on relation to the event, and having analysed the same and come to the same conclusions on the risks, when questioned by their ministry as to any knowledge of such events the safety investigating agency replied "NO". Subsequently, having passed back the additional data of 8 further events in their own envelope (which remains sealed) they found "no events had occurred" which is at variance to the companies own findings of the time. Someday, that envelope, contents, and the audiotapes are going into the public domain...

Don't get me wrong, I believe in reporting, but I also would be surprised to find any organisation which doesn't take retributive action directly or indirectly to you for doing so. Relying on the integrity of the safety oversight institution is additionally questionable. At the end of the day, you have a duty of care to discharge, that will place you in conflict with the system frequently. Even the good ones. The final choice you have is to vote with your feet.

good luck.

PS: there is a large and growing group of people that have been treated this way by the systems, which stand in mute testimony to the stated code of conduct of the companies and the safety oversight institutions. IOSA audit and other compliance programs habitually ignore the evidence of inconsistency between policy and practice, or the failure to implement the same. It is not difficult to identify the discrepancy, yet it fails to be reported as a non compliance, so the rubber stamping continues.

FDR

[Rananim]

"Pilots" are a dying breed mark my words.Ironically,this FDM/QAR has quite a bit to do with it.Not only do SOPS prohibit manual flying but the pilots are afraid to operate manually in case the FDM lands them in trouble.I wont play the race card but I am quite certain that many pilots will kill everyone on board if automation fails/tricks them.Youd have to have been an expat to know this although its fair to say that automation-reliance infects the whole industry.I find it ironic that one of the first comments was to mention Airbus alpha floor NOT that the pilot didnt know how to fly his aircraft.Thats kinda like saying "Damn,we know pilots cant actually fly the thing-put more protection in instead of train the pilot".Like that Turkish crash..all that convoluted discussion about which radalt fed the AT computer and Boeing was a bad boy for not warning the pilot of subtle RA failure.My God,they even forced a company like Boeing to issue a reminder to all pilots about how important it is to monitor AS during approach.

So it doesnt surprise me..pilots in the true sense of the word are dying out rapidly and a new breed is taking over.One that can program the FMS,engage automation at 500' and sit back and watch.Trained monkeys.No joke,you could train a chimp to do same.Its trained and encouraged world-wide.FDM,actually a safety tool but being misused,enforces it.

Why would a Captain of big heavy metal accept an initial clearance of 1000' anyways?Relates to airmanship,another thing of bygone days.Today you have SOP's,blind automation reliance and big brother.Anyone wanting to be a pilot today must be nuts.

[Huck]

It's not like that everywhere.

We are required to keep up our hand-flying skills. And demonstrate them regularly. Our philosophy has swung back from the other side.

[FoxHunter]

Huck

It's not like that everywhere.

We are required to keep up our hand-flying skills. And demonstrate them regularly. Our philosophy has swung back from the other side.

And it was about time!!

[qsyenroute]

"Notwithstanding, of course, the stupid low first stop altitude in the first place. Another example of daft Indian ATC procedures"


Another example: Tripoli/Afriqiyah Airways, Airbus A330, fine technology aircraft low-tech ATC/Navigation infrastructure – result pointless deaths.

In this latest and similar incident - had Indian ATC benefited from decent equipment/training all of this high tech equipment could fly safely and it is intended to do so. The controller would or should not have to issue ludicrously unsafe clearances that compromise the safe operation of transport aircraft.

There is a huge disconnect in the ATM/Aviation system and so pointless. Pilots - you need to make this disconnect better known and/or refuse to accept dangerous departure clearances. The word to ATC is “unable”

[GlueBall]

jstars2 . . .

"...thundered down the runway with no means of rotating and hence getting safely airborne."

Question from non 777 jock: Wouldn't pulling the stick override the engaged autopilot...?

[troff]

Glueball: Yes, the autopilot would disengage.

[jstars2]

Glueball

Very difficult to know if the PF could have been able to exert enough force to disengage the autopilot and then quickly reduce the applied force to make an acceptable rotation in the time/runway space available.

The expat P2 captain maintains that the takeoff would not have been possible without autopilot disconnection. He was very badly shocked by the event.

From the Wall Street Journal 17 March 2010:

By ANDY PASZTOR

Air-safety regulators are ordering U.S. airlines to install new software on Boeing 777s to keep the jetliners from possibly running off the end of runways, a mandate that could ultimately affect more than 800 planes world-wide.

In a safety directive released Tuesday, the Federal Aviation Administration ordered the fix to prevent problems when the autopilot system is inadvertently on while a Boeing 777 aircraft is rolling down the runway just before takeoff.

When pilots try to climb under such circumstances without realizing the autopilot is engaged, they encounter greater than usual resistance in raising the aircraft's nose. As a result, the FAA said, the pilots decide to halt the takeoff at a dangerously high speed.

The order comes in the wake of two Boeing 777 incidents in January in which pilots inadvertently engaged the autopilot before starting to take off. When the crews felt unusually strong resistance from their flight controls as they were trying to overcome the autopilot, they opted to stop at a speed that was too high for such a maneuver. Both planes remained on their runways, Boeing Co. said.

Since 1995, the FAA and Boeing have identified a total of nine similar incidents.

U.S. airlines operate nearly 150 Boeing 777s. Boeing and the FAA said that if, as expected, the agency's order is accepted by foreign regulators, it would affect more than 800 planes.

A Boeing spokeswoman said that since 1995, when the Boeing twin-engine 777 was introduced, the planes have made a total of 4.8 million flights without any injuries or accidents attributed to such autopilot issues.

The FAA's airworthiness directive also calls for other software changes to ensure that Boeing 777s can climb steeply enough to avoid obstacles if one engine fails on takeoff. The FAA said Boeing found during simulator testing that after some 777 takeoffs with only one engine operating, the plane could fail to climb steeply enough on autopilot during the initial phase of flight.

The FAA said that if the autopilots aren't modified, more takeoffs could be halted by pilots just as the front wheels of a Boeing 777 lift off the runway. It is particularly hard for pilots to slow down at that point.

The results include "possible overrun of the runway," the agency said.

Around the time of the January incidents, Boeing issued a service bulletin alerting airlines to install new autopilot software making it impossible for pilots to engage autopilots before takeoffs. Compliance with such bulletins is voluntary. Boeing called for the software changes to be completed within a year.

The FAA decided the matter was more urgent, and that it would require airlines to comply with its order within 90 days after it becomes final.

Corrections & Amplifications
An earlier version of this article inaccurately described a potential problem that could result if a Boeing 777's autopilot is inadvertently engaged during takeoff.