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Air India Near Death Incident

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Air India Near Death Incident

Old 9th Oct 2010, 17:59
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Air India Near Death Incident

Just been sent this by an old fiend and colleague from Air India days. Must say, I'm not surprised and glad I left some time ago. I know the personalities involved and I am certain of both the truthfulness and accuracy of the narrative.

I am writing this for two reasons:

1. To absolve myself of the professional duty to report an Incident. I feel it will do much more good to send this to you all than send it to Air India Management. They will just deny that it ever happened, accuse me of somehow exaggerating the event, or fire me for my insolence in bringing it up at all.

2. I also fear for my safety in country. Jail in India? Hospitalization? I don’t think so!


Recent Air India B777-200LR Flight, DEL - JFK.

It was late at night. 0025L. I was Second in Command (P-2: expats are never in command if there is an Indian commander present). We were very heavy weight and the temperature was hot. No Assumed Temperature thrust reduction was used and we requested RWY 29 for departure to avail ourselves of the extra ground run.

Takeoff was normal except for the fact that our lift-off speed was well above V2 and we had a low altitude “hold down” of 1,700’ (not even 1000’ above the airport elevation of 777 feet). The aircraft climbed rapidly as the nose was pulled to a higher than normal attitude to bleed off the extra airspeed and the autopilot was engaged rapidly after takeoff at approximately 200’ AGL.

The aircraft automation captured the altitude set in the Altitude Window immediately and started the automatic level off maneuver. Since the throttles were at a high power setting (no Assumed Temperature setting) and since the flaps were still set at 15 from takeoff, the aircraft Autothrottles retarded the engine power to idle to protect against flap overspeed (I think it was trying to limit the speed to below 230 knots).

At the same time that the throttles were retarding to idle, Air Traffic Control (ATC) directed a large left hand turn followed shortly thereafter with a separate radio call directing us to climb to 2800’ (only a 1,100’ foot change in altitude). The First Officer was preoccupied with the radio calls and missed the next crucial event.

Just prior to beginning the turn the Captain disconnected the Autothrottles because he didn’t know why they had reduced the thrust to idle. He thought they were malfuntioning. He then commenced the turn with the Heading Select knob as directed by ATC and forgot about the throttles being at idle. The airspeed continued to bleed off.

When the next altitude change was given by ATC, it was dialled in by the First Officer (while the aircraft was in a turn) even though the autopilot was engaged and this Mode Control Panel (MCP) change should have been executed by the Captain (the Pilot Flying). At this point I am not sure if Flt Level Change was selected or if it was still in VNAV, but the aircraft began a climb while still in the turn.

I was preoccupied with watching the airspeed which was rapidly decreasing. I was sitting in the left jump seat (located just between the Captain and First Officer) and started announcing loudly “Airspeed!”, “Airspeed!” as the speed decreased below 200 knots. When there was no appropriate response and as the airspeed decreased below V2 I yelled as loud as I could “Lower the Nose!” “Maximum Power!”, “Maximum Power!” I undid my seat belt and was leaning forward to push the throttles to the firewall when the Commander beat me to it and fire-walled the throttles as he disconnected the autopilot and lowered the nose of the aircraft. The First Officer had placed her hand behind the throttles as they were moved forward but did not touch them. TOGA was NOT pushed. We were at V2 minus 15 knots and the stick shaker had activated along with stall buffet onset by the time the engines spooled.

We were in an undeveloped, (but rapidly developing) heavyweight takeoff stall. Had it been one more nanosecond, we would have been way too far behind the power curve to recover. There was no altitude to exchange for airspeed. The aircraft’s 110,000 lb. thrust engines spooled to full power and thankfully we accelerated (slowly at first) to a safe airspeed.

The flaps were oversped during the recovery (since there was no Autothrottle protection). The flaps were retracted by the Captain during the recovery (NOT by the First Officer). The First Officer called for “Autothrottles” and they were reengaged. The throttles went from maximum thrust to climb power as expected. Another altitude change was given and we continued the climb to cruise altitude in VNAV.


Some lessons:

a. Brief a low altitude hold down and how you are going to accomplish it - especially if you have a new First Officer in the right seat. Low altitude hold-downs are often screwed up. This was almost fatal! I like to hand fly hold-downs and let the First Officer use the airspeed bug for acceleration. That means the First Officer has to be able to operate the MCP along with the radios.

b. ‘Autopilot – ON’ with ‘Auto Throttles – OFF’ = bad Juju!

c. Autopilot ON at 200’ AGL after EVERY takeoff on EVERY flight = no pilot proficiency.

d. First Officer changing the Altitude Window or any other item on the MCP when the autopilot is on and changes are supposed to be Pilot Flying responsibility = more bad Juju.

e. Once this crew was out of their normal ‘habit pattern’ they were lost as to what to do about regaining control of the aircraft. MAINTAIN AIRCRAFT CONTROL

f. Air India needs more experienced ex-pats to avoid future fatalities.

The dilemma:

a. I told the Commander it was his obligation to report the event. He almost killed 300 people. What is my obligation to report this? If I report, I am fired for sure – or found dead in my hotel room in Delhi. I am sure he is politically well connected.

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.
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Old 9th Oct 2010, 18:25
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jstars2;

Can you ask your friend:

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

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

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

Does Air India practise SMS?

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?

These are standard approaches to flight safety that are in place at most major carriers. Flight data analysis programs are used to examine this very kind of event.

I am well aware of the criticisms of some aspects of aviation in India and that cultural issues can be a factor in CRM and open safety reporting but none of this negates the requirement to have in place these minimum safety tools.

PJ2

Last edited by PJ2; 9th Oct 2010 at 19:44. Reason: clarification
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Old 9th Oct 2010, 19:02
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Sounds like the Captain should have been found in the Hotel Room It's quite sad that it took an observer or a jumpseater to save the day. After all that's the job of the Captain.

Another reason to have Professional Flight Engineers,

Last edited by fesmokie; 9th Oct 2010 at 19:38.
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Old 9th Oct 2010, 19:11
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Sad

Should that ended up on a big smoking hole the Times Of India headline news would include "...another tragedy caused by an expat captain..."
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Old 9th Oct 2010, 19:19
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Notwithstanding, of course, the stupid low first stop altitude in the first place. Another example of daft Indian ATC procedures.

Well done for reporting on this forum though. It clearly would not get reported by that corrupt country's authorities.
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Old 9th Oct 2010, 19:23
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I like to hand fly hold-downs and let the First Officer use the airspeed bug for acceleration. That means the First Officer has to be able to operate the MCP along with the radios.

b. ‘Autopilot – ON’ with ‘Auto Throttles – OFF’ = bad Juju!

c. Autopilot ON at 200’ AGL after EVERY takeoff on EVERY flight = no pilot proficiency.

d. First Officer changing the Altitude Window or any other item on the MCP when the autopilot is on and changes are supposed to be Pilot Flying responsibility = more bad Juju.
Seems like some contradictions in your "wish list" here; there is a time and place for manual flying (discussed ad nauseam on this forum). A better understanding/appreciation of automation might have prevented this near catastrophe. 777 is a great airplane, but there are lots of things waiting to bite you.
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Old 9th Oct 2010, 21:23
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Jesus christ.....

Not sure what else to say to this really. Is India really that bad in terms of corruption and lack of any CRM?

I'm amazed that as a flag carrier there's no incident reporting system that can be used without fear of finding a razor blade in your Bhuna!

Frightening and sad that in this day and age we're not beyond situations that could so easily have turned into a very large smoking hole.

Very well done for the expat guy jumping in though. Shame the other 2 muppets in the front seats needed prompting to firewall the throttles when the airspeed bled below 200kts in the turn.
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Old 9th Oct 2010, 21:44
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...excuse my ignorance...

...but it seems that the Autopilot Cowboys just won't learn. Same goes for the incident in Ireland with the Indian G-IV (V?) who were too busy following lines and playing with the FMS to notice they were just about to fly into terrain - thank God for the alert ATCO.

FLY the aircraft, deal with anything else later. No f^~$&% use of being on the right heading with the right autopilot setting when you hit the ground is there?

Sadly there's pilots out there who see raw data / FD AP-off flying as something unnecessary - but then again most airlines don't really recommend aviating anymore do they.

I for one will continue to fly raw-data departures and arrivals as often as possible, because I am certain it will save my butt one unfortunate day.
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Old 9th Oct 2010, 22:25
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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.

Still pretty poor piloting though, lucky your friend was there.
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Old 9th Oct 2010, 22:33
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Innflight

Sorry for disagree with you: decades of research and advance on electronic/software/systems have proven that the automatic devices we have on modern aircraft have been much more saving buts than burning them.

The fact that a poorly trained crew that don't understand the basics of the aircraft systems they are operating cannot be used to validate the argument that technology is in any way 'bad'.

This was a gross and unnaceptable lack of basic airmanship. The pilot who did this report lost a golden chance to get things on track if he requested FAA (he could do that in conditions of annonimity) do download the CVR upon landing at JFK. Lots of eyebrows will be rising and maybe some corrective measures would be taken more quickly and effectively.

May I humbly suggest you to use the automatic devices of your ship AT THE MAXIMUM extent. They are there to help you, and will much more likely save your day than burn your butt.


KBROCKMAN: OH NO! You will spare us of another BORING Abs x Boeing thread, for God sake!

Last edited by fullforward; 9th Oct 2010 at 22:49.
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Old 9th Oct 2010, 22:52
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Okay than , no A vs B.

KBROCKMAN: OH NO! You will spare us of another BORING Abs x Boeing thread, for God sake!
Okay, maybe that remark was not really contributing much to this thread but that was the first thing that went through my mind, but you're right this has more to do with poor airmanship ,and also poor communication in the cockpit.
Also some pretty weird ATC demands ,1700ft MSL at a 777ft Airport with a plane close to or at MTOW on a hot day , what's up with that ?
That's only a little over 500 ft above second segment climb, talk about unnecessary flight-deck stress.
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Old 9th Oct 2010, 22:56
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flaps were oversped during the recovery (since there was no Autothrottle protection).
Are you sure?
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Old 9th Oct 2010, 23:02
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Yes

"Also some pretty weird ATC demands ,1700ft MSL at a 777ft Airport with a plane close to or at MTOW on a hot day , what's up with that ?
That's only a little over 500 ft above second segment climb, talk about unnecessary flight-deck stress."

Fully agree.
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Old 9th Oct 2010, 23:16
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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. - This commander does not know if his aircraft is fitted with OFDM. - This crew reduced thrust on their aircraft, while configured with flaps, to IDLE while below 1000 ft. AGL. with automation engaged. - The flight was continued to JFK while all crew were aware that their aircraft went out of the flight envelope during takeoff with possible inherent structural damage due to a flap overspeed. While I have heard of difference in standards between EU/USA/AUS carriers and the rest, this is beyond me...
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Old 9th Oct 2010, 23:21
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Innflight is correct. Expecting automation to be better than handflying is not what a pilot should be. The pilot should be better than automation. A pilot has the ability to use judgement on what is happening at the moment. He can annalyze what is a possible problem on his approach such as windwhear and other factors. I always assume an autoland approach will throw me the airplane in a bank and have me recover at low altitude as it has happened to me and I have to recover. Human intervention fixed it.
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Old 9th Oct 2010, 23:29
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could be a good idea, but...

105

"The flight was continued to JFK while all crew were aware that their aircraft went out of the flight envelope during takeoff with possible inherent structural damage due to a flap overspeed. While I have heard of difference in standards between EU/USA/AUS carriers and the rest, this is beyond me...".

It's very likely a status/eicas msg woul be triggered and the operating crew would notice it.
Regarding a damage due to flap overspeed again if real it would trigger a warning and a very clear eicas message. A proper checklist would call for immediate actions.
A CVR download by the FAA at JFK would be very effective.

P51

Mate: there's probably thousands of lines here debating hand flight x automation. I don't know your backgrounds, but there's a lot of wrong assumptions on your statements. Do you have a built in windshear predictions device? Or have you ever tried a CAT II or CAT III approach on a windy and rainny night?
The botom line is: it's SAFER to operate a modern aircraft using the automatic features as we can manage more effectively our flight. On the other hand, it's our job to constantly monitor them and if it screw up immediately take over!
Furthermore, it's against of the SOPs on majority of the airlines to go manual at will. 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.
We need to be proficient both on managing the electronics and flying by the seat of the pants.

Last edited by fullforward; 9th Oct 2010 at 23:50.
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Old 9th Oct 2010, 23:36
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I am not familiar with the 777 so I'm relating the incident to my own aircraft (737)
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Old 9th Oct 2010, 23:59
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I have a few questions for my general culture (I'm a TP driver and have never used autothrottle):

1.
The automation reduced the power to idle so as not to exceed the max flaps speed.
They were levelled at 1700ft.
In this particular situation and without human intervention, what speed would the automation have flown ? and is there a way for the PF to know or see that speed somewhere so as to be sure it is safe ?

2.
On this type of a/c is it normally an acceptable reflex to disconnect only the autothrottles while keeping autopilot engaged like he did. That sounds a bit odd to me from the persepective of a pilot needing to actually feel what's his a/c doin', specially while suspecting that somthing's wrong at such a low altitude... just a thought...

thanx
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Old 10th Oct 2010, 00:41
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bleeds off;
The automation reduced the power to idle so as not to exceed the max flaps speed.
While the "report" mentions the possibility, the B777 autothrust does not reduce to prevent "overspeed" of the flaps - in fact no transport's autothrust I have flown does this. There is a load relief function which will accomplish this however. Autothrust is targeted for the FMS or selected speed. On the Airbus, (and I agree, it is a waste of bandwidth to turn this into an A vs B commentary), but the autothrust also targets "over and underspeed" flight circumstances.
On this type of a/c is it normally an acceptable reflex to disconnect only the autothrottles while keeping autopilot engaged like he did.
Although not actually stated in any FCOM/AOM I've used, it is nevertheless a serious operational error to disconnect the autothrust and leave the autopilot engaged. The reverse, (autopilot disengaged, autothrust engaged) is normal. Notwithstanding the poor navigation constraints on the departure, they are no excuse for not handling the aircraft correctly - the takeoff briefing should cover this and make expectations clear to everyone on the deck before the thrust levers are advanced.

Lot of folks setting their hair on fire here but we still have no information on the questions I asked at the start of the thread regarding the safety processes which are in place and used at Air India.

PJ2
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Old 10th Oct 2010, 00:45
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ACARS would have captured this for sure,certainly in my airline anyway.

In an IDEAL world he should have dumped fuel and gone back if he thought there was damage to the flaps,but he was not in command.

Anyway he is sharing information here and I can tell you things happen VERY rapidly when you have a low altitude level off followed by a turn and I am not going to criticise him on this forum,just learn from it.

I am about to retire from my present airline and briefly flirted with the idea of flying for AI for a year or two now I am glad I did not,too old to have to deal with an operation like this.

Last edited by faheel; 10th Oct 2010 at 00:57.
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