Sleepy pilot caused Indian passenger plane crash
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If there was also a "cold war" atmosphere in the cockpit, then there is a lesson for us all here. If there is animosity in the cockpit we must still function as a team, as hard as it may seem to a lot of us. It is imperative we continue to communicate, even if the other crew member is "sleeping with your wife".
The moment the communication breaks down you are, for all intensive purposes, "single crew". In fact the, the situation would be so bad if there is no communication, the PF would possibly be better off doing "everything" him/her self, then they will be aware it has been done. That is the seriousness of a communication breakdown. This also would include not waking up your fellow crew member at least ONE hour before landing.
Setting a trap, or making a deliberate mistake, for your fellow crew member, endangers all on board.
The moment the communication breaks down you are, for all intensive purposes, "single crew". In fact the, the situation would be so bad if there is no communication, the PF would possibly be better off doing "everything" him/her self, then they will be aware it has been done. That is the seriousness of a communication breakdown. This also would include not waking up your fellow crew member at least ONE hour before landing.
Setting a trap, or making a deliberate mistake, for your fellow crew member, endangers all on board.
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Link To Report
The actual 191 page report can be found here:
http://www.civilaviation.gov.in/Moca...rashReport.pdf
It's a slow download....
http://www.civilaviation.gov.in/Moca...rashReport.pdf
It's a slow download....
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Thanks for linking the report.
I'm not thrilled by the way it was written but I think the overall quality of the work was high and I think the facts support their conclusion. I would have chosen to focus more on the CRM factors in this crash because it was atrocious.
Cause of the crash:
Captain violating just about every SOP there is...
Co-pilot not doing anything about it...just whining.
I'm not thrilled by the way it was written but I think the overall quality of the work was high and I think the facts support their conclusion. I would have chosen to focus more on the CRM factors in this crash because it was atrocious.
Cause of the crash:
Captain violating just about every SOP there is...
Co-pilot not doing anything about it...just whining.
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A new article published on FlightGlobal indicates the aircraft could have stopped on the hardsurface based upon Boeing simulations. I'll leave the comments to the rest of you. This is supposed to be hidden in the accident report (which never fully downloaded for me).
Overrun Air India 737 could have stopped despite late landing
Is this news?
Overrun Air India 737 could have stopped despite late landing
Is this news?
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2.2.15 Braking
Although the runway length of 8003 feet at Mangalore is adequate for Boeing 737-800 operations, most of the pilots prefer to use Auto Brake setting 3 or MAX to ensure timely stoppage of the aircraft. However, in the accident aircraft, the Auto Brake setting was set at 2. After touchdown, the Captain had selected Thrust Reversers and commenced braking. It was initially gradual due to this setting. However, later when the brake pressure had been increased manually, as per aircraft braking system, the aircraft started decelerating much faster. It was brought out by the Boeing Test Pilot during Public Hearing that if the Captain had deployed detent reverse thrust and had applied maximum manual braking at touchdown, the aircraft could have stopped by 7600 feet beyond R/W 24 threshold i.e. on the paved portion of R/W 24.
While such stoppage figures are demonstrable during controlled test flying scenarios, these cannot be considered for landings during routine line operations. However, if the Captain had initiated maxmimum manual braking with Thrust Reversers, the aircraft could have stopped in the overshot area and the accident might have been averted.
Although the runway length of 8003 feet at Mangalore is adequate for Boeing 737-800 operations, most of the pilots prefer to use Auto Brake setting 3 or MAX to ensure timely stoppage of the aircraft. However, in the accident aircraft, the Auto Brake setting was set at 2. After touchdown, the Captain had selected Thrust Reversers and commenced braking. It was initially gradual due to this setting. However, later when the brake pressure had been increased manually, as per aircraft braking system, the aircraft started decelerating much faster. It was brought out by the Boeing Test Pilot during Public Hearing that if the Captain had deployed detent reverse thrust and had applied maximum manual braking at touchdown, the aircraft could have stopped by 7600 feet beyond R/W 24 threshold i.e. on the paved portion of R/W 24.
While such stoppage figures are demonstrable during controlled test flying scenarios, these cannot be considered for landings during routine line operations. However, if the Captain had initiated maxmimum manual braking with Thrust Reversers, the aircraft could have stopped in the overshot area and the accident might have been averted.
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More on Air India Express tragedy
Flight International 3-9 May 2011, reports on the latest information by Indian investigators on the Air India Express Boeing 737-800 crash at Mangalore. The aircraft flown by the Serbian captain was over 1200 ft high above the glide slope at two miles from the runway. At one mile the aircraft was descending at 4,000ft/min with GPWS sink rate and six `pull-up` alarms and crossed the threshold at 200 ft and 160 knots with flaps blown back to Flaps 30.
Pressing on regardless and disregarding the Indian first officer's suggestion to go-around, the captain allowed the aircraft to float as the remainder of the flaps extended and touch down 1590 metres beyond the landing threshold leaving 855 metres to stop. Having already applied brakes and reverse he then attempted a late go-around and finished up in a ravine killing 150 people including the crew.
The first officer proved to be `submissive`and made no attempt to take over the controls to discontinue the ill-fated approach.
The report does not say exactly how he should have wrested control from the captain who was intent on landing. Bash him over the head, maybe? Did the Indian investigation really expect the captain to meekly hand over control to the first officer? If the first officer had been taught to call for a go-around and simultaneously raise the landing gear lever, the outcome could not have been worse than meekly watching death fast approaching.
Crazy self centred captains are a fact of life in some culture driven airlines. At least give the first officer something more tangible to work with than the wide-spread warm and fuzzy but useless mealy-mouthed advice starting with "Please captain we are too high -you should go-around". A fat lot of good that does with some characters in the left seat.
Apart from pointing a gun at the head of the captain the easiest and most effective of last resort is to whip up the landing gear lever and order "Go-Around". At least then a culture obsessed captain can transfer the blame on the first officer for a go-around while taking credit himself for a good decision.
Pressing on regardless and disregarding the Indian first officer's suggestion to go-around, the captain allowed the aircraft to float as the remainder of the flaps extended and touch down 1590 metres beyond the landing threshold leaving 855 metres to stop. Having already applied brakes and reverse he then attempted a late go-around and finished up in a ravine killing 150 people including the crew.
The first officer proved to be `submissive`and made no attempt to take over the controls to discontinue the ill-fated approach.
The report does not say exactly how he should have wrested control from the captain who was intent on landing. Bash him over the head, maybe? Did the Indian investigation really expect the captain to meekly hand over control to the first officer? If the first officer had been taught to call for a go-around and simultaneously raise the landing gear lever, the outcome could not have been worse than meekly watching death fast approaching.
Crazy self centred captains are a fact of life in some culture driven airlines. At least give the first officer something more tangible to work with than the wide-spread warm and fuzzy but useless mealy-mouthed advice starting with "Please captain we are too high -you should go-around". A fat lot of good that does with some characters in the left seat.
Apart from pointing a gun at the head of the captain the easiest and most effective of last resort is to whip up the landing gear lever and order "Go-Around". At least then a culture obsessed captain can transfer the blame on the first officer for a go-around while taking credit himself for a good decision.
But surely the real answer is selection (or even deselection), training, and regulation?
In a well regulated airline things would never have got to this stage in the first place.
In a well regulated airline things would never have got to this stage in the first place.
I like it!
Gear up
Announce G/A on the radio
Push for / select TOGA
Be ready for him to punch you
Gear up
Announce G/A on the radio
Push for / select TOGA
Be ready for him to punch you
If the captain has his hands gripping the thrust levers and by then the autothrottle is already disengaged, the first officer pressing TOGA is wasting his time.
The captain will be too busy cursing and shoving open the thrust levers to punch you anyway. Later maybe - but not if the F/O is bigger than him.
In a well regulated airline things would never have got to this stage in the first place.
In an ideal world perhaps - but not in real life
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A local FTO (courses ranging from PPL to fATPL) organized an introductory presentation at a university and brought an airline pilot to discuss the life of a pilot, training, etc. In the Q&A section, mostly because the pilot is ex-Air Force, the crash of Birgenair Flight 301 (Boeing 757 crashed shortly after takeoff) was brought up in regards to whether CRM was hindered with an all ex-military cockpit crew.
When it was stated that the FO at one point should have take command of the airplane when the Captain refused to listen to both his and the SO's suggestions to keep the airplane level and kept pulling back on the yoke, the airline captain stated very matter of fact that unless the captain was dead or incapacitated, there was no way in hell that the first officer could take command of the airplane. As far as I know, its contrary to what is taught and encouraged but perhaps means you have a job when you get off the plane... but as Tee Emm said, sure beats not being able to walk away at all!
When it was stated that the FO at one point should have take command of the airplane when the Captain refused to listen to both his and the SO's suggestions to keep the airplane level and kept pulling back on the yoke, the airline captain stated very matter of fact that unless the captain was dead or incapacitated, there was no way in hell that the first officer could take command of the airplane. As far as I know, its contrary to what is taught and encouraged but perhaps means you have a job when you get off the plane... but as Tee Emm said, sure beats not being able to walk away at all!
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If the captain has his hands gripping the thrust levers and by then the autothrottle is already disengaged, the first officer pressing TOGA is wasting his time.
This message has been brought to you by cabernet sauvignon
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Might want to have a re-read of that technical manual and the autothrottle section.
The autothrottle ARM mode is normally not recommended because its function can be confusing.
Without having read the full Indian investigation report one could safely assume the captain had disconnected the AT if he intended to manually fly the aircraft resulting in over the fence 200 ft high and 160 knots which is real fast. In that case, given the unusual (?) profile, pressing TOGA in the hope that it would automatically advance the thrust levers with the AT switched off, then nothing will happen apart from FD operation.
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Fireflybob says...
Remember Ameican 1420 in Little Rock, AK on the 1st of June, 1999?
Contiuned approach into severe weather resulting in long landing and overrun... and fatalities at the hands of a "gotta complete the mission" captain. F/O also said "I think we should go around." Even worse was the Captain of that ill fated flight was a management pilot too
!
But surely the real answer is selection (or even deselection), training, and regulation?
In a well regulated airline things would never have got to this stage in the first place
In a well regulated airline things would never have got to this stage in the first place
Contiuned approach into severe weather resulting in long landing and overrun... and fatalities at the hands of a "gotta complete the mission" captain. F/O also said "I think we should go around." Even worse was the Captain of that ill fated flight was a management pilot too
!
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Go-around from the SO seat
30 years ago I found myself in this first officer's position, except I was the second officer (727). After repeated calls for a go-around, I reached up and pushed the throttles up and locked my arm so they couldn't pull 'em back. Eventually, the speed got so high, they both gave up and went around. Ha!
I figured I'd be fired, but when we landed after a nice comfortable stabilized second approach, the captain reached back and squeezed my knee and said thank you.
All you first officers out there: when you know you are right, and your life depends on intervention, you have to speak up. If that doesn't work, get creative. But don't just sit there and let him/her kill you.
I figured I'd be fired, but when we landed after a nice comfortable stabilized second approach, the captain reached back and squeezed my knee and said thank you.
All you first officers out there: when you know you are right, and your life depends on intervention, you have to speak up. If that doesn't work, get creative. But don't just sit there and let him/her kill you.
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pressing TOGA in the hope that it would automatically advance the thrust levers with the AT switched off, then nothing will happen apart from FD operation.
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Getting creative
If they where really way too high and too fast on what is sounding like a very unstabilized approach, and the FO is calling for a GA with the Captain not responding, it would be wise for him to select (and very clearly announce) gear up sooner rather than later forcing a GA while still high enough and far enough from the treshold.
Let the bickering of who was at fault commence after a save second landing attempt under the supervision of management/other company pilots and even if need arises someone from an external overseeing body (eg FAA in the US) with the aid of ATC and flight data.
No reason to die just because someone lost the plot and you where afraid to speak/act up.
Let the bickering of who was at fault commence after a save second landing attempt under the supervision of management/other company pilots and even if need arises someone from an external overseeing body (eg FAA in the US) with the aid of ATC and flight data.
No reason to die just because someone lost the plot and you where afraid to speak/act up.
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If they where really way too high and too fast on what is sounding like a very unstabilized approach, and the FO is calling for a GA with the Captain not responding
I know it is not always easy, and I have met characters that made me think twice as well, but never to the point that I allowed the situation to become dangerous.
But I agree with the view that once it has gotten to this point, a lot of preventive measures have already been missed and that needs to be adressed. Just blaming unassertive copilots for actions from dangerous captains will not solve the problem.
Mindset
In a vintage turboprop simulator with white on black AH, I watched the left seat allow an overbank progress to inverted at 16000'. I was screaming directly in his ear that he was inverted and had to roll the other way. He just sat there all the way down and did not change a thing.
I had a talk with myself about why I allowed the guy to "kill" us. My excuse was that it was only a sim, but what would I really do if it was for real?
Perhaps training needs to be done that persistence in an obviously wrong course is a form of subtle incapacitation subject to the two communications rule. Perhaps part of sim training should be that PF is briefed to do something wrong that PNF is expected to recognise and take over.
I had a talk with myself about why I allowed the guy to "kill" us. My excuse was that it was only a sim, but what would I really do if it was for real?
Perhaps training needs to be done that persistence in an obviously wrong course is a form of subtle incapacitation subject to the two communications rule. Perhaps part of sim training should be that PF is briefed to do something wrong that PNF is expected to recognise and take over.
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Besides being too submissive, insufficiently assertive . . . the F/O had lacked elementary survival instinct.
Staying alive may require immediate, dramatic action not covered by SOP or CRM.
In this case, it was the copilot's duty to physically override the captain's control inputs and effect an immediate go-around by whatever means necessary.
A previous poster had made an excellent suggestion by raising the gear. An excellent option! It undoubtedly would have forced the captain to go-around.
Staying alive may require immediate, dramatic action not covered by SOP or CRM.
In this case, it was the copilot's duty to physically override the captain's control inputs and effect an immediate go-around by whatever means necessary.
A previous poster had made an excellent suggestion by raising the gear. An excellent option! It undoubtedly would have forced the captain to go-around.