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Sleepy pilot caused Indian passenger plane crash

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Sleepy pilot caused Indian passenger plane crash

Old 13th May 2011, 20:39
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Wow. Just...wow. Did any of you bother to read the report in full. Trying to pin this on the co-pilot is ridiculous.

If you have read the report in full you would know that according to simulations done after the fact, despite the unstabilized approach, the plane would have landed safely (albeit long). The deadly decision was the PF's decision to attempt to take off again, after the thrust reversers had been deployed. The report called this a "grave mistake".

I agree that the CRM in this case was terrible and that they should have never tried to land from such an unstabilized approach. But it wasn't that approach that killed them. It wasn't the landing that did so. It wasn't the fact they couldn't stop in time. It was the fact they attempted to take-off again; that's what killed them.
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Old 13th May 2011, 22:35
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I seem to remember something like this happening with into a Swedish airport (Skavska maybe) some years ago in a 738 with a Captain on his last day in the job, before departing to the fly the great southern skies. 180 kts and the wrong flap setting but he managed to stop it on the runway and all but got away with it. Report here; http://www.aaiu.ie/upload/general/69...2005_018-0.PDF

These days flight data monitoring would cause most to think twice but it does remind me of my first day ever with a line Captain (after final line check) many years ago and looking a wrong shape runway and hearing the GPWS shouting 'sink rate, sink rate...'. I asked the question and he went around but it was a bit of a baptism of fire.
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Old 13th May 2011, 22:43
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Pontius

Mate, nobody disconnects the autothrottle by turning off the A/T Arm switch (unless you've lost an engine). You must surely know you just use the A/T disconnect switches! Thereafter, assuming you haven't been below 5' RA for 2 seconds (or whatever it is....irrelevant here), pushing the TOGA switches will give you 2000 fpm or TOGA power on the second push of the switches.
Really? I suggest you try this next time you are in the sim. Or, next time you disconnect the A/T (on thrust levers) out on line have a look and see where the ARM switch on the MCP ends up.

Centauras is spot on.

FCOM 4.20.8

Any of the following conditions or actions disengages the A/T:
moving the A/T Arm switch to OFF
pushing either A/T Disengage switch
an A/T system fault is detected
two seconds have elapsed since landing touchdown

A/T disengagement is followed by A/T Arm switch releasing to OFF and flashing red A/T Disengage lights. The A/T Disengage lights do not illuminate when the A/T automatically disengages after landing touchdown
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Old 14th May 2011, 00:26
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Having sobered up I would like to apologise to Centaurus for maligning his technical knowledge. Not being current on type I had forgotten the A/T Arm switch is magnetically held on the 737, as opposed to non-magnetically on the other Boeings I've flown/fly. When the A/T is disengaged the Arm switch moves to off on the 737, whereas it remains armed, ready for action, on the others and my dim memory had forgotten that causing me to (a)cause unnecessary offence to Centaurus (b)prove how I should not spout off, especially when not current on type and (c)confirm the adage that one should not drink and type.

Sorry Centaurus
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Old 14th May 2011, 03:15
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Sorry Centaurus
No problem, Pontius. At least it got me going back into the books to check if I had the wrong aircraft too!
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Old 14th May 2011, 03:37
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But it wasn't that approach that killed them. It wasn't the landing that did so. It wasn't the fact they couldn't stop in time. It was the fact they attempted to take-off again; that's what killed them.



That's like saying it wasn't high speed that killed the occupants of a car - it was their heads through the windshield that killed them. Therefore not the drivers fault.

The captain broke all the rules of a stable approach. There was no guarantee if he had not selected reverse and braking he would have not gone off the end on the wet runway. With his obvious cowboy flying technique would you like to take a bet that his retardation technique on the remaining length of runway would have been test pilot skill stuff? Of course not.

The parallel between the Garuda 737 Jogjakarta fatal accident and this one is clear. In both cases the captains pressed on with a demonstrated high lethal unstable approach, regardless of their first officers stated doubts.

In both cases there is no doubt that lives would not have been lost if both first officers had taken firm decisive action to counter the criminal recklessness of their captains. Both first officers were legally and morally second in command. Their responsibilities include monitoring the safety of the flight and taking appropriate action where safety is compromised. They do not require the permission of the captain although he would be consulted if time permits.

Both first officers and their captains in both crashes failed their reponsibilities to the crew and passengers and lives were lost partly because of their gutless lack of action.

Last edited by Centaurus; 14th May 2011 at 08:57.
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Old 14th May 2011, 08:47
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Through my years of experience as a captain and a trainer,I have learnt to understand that most captains(or at least a very very large percentage),are quite wary and have very good SA when it comes to the actual landing part of the sector. It is another story that the actual execution of the landing might be pathetic,however at any given point in the approach if quizzed about the 'progress' of the approach,most would have a very accurate assessment of their actual situation. That is to say,is he high,fast,low or slow.
That being said,I shall not particularly credit the individual for being that good,rather the training methods involved by various companies by and large in the making of a captain. By and large,the training involved in aquiring the four bars is reasonably adequate,given a world average.
My personal(and reasonably well informed i might add)opinion in the mangalore accident is that the captain was reasonably sure of his SA and was quite certain that he was in position to make a safe land and stop out of the high and fast approach. If nothing else he had several gates where to check himself and correct the situation,IF in fact,in his mind the situation needed to be corrected.
What then went wrong. Was this hugely experienced captain wrong on this one particular approach.If so why didn't he correct himself during one of the several gates. Besides being prodded verbally by the 'experienced FO'.
What I think happened is this.
The captain was quite certain in his mind that he was able to salvage the unstable approach safely and convert it into a safe landing. And given his vast prior experience AND his previous history,I wouldn't contest that. However he would have known in the back of his mind that it was going to be a landing with very little or no margins for error. THIS fact he might not have appropriately been able to communicate to the FO.Or for that matter he might not have even tried to convey it. Now the 'experienced FO' feels here is a captain who looks sloppy(sleeping thru flight,high and fast on approach etc),and who is making no attempt whatsoever to correct a situation going rapidly wrong. The FO thinks poorly of the expat captain,and has his own ass to cover,keeping in mind that he is close to command selection himself.
I think the captain would have managed to salvage the landing in the remaining landing distance available.This has been amply been proven by Boeing.
But I think the FO's interference(which is not so apparent),or lack of,either coerced the capt to abort the landing roll or the FO himself might have tried to initiate a go around from a very late landing. Either way it was a reciepe for a disaster.
The safest PM's or CM2's are those that are one hundred pro active or not at all. Anything in between,in a low CRM exercise,such as a RTO or a rejected landing,will spell disaster.
Like I said before,this is entirely my opinion.And I could be 100% wrong on it. With no finger pointing here,I would however,highly contest that...
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Last edited by King on a Wing; 14th May 2011 at 08:57. Reason: Typos
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Old 14th May 2011, 09:54
  #108 (permalink)  
 
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Some very valuable information here. As a trainee this is vital for me
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Old 14th May 2011, 10:15
  #109 (permalink)  
 
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The captain was quite certain in his mind that he was able to salvage the unstable approach safely and convert it into a safe landing. And given his vast prior experience AND his previous history,I wouldn't contest that. However he would have known in the back of his mind that it was going to be a landing with very little or no margins for error.
Simple solution , decide to Go Around, or at least do so after the FO first asks for it.

THIS fact he might not have appropriately been able to communicate to the FO.Or for that matter he might not have even tried to convey it.
If so, that would be simply inexcusable.

Now the 'experienced FO' feels here is a captain who looks sloppy(sleeping thru flight,high and fast on approach etc),and who is making no attempt whatsoever to correct a situation going rapidly wrong. The FO thinks poorly of the expat captain,and has his own ass to cover,keeping in mind that he is close to command selection himself.
The captain was sloppy, he (FO) obviously suggested a GA but was not assertive enough to take initiative and execute a GA himself, maybe he showed a severe lack of ass covering, as in making sure his ass was covered enough to get out alive.

I think the captain would have managed to salvage the landing in the remaining landing distance available.This has been amply been proven by Boeing.
But I think the FO's interference(which is not so apparent),or lack of,either coerced the capt to abort the landing roll or the FO himself might have tried to initiate a go around from a very late landing.
Boeing indeed stated that with full autobrake and thrust reverse the final 1/3th of the runway would have been just enough, provided quick action on the flightdeck (going for full brake), however that's already way behind the curve, they shouldn't have been there in the first place.

Even more, another missed opportunity from the FO to save the day, Boeing makes it clear that for all its aircraft it is simple not done to initiate a GA after starting reverse thrust (no less than 6 seconds later !!! ).
Still when the Captain aborted, any pilot should have automatically realized that at that point ,far on the Runway, Autobrake active, spoilers deployed and thrust reverse active they where absolutely committed to land.


This accident is AF358 in Toronto or AA1420 at Little Rock over again (without the bad weather) , we can only shiver at the the idea what would have happened if those crews decided a late GA ,after Reverse thrust initiated, would have been the way to go, nobody would have come out alive.
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Old 14th May 2011, 10:18
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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
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!
What I am meaning is that in a well regulated airline in 2011 things would (or should) never have got to this stage in the first place.

The concept of an approach gate is a basic requirement for safe operation. There is at least one operator that I am aware of that requires a "five hundred feet continue or go-around" by the non flying pilot and if a go around is stated this is MANDATORY. There is also a signed letter from the CEO stating that by not doing so pilots will expect to be dismissed from employment forthwith.

! agree that even given this sort of regulation there is always a possibility of the rules being broken but that is not a reason for not having good selection, training and regulation.

Psychologists have also established that when human beings are "maxed out" the first sense which the brain deletes is that of hearing. So as non flying pilot you can say as much as you like but he might not hear you! Better to do a "pattern interrupt" such as physically shaking the flying pilot or even, as has been suggested, raising the gear.
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Old 14th May 2011, 10:45
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Nigel Nigel we MUST go around...silence

Nigel Nigel we MUST go around...still silence

Click Click.. I HAVE CONTROL !


anyone out there ever taken control from a Captain?
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Old 14th May 2011, 10:49
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here is the report itself. horror story.
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Old 14th May 2011, 15:55
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As Centaurus says,lots of similarities with Garuda crash.Its important to be honest when discussing these accidents;many pilots have continued approaches when technically speaking they really shouldnt have.Whats important is that if you do decide to go outside SOP,you know your own limitations and that of your aircraft.To blindly ignore SOP and hope for the best is reckless endangerment.You need to apply certain hard and fast rules in making your decision and you need training and the technique to pull it off.Its not trained because an airline can hardly train for something thats outside their own mandated SOP's.But is it unsafe to continue an unstabilized approach?No,not necessarily.Life isnt black and white like that.But its never ever wrong to do a go-around if youre unsure/unhappy.

If the figure of 4000' ROD within the last 1000' is accurate(None of the links to the report actually work!!!!) this is clearly a case of reckless endangerment and not a calculated and perfectly safe decision to continue a landing off an unstabilized approach.

The FO can raise the gear as a last resort to force the Captain to go-around but not below 200-300'.It must be done early enough or he becomes more dangerous than the guy sitting next to him.Its a last resort maneuver and so he/she must know what they're doing.I mean we wouldnt want FO's pulling the gear up every time the skipper is technically outside SOP.Its to be used in a life or death situation.
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Old 14th May 2011, 16:22
  #114 (permalink)  
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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
Nice thought there Glue but if the F/O's worst experience has been just reset the simulator then I would doubt that the thought of losing his life or anyone else's life entered his mind.
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Old 14th May 2011, 18:30
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I see the that the two threads have been merged and for those who want to play the blame game I refer them to my initial post #84 which I made back in April. Everything I said then I still think now.

But for those who are interested in safety and who want a more nuanced understanding (not justification, not excuse, not rationalization) of what happened I think reading the report in detail is worthwhile.

But I think the FO's interference(which is not so apparent),or lack of,either coerced the capt to abort the landing roll or the FO himself might have tried to initiate a go around from a very late landing. Either way it was a reciepe for a disaster.
The safest PM's or CM2's are those that are one hundred pro active or not at all.
Quite so. The lesson I took away from reading this report is best expressed in our American phrase of "put up or shut up."

One of the things we know about sleep inertia and mental fixation is that they are not all or nothing affairs. Rather, they are akin to mental 'fogs'. Outlines are glimpsed but the full reality doesn't penetrate until it's right in front of your face. In my opinion, the captain was operating in just such a mental fog where his primary responses to flight conditions were not conscious but rather based upon his training. It took some time for his brain to process what the FO was telling him...that is, he was suffering from mental lag.

Taking off again after thrust reversers had been deployed was not only against SOP it was against all the captain's training. So why did he do it? I think the germane fact is that the last words out of the FO's mouth were "not enough runway left." Contrary to what many people in this thread are suggesting, I think the Captain was in fact trying to listen to his FO but his mental fog due to sleep inertia created a processing lag that prevented him from heeding that advice promptly. It wasn't, to continue the prior analogy, until he saw the lorry dead in front of him in the fog that he realized he was on the wrong side of the rode.

That's like saying it wasn't high speed that killed the occupants of a car - it was their heads through the windshield that killed them.
Quite so. And that fact is the very reason that safety glass was invented. Your car windscreen has a plastic film in the middle precisely to keep the windscreen from shattering upon impact and injuring the occupants. The windscreen was in fact killing people, so auto manufactures changed the technology so the windscreen couldn't kill anyone any more.

With his obvious cowboy flying technique would you like to take a bet that his retardation technique on the remaining length of runway would have been test pilot skill stuff? Of course not.
I admit that my conclusion is a supposition but I think it's a rational supposition. He'd already deployed the reversers, he'd already applied some braking, all he need to do to stop the plane safely was to "stand on the manual brakes". That's not test pilot stuff. If he'd continued doing what he was already doing it would have end with the plane still on the pavement.

Perhaps a point of clarification would help you. The report ascribes the direct cause of the accident to an unstable approach, a conclusion on which I agree. However, the report does not detail a proximate cause to the crash. It's my opinion that the decision to abort the landing and take off again while not the direct cause of the crash was the proximate cause of the crash. Up until that point in time the situation was, at least in theory, recoverable. The diction in the report is that it was a "grave mistake," which is chillingly apposite. It was that decision, and that decision alone, that proximately lead them to their graves.
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Old 14th May 2011, 20:24
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Fair quote from the report

It is evident from the investigation that the flight crew had failed to plan the descent profile properly , due to which the aircraft was high and did not intercept the ILS Glide Slope from below , which is the standard procedure.
This led to the aircraft being at almost twice the altitude on finals, as compared to a standard ILS approach.
In the ensuing 'Unstabilised Approach', the First Officer gave three calls to the Captain to 'Go Around'. Also there were a number of EGPWS warnings of SINK RATE and PULL UP.

Despite the EGPWS warnings and calls from the FO to 'Go Around', the Captain persisted with the approach in unstabilised conditions.
The final touchdown of the aircraft was at 5200ft from the beginning of RWY24, leaving only about 2800ft to the end of the paved surface, to stop the aircraft.

Soon after the touchdown, the Captain had selected Thrust Reversers. But, within a very short time of applying brakes, the Captain had initiated a rather delayed 'go around' or an attempted take off, in contravention to SOP laid down by the manufacturer i.e. Boeing Commercial Airplane Company, USA.

The aircraft overshot the runway and its right wing impacted ILS Localizer antenna mounting structure. Thereafter, aircraft hit the airport boundary fence and fell into the gorge. Due to impact and fire, the aircraft was destroyed.
In this tragic accident, 152 passengers and all 6 crew members lost their lives.There where only 8 survivors. the investigation determined that there were no airwhortiness issues with the aircraft and there was no sign of birdstrike or any evidence of sabotage.





Direct cause of the Accident:

The Court of Inquire determines that cause of this accident was the
Captain's failure to discontinue the 'unstabilised approach' and his persistence in continuing with the landing, despitethree calls from the First Officer to
'go around' and a number of warnings from the EGPWS.

The Contributory factors were:

(a) In spite of availability of adequate rest prior to the flight, the Captain was in prolonged sleep during flight, which could have led to sleep inertia.
As a result of relatively short period of time between his awakening and the approach, it possibly led to impaired judgement.
This aspect might have got accentuated while flying in the Window of Circadian Low (WOCL).

(b) In the absence of Mangalore Area Control Radar (MSSR), due to un-seviceability, the aircraft was given descent at a shorter distance on DME as compared to the normal. However, the flight crew did not plan the descent profile properly, resulting in remaining high on approach.

(c) Probably in view of ambiguity in various instructions empowering the 'co-pilot' to initiate a 'go around', the First Officer gave repeated calls to this effect, but did not take over controls to actually discontinue the ill-fated approach.

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Old 15th May 2011, 09:20
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MountainBear . . .

Wow. Just...wow. Did any of you bother to read the report in full. Trying to pin this on the co-pilot is ridiculous.
The copilot had the last chance to prevent this crash. When the captain is in La-La-Land, it's the copilot's duty to take decisive action(s) in order to keep himself, the rest of his crew and his passengers alive.

...For the last 88 seconds the copilot had sat on his hands and let the captain kill him.
F/O CVR
06:03:33 "It's too High"
06:03:53 "Go around"
06:04:06 "Go around"
06:04:07 "Captain"
06:04:08 "Un-stabilised"
06:04:38 "Go around captain"
06:04:44 "We don't have runway left."

06:05:01 IMPACT
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Old 15th May 2011, 12:40
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What about the CRM between these two?

At 05:52 the Captain gave a brief brief. Other than RT, imagine the conversation while they manage this high approach:

05:55 FO: Huh huh ho
05:56 FO: whistling
05:58 FO: whistling
05:59 Capt: Speed 210, Gear down

Then they run through the flaps, but at selecting Flap 15:

06:02 FO: Humming
At this point they are at about 5 miles and massively high. Yet he just hums.

At 06:03 they make the last dive for the runway.

The FO was on a No-Fly with another foreign Captain who he had reported in writing for CRM and SOP issues. "He was known to be a man of few words".

This is something that happens. The FO wants to watch the Captain screw it up, so will hum and whistle to indicate that all is fine and he is "relaxed", only so the FO can later write the report about how terrible the Captain is, and how poor his CRM skills are. To me, the relationship in that flight deck had long broken down, and if the FO had spotted the wildly incorrect profile (and false g/s) then he should have mentioned this, rather than humming.

I suspect he was fully aware.
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Old 15th May 2011, 14:28
  #119 (permalink)  
 
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The copilot was a dud.

The FO wants to watch the Captain screw it up,...
That's entirely conceivable. But in this case it's about staying alive. The pavement is on a plateau with a steep drop off at the end.

Now and then there comes a time when you either have to shit or get off the pot. The copilot, sitting on his hands for the last 88 seconds of his life, was a dud . . . because he lacked basic survival instinct.
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Old 15th May 2011, 20:15
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Yes, but how did they get into that position in the first place? Investigators, airlines and authorities will all point at lack of SOP adherence. But how did those two not prevent the cock up?

I read the FO as one who is annoyed at having to fly with a foreign captain. He is ready for command, but somehow a foreigner is in his seat. And he knows it all, and has already reported another foreign captain.

When this experienced, but tired captain is busy trying to get on to profile (speedbrake, very early selection of gear), the FO is just whistling. A good FO would be already making it clear that they should both be "on alert" because the approach is a mess. But no, just more whistling. He was not assisting the captain, just watching him struggle.

Then they pick up the false glide. The FO is too busy whistling to notice, or if he did notice, he is criminally negligent in not calling it. This is the role of the PNF (PM in the Boeing).

Suddenly, the (I imagine slightly confused) captain sees the real situation, and makes the wrong decision to try and make a landing of it. When the FO sees this, he stops whistling and calls a go-around. But the captain will have excluded this fool from his world, since all the FO has done for the last 20 minutes is whistle and hum.

They were not working as a team.

Quite why the captain didn't just give in even at 5 RA, I don't know. There are clues and hints in the report about AIE culture, but he must have seen that it was very high risk just before he touched down.

One crap decision by the Captain, and no help at all from a chip-on-shoulder FO who failed to perform his most fundamental duties more or less from the start of the tape. I expect to see that CVR transcript in CRM sessions in the future.
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