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Air India Runway Excursion

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Air India Runway Excursion

Old 12th Aug 2020, 16:31
  #221 (permalink)  
swh

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Captain Hindsight,

Their first approach was in the other direction and they were unable to get in, they went around and tried RW28.
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Old 12th Aug 2020, 16:50
  #222 (permalink)  

de minimus non curat lex
 
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alf...

Have you ever thought about posting your thoughts on a philosophy website where aspects of knowledge, existence and reality of CRM / accidents can be discussed from an academic point of view?

A UK cultural point of view...
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Old 12th Aug 2020, 17:08
  #223 (permalink)  
 
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Originally Posted by alf5071h View Post
Context - subjective; beliefs, motivations, perceptions and values of the individuals involved. Any judgement of these will be subjective, according to viewpoint, and cannot be stated with any certainty.
We must not be judgmental, several planes run off the runway in India every year in the monsoon season, it's a cultural thing can't be helped. The pilots didn't have the correct shared mental model, the stable approach criteria were not correctly applied in this case, there was a command gradient etc...

'Well, I admit the human element seems to have failed us here.' - General Buck Turgidson
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Old 12th Aug 2020, 17:41
  #224 (permalink)  
 
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Originally Posted by Airbubba View Post
Not sure what sarcasm you think I'm using. I put 'pilot' in quotes since the early news stories said the 'pilot' turned off the 'engine'. Obviously there were two pilots and two engines.
I made a similar point earlier on the thread:

Originally Posted by DaveReidUK View Post
BBC News reporting 15 fatalities, including "the pilot".
Like your post, it was intended as a criticism of the media coverage, certainly not as sarcasm at the expense of the deceased crew.
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Old 12th Aug 2020, 18:01
  #225 (permalink)  
 
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Assumed Certainty

42go,
As yet, there is no factual evidence (for accident investigation purposes opposed to a legal view) stating the touchdown position. Similarly, the tailwind value is unknown; forecast, reported (when), accuracy of recording, unknown, … some of the uncertainties which pilots have to manage every flight.

'Marginal landing distance' is subjective - it implies that the margins of performance were known beforehand, not as assumed with hindsight.
What was the landing distance required as defined by national / operator requirements - not referenced so far; nor the basis of aircraft performance (repeated questioned in previous posts), then what procedure or guidance as to how this is used; e.g. additional factors, considering next worst case runway condition (no facts as to what the crew were told nor the actual runway conditions - including grooved or not, rubber contamination, …)

We need to reflect on our own experiences. How often do we judge the actual point of touchdown - how precise, what was the achieved landing distance opposed to what was expected, again how would we know, runway braking action, tyre tread wear.

For those who have flown a go around in similar circumstances - what was the trigger factor which changed the original plan, why.
"Why', how did this situation differ from similar marginal approaches with a satisfactory landing.
If we can answer why, then this is a basis for questioning the crews action, always subjective, even if we have assumed certainty.
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Old 12th Aug 2020, 19:25
  #226 (permalink)  

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Originally Posted by alf5071h View Post
......
"Why', how did this situation differ from similar marginal approaches with a satisfactory landing.
......
I doubt from the information available that this was a ‘marginal approach’. In other words the approach was not stable under generally accepted criteria and merited a go around and diversion.
As things are never black and white, a marginal approach might be regarded as in the ‘grey area’ where on a good day ‘your get away with it’ given the built in safety margin into performance criteria. Regrettably that was clearly not the case here.
The holes in the “Swiss Cheese” unfortunately aligned.

I am not entirely convinced that a ‘satisfactory landing‘ always occurs from a marginal landing.
Satisfactory would infer that the outcome (from a marginal approach) was never in doubt.
Again not the case here.
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Old 12th Aug 2020, 21:23
  #227 (permalink)  
 
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parkfell, #223, CRM.
If you are able to identify which aspects of CRM were poor, or even what CRM consists, and how applied (not the oft quoted academic definition), then we might consider the 'reality' of CRM

The occurrence - reality, of 'CRM accidents' is that we, the industry, assume that CRM, monitoring, intervention, etc, will aways work; it doesn't.
In order to understand this we need answer how CRM factors - HF coincide with other aspects of the situation result in an accident. Only then might we discuss the practicalities in operation and why these differ from the academic concepts.

#227, the question 'why' was asked of you, not the accident crew.
If we are able to first understand ourselves, then we might ask similar questions about this accident, but don't expect anything other than subjective opinion.

Satisfactory outcome is judgement after the fact; we can never ensure a satisfactory outcome, only mitigate the risk which we perceive.
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Old 12th Aug 2020, 23:24
  #228 (permalink)  
 
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I want to know what you’re smoking, it must be the good stuff.

The Boeing FCTM guidance leaves no doubt that if an approach is unstabilised, the flight crew MUST go-around. That is not up for debate. I suggest you look up Recommended elements of stabilised approach.

Yes absolutely, not all unstabilised approaches result in accidents BUT most ALAR are the result of an unstabilised approach. Look this up if you think I’m making stuff up.

Operating an airworthy aircraft isn’t mystical. There are systems in place. However when there are multiple inflight failures, then of course, all bets are off.

CRM wasn’t effective in this case because - the investigation report will have the cause for that. They will answer the WHY did it happen question. This forum is to get a clue of the WHAT happened. If you get what I mean?
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Old 12th Aug 2020, 23:45
  #229 (permalink)  
 
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Originally Posted by alf5071h View Post
For those who have flown a go around in similar circumstances - what was the trigger factor which changed the original plan, why.
"Why', how did this situation differ from similar marginal approaches with a satisfactory landing.
If we can answer why, then this is a basis for questioning the crews action, always subjective, even if we have assumed certainty.
If a VERY highly experienced ex Air Force ‘Wing Commander‘, ex test pilot, training captain cannot judge ‘why’ the need for a timely go-around, then sorry, he has no place in command of an airliner, full of passengers.

How did this situation differ? Are you serious? Have you not been reading other posts in this thread? Long landing? Wet runway? Tailwind? Marginal weather? This is basic Threat & Error Management.

If anything, he should have been go-around minded right from the start of the approach. In fact he was during the first approach to Runway 28. Why didn’t he go around again on the subsequent approach to Runway 10? The officials say he still had plenty of fuel onboard.
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Old 13th Aug 2020, 01:04
  #230 (permalink)  
 
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One for the HF people.At what point in the human thought process does logic, training, experience and sound judgement get trumped by presonitis and wishful thinking? In both of the recent accidents professional pilots shake their head at why an approach was continued but I have no doubt that the PIC of both aircraft would have been also shaking their heads in disbelief if they were reviewing the sequence of events.
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Old 13th Aug 2020, 01:48
  #231 (permalink)  
 
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Some pilot views on the mishap from the Hindustan Times and the Press Trust of India.

‘Kozhikode plane crash not an accident but murder’: Air safety expert Capt Mohan RanganathanRanganathan explained how table-top runways, the one in the case of the Kozhikode airport, have very little space and therefore require more safety features. “There’s no escape for an aircraft if it overruns,” Ranganathan told HT.INDIA Updated: Aug 08, 2020 16:01 IST
Aditi Prasad | Edited by Sparshita Saxena

Hindustan Times, New Delhi - If appropriate steps are not taken, accident similar to Friday’s airplane crash in Kozhikode could occur next at Patna, Jammu airports, air safety expert Captain Mohan Ranganathan said in a conversation with Hindustan Times. During the interview, Ranganathan, who is a member of a safety advisory committee constituted by the civil aviation ministry, said he had submitted a report around nine years ago, warning that the Calicut (now Kozhikode) airport was not safe for landings.

“The warnings were ignored... in my opinion, it is not an accident but a murder. Their own audits have had flagged safety issues” Ranganathan said, adding that the crash could have been well avoided.

Ranganathan explained how table-top runways, the one in the case of the Kozhikode airport, have very little space and therefore require more safety features.

“There’s a drop of around 70 metres at the end of the runway at the Kozhikode airport, in the case of Mangalore it is about a 100 metres. There’s no escape for an aircraft if it overruns,” he explained.

“You will find another major accident either in Patna or Jammu airport. Both of them are dangerous airfields and don’t have safety features” he said.

“I understand that Runway 10 ILS is being used on a trial basis at Calicut. Some of the crew are accepting even VOR approach on Runway 10. The reason is the lower minima than Runway 28. However, all the flights that land on Runway 10 in tailwind conditions in rain, are endangering the lives of all on board,” he had said.

He also said that the airport does not have the minimum Runway End Safety Area (RESA).

“The runway strip is just half the minimum width laid down in ICAO Annex 14. This fact was known to the DGCA team that has been conducting inspections and safety assessments during the past several years. Have they considered the danger involved? Has the DGCA or the airlines laid down any operational restrictions or special procedures?” he had written.

At least 18 people, including the pilot and the co-pilot, have been killed as Air India Express flight IX 1344 overshot the runway at Kerala’s Kozhikode airport and fell into a valley, breaking into two on Friday evening. The flight was bringing Indians stranded in Dubai amid Covid-19 pandemic under the government’s Vande Bharat Mission.
Video interview of Captain Ranganathan in the article linked below.

https://www.hindustantimes.com/india...gFQm7ySwJ.html


Wrong Call By Pilots Among Many Likely Reasons For Kerala Crash: ExpertsThe dominant reason cited by the experts was the decision by the pilots to not divert the plane to another airport after the first attempt to land at the designated strip failed amid rain. All India Press Trust of India

Updated: August 11, 2020 11:03 pm IST


New Delhi: A gust of wind, wrong decision by the pilots, the condition of the air strip and even faulty indication by the instrument landing system could be possible reasons for the crash of the Air India Express on Friday in Kerala's Kozhikode, according to aviation experts.

The dominant reason cited by the experts was the decision by the pilots to not divert the plane to another airport after the first attempt to land at the designated strip failed amid rain.

The Boeing 737, bringing back 190 stranded Indians from Dubai, broke into pieces after it overshot the table-top runway 10 and fell into a valley 35 feet below, leaving 18 people including both the pilots dead.

"It is foolish to land with a tailwind on a wet runway...This is what I have been pointing out for years. I said in 2011 that landing with a tailwind in rain on runway 10 will result in an accident one day," leading expert Captain Mohan Ranganathan told PTI.

Mr Ranganathan was a member of the operations group of the Civil Aviation Safety Advisory Committee (CASAC) in 2011. He has been a part of various other safety committees of aviation regulator DGCA.

As the investigators begin probe into the accident, another aviation expert referred to the "widely recognised Swiss Cheese" model while talking about possible reasons for the crash that included breaking apart of the plane's fuselage.

"Any aeroplane accident that happens is never dependent on a single factor. Top air accident investigation teams across the world believe in the Swiss Cheese model. It says that only when the holes of all the slices of Swiss cheese get aligned, then only an accident happens," the expert said on condition of anonymity.

"It is just a metaphor. The Swiss cheese has lot of holes. If you put slices of Swiss cheese in a string and spin them, there will be one in a million times that all the holes would be aligned. That will be a precursor to an accident," he explained.

The expert said the reasons for the crash could include environmental factor, human factor, technical factor, health of the plane, administrative factor and external factor like what the air traffic controller is telling the pilots.

He said a sudden gust of wind leading to a wrong decision by the pilots, condition of the aircraft, wrong signalling by the instrument landing system or pure human error could be some of the reasons for the crash.

"It can be a multiple reasons. We cannot speculate. Wind speed could be a reason. When you are at low speed, you are susceptible to impact of the wind. One gust of wind can play havoc," he explained.

The runway 10 at the Kozhikode airport is approximately 2,700 metres long. The aircraft touched down approximately 1,000 metres from the beginning of runway 10 while landing, according to the AAI.

Captain S S Panesar, former director of flight safety and training at the Indian Airlines said the pilot should have diverted immediately to one of the nearby airports like Trivandrum or Bengaluru after he did not succeed in its first attempt to land on runway 10 in bad weather condition, using the instrument landing system (ILS).

The ILS uses radio beams to give pilots vertical and horizontal guidance while landing the plane.

"The authorities have found the DFDR (digital flight data recorder) and CVR (cockpit voice recorder), but one thing will remain unanswered, that why didn't he divert?" Mr Panesar asked.

The experts said the flight data recorder would give the investigators condition of the health of the aircraft, while the cockpit voice recorder will provide details of what the pilots were thinking and what they were going through before the crash.

Captain Deepak Sathe was the pilot-in-command and Captain Akhilesh Kumar was the first officer of the flight AIX1344.

According to the AAI, the visibility at Kozhikode airport when the flight landed was 2,000 metres.

The Kozhikode airport is a CAT-1 airport where flights can land with visibility of 801110 [sic] metres or more. At a CAT-IIIB airport, the runway visual range can be as low as 50 metres.

B737 is one of the most popular aircraft models of Boeing. According to the aircraft manufacturers' operations manual, a B737 plane can satisfactorily land or take off when the tailwinds are not more than 15 knots.

A former DGCA official told PTI that the accident could have been averted had the runway been extended some more during the last few years.

In 2017, the AAI had attempted to procure land to extend the runway, but it was not able to do so as the land acquisition was proving to be expensive and there was stiff resistance from locals, said the official.

Addressing the questions on runway 10, Civil Aviation Minister Hardeep Singh Puri said on Monday the airport is equipped with Runway End Safety Area (RESA) as per International Civil Aviation Organisation (ICAO).

Ten years back, an Air India Express aircraft overshot the table top runway at Mangalore airport, fell into a gorge and caught fire, resulting in loss of 158 lives.
https://www.ndtv.com/india-news/air-...-crash-2277999

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Old 13th Aug 2020, 03:04
  #232 (permalink)  
 
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Originally Posted by Lookleft View Post
One for the HF people.At what point in the human thought process does logic, training, experience and sound judgement get trumped by presonitis and wishful thinking? In both of the recent accidents professional pilots shake their head at why an approach was continued but I have no doubt that the PIC of both aircraft would have been also shaking their heads in disbelief if they were reviewing the sequence of events.
This is a great question, thank you!

I would guess when the loss of situational awareness, target fixation and/or overconfidence sets it, they create for a very slippery situation in the cockpit. Add to that a steep cockpit gradient, an FO who is unwilling to speak up to a very senior Captain and the situation can go from a boring flight to a very very sudden life or death situation.

I have flown with some captains who’s SA was so bad, that they had no idea what they were bringing upon themselves had I not been assertive (think 4 whites on short final and not self-correcting). Then again, nobody is perfect, but that’s the reason there’s another pilot upfront, to prevent one guy from killing everybody else on the aeroplane, due to losing situational awareness & overconfidence.

What do the other senior pilots/captains think?
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Old 13th Aug 2020, 04:10
  #233 (permalink)  
 
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Angel How about not over running the runway?

These "AIR SAFETY EXPERTS" are making some of the right noises, but, how about focussing on a few of these areas:
Stabilised Approaches, Long Landings, Tail Wind Limitations, woeful CRM, lack of Runway Grooving, Poor ATC equipment and standards, Approach Aids U/S, FLT limitation breaches, Fake Licenses, Recurrent Training Scams, Company Pressure, the list goes on.

I flew in India over 10 years ago, mainly in the South, and the ATC standard was woeful back then, and I doubt it has improved much. Being able to argue with the controller to get yourself a better position in the sequence, getting "Vectored" toward terrain in a Non Radar Procedural TMA below MSA, disregarding procedure entries onto approaches that take you below MSA so you can save a few minutes, it was mind boggling.

Like all countries, there where some great pilots, but there where also some very average ones. I can assure you, I am no Ace of the Base, but I understand the importance of the SOP and the responsibility I have to the passengers and crew.

Back then, F/O's were NOT allowed to land during the "Monsoon Season", July to October. ie: no PF sectors at all for those months. (I don't know if this is still the case?) It could be a CAVOK day on the East Coast, eg VOMM, but the F/O's were prohibited from acting as PF?? Their skills were eroded quickly during these months. Remembering, a lot of these F/O's were straight from flying school into the RH seat of a Jet.

So when you are doing 6 sector days, in this sort of weather, it was very taxing. The good guys and girls were an asset during the bad weather approaches, the others would be varying degrees of useless to you, as they had no idea of why it was so hard, and what support to provide.

The resistance to Go Arounds and to a greater extent diverting was phenomenal. The questions of my manhood that were expressed on the radio when I went around once was unbelievable. Leading into these sort of comments about the runway being dangerous because WHEN you over run it, the terrain is dangerous, HOW ABOUT NOT OVER RUNNING THE RUNWAY?

Calicut, VOCL, is 64nm from Cochin, VOCI, which has an ILS ON RWY 27, into the prevailing wind. In fact, there are 5 ILS equiped Runways within 150nm.

It's good to see these "AIR SAFETY EXPERTS" highlighting some of the infrastructure issues in Indian aviation, but a possible look in the mirror for all the Standards departments of all the Airlines is in order. I am sure there will be findings from this accident similar to the Mangalore accident, and the PIA Karachi accident too.

Things need to change in the way these aircraft are operated, the way pilots are trained, and most importantly, the way the companies support the Crew everyday. Until this change is effected, these accidents will continue to occur.
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Old 13th Aug 2020, 08:48
  #234 (permalink)  

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The AIR SAFETY EXPERTS and others know exactly what needs to improve, and what investment is required.
I suspect that will only occur when you can convince the Politicians that appropriate action is necessary.
How effective will the democratic process be in encouraging them to do the right thing?

This will occur at best at ‘glacier’ speed as the Cultural aspects will prove to be as solid as bedrock.

Don’t expect change anytime soon, as earthquakes aren’t that predictable.

Last edited by parkfell; 13th Aug 2020 at 09:19.
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Old 13th Aug 2020, 12:16
  #235 (permalink)  
 
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Apols if I have missed it but why (is it conjectured) that after an approach to 27 with a wind of 240 (and apparently a GS of 149 kts) were approaches to 10 (with a GS of 176 kts) then attempted. What was the reason ?
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Old 13th Aug 2020, 15:30
  #236 (permalink)  
 
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Better vis and lower minimums at the other end?

But a 10kt tailwind and torrential rain is a very bad combination. If you absolutely must do it, then you need to make a "carrier deck" landing and firmly plant it within the touchdown zone. Continuing a landing as they did when they must have known they had floated far beyond the touchdown zone, seems crazy. I really hope there is a technical reason for this crash, not a human one.

If there was that much rain, then there must presumably have been a cell of convective above the airport- so why attempt to land underneath a cell with the dangers of a microburst?, let alone the torrential rain, and potential turbulence.

Why not hold and wait for 20 mins until the cell has moved off? I have had this conversation with Captains a few times - what about the cell over the airport? - what about it? - well what about microburst? what about the torrential rain? why not wait or go somewhere else? = "No, it'll be fine".

This Air India flight might have floated because of the outflow from a microburst at the other end of the runway.....
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Old 13th Aug 2020, 16:39
  #237 (permalink)  
 
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Uplinker

Do monsoons in India really have cells that move on in an hour
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Old 13th Aug 2020, 23:53
  #238 (permalink)  
swh

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Yes they do.
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Old 14th Aug 2020, 04:14
  #239 (permalink)  
 
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Don't they do that in FL as well?
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Old 14th Aug 2020, 06:25
  #240 (permalink)  
 
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Monsoon rains come with a steady drizzle for the most part interspersed with strong short bursts which badly reduce visibility. Aircraft approaching minimums is forced to go round. It's deceptive because another aircraft may have landed just before or may be able to land after that. How long to hold will depend on fuel situation. But at critical airports the company OM should forbid tailwind landings in wet conditions.
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