Air India Runway Excursion

[kiers]

ATC too passive?

I note that many small town airports in India don't have ATC radar ( you can check the article at economic times (.com) newspaper headline: "Many airports don't have approach radars" )

SO given that this runway excursion/overshoot was likely due to overshooting the landing touchdown by a significant distance, shouldn't Calicut ATC have done a verbal altitude check with the pilot to make sure the plane was properly tracking the right glide path at an proper altitude at a given DME reading? I think (having read the Indian DGCA report on the Mangalore Tabletop runway crash from 2010) i deduce that the Mangalore ATC were silent on altitude correction advisement many miles before even the pilot got near the tabletop. It's not like Calicut ATC would be burdened by too many flights, (probably handling 3-4 or 5 flights per day tops) and they know their own tabletop better than others so it seems feasible that they could've talked the pilot to a proper altitude and thereby avoid altitude errors despite having no radar.

PS this thread is SO big it scares me, so if i'm a little late to this thread or in a different area excuse me..

[Gordomac]

Not waded through all 16 pages but does AI have an "Imminent Over-run" drill ? Way back, on the tripots at LHR we did. Handling pilot called for it & non HP carried it out. Just involved shutting off fuel supply and pulling the fire handles & discharging. Worked if you recognised the imminency , called correctly and got what you wanted done, correctly.

[FlyingStone]

Originally Posted by kiers

I note that many small town airports in India don't have ATC radar ( you can check the article at economic times (.com) newspaper: 5967775.cms );

A lot of regional airports in Europe don't have it as well.

Originally Posted by kiers

SO given that this runway excursion/overshoot was likely due to overshooting the landing touchdown by a significant distance, shouldn't Calicut ATC have done a verbal altitude check with the pilot to make sure the plane was properly tracking the right glide path at an proper altitude at a given DME reading?

Most runway overruns tend to happen because the aircraft is too fast on approach and then bleeds the energy in a float over the runway as opposed to a firm touchdown in the touchdown zone (beginning of the runway). So the aircraft could be perfectly on profile for the entire approach and still overrun the runway.

[vilas]

True to some extent. Excess speed and long float has been the reason in most 737 overruns in India. But that wasn't the case in Mangalore accident which was never on profile.

[Herod]

If the crew can't work out altitude versus distance-to-go, it's not ATC's responsibility to monitor and warn them.

[parkfell]

Originally Posted by kiers

.....given that this runway excursion/overshoot was likely due to overshooting the landing touchdown by a significant distance, shouldn't Calicut ATC have done a verbal altitude check with the pilot to make sure the plane was properly tracking the right glide path at an proper altitude at a given DME reading? ..

Unless the Airport Authority specifically ban landing with a tailwind on RW10, it was not the function in these particular circumstances for ATC to ‘interfere’ in the way you describe.

ATC could not foresee that the landing would be deep. They might well have expected a touchdown at the start of the touchdown zone given the prevailing circumstances.

So in a nutshell, NO.

[maddog2872]

Atc gives traffic separation. If a pilot can't navigate to a runway in 3d its not atcs fault, not one bit, radar or no radar.

[vilas]

Landing on RW10 with tailwind is pilot's decision. He is supposed to calculate the FLD before undertaking it. That's why you must only do what was briefed and not switch runways or type of approach unless in emergency situation.

[parkfell]

How do you know yet that a new briefing did not occur for RW10 ?
The CVR will reveal all, and hopefully a transcript of the salient aspects will be revealed.

Was diversion ever mentioned / discussed?

It could be of course that a “SKYGOD style” briefing in which case the FO was is “catch up” and simply was more or less a passenger for the second approach RW10.

[vilas]

I mentioned it in connection with ATC role.

[Roj approved]

Originally Posted by Gordomac

Not waded through all 16 pages but does AI have an "Imminent Over-run" drill ? Way back, on the tripots at LHR we did. Handling pilot called for it & non HP carried it out. Just involved shutting off fuel supply and pulling the fire handles & discharging. Worked if you recognised the imminency , called correctly and got what you wanted done, correctly.

In these modern times the “Imminent Over-run” drill should be negated by SOP’s, the on board LDR Calculations, Stabilised Approaches and correct touch down zone at the correct speed, if you get over the runway and it’s not working out, a Go-Around should be initiated.

Lots of “Should’s”. Unfortunately, we see a little to often, that something has gone amiss, the approach/landing is pushed beyond the limits and we see this type of accident occur again.

If a crew finds themselves in this predicament, they are a little off script so what they do now, while it may be a good idea, is uncharted territory.

The drill as you describe it sounds like the actions of the “Evacuation” Checklist

[FlightDetent]

In an effort to prevent re-occurrence, the investigators will need to answer why no G/A from a misadjusted approach and what can be done in the future to ensure the landing is not continued. A neighbouring country realized some time ago and enforced a punitive non-go-around policy (as opposed to a non-punitive go-around one).

And I'd vote in favour. What else there is, TEM and CRM training does not seem to deliver since people keep crashing airworthy aeroplanes under the impression they are performing alright and the dark side of HF does not apply to them. Which itself is one of the HF dark sides. The prospect of dying and killing everyone seems too distant and severe so that it gets suppressed by the unconscious and does not enter the decision making when needed. The OLD / FLD concept fails to save lives, since when rushed pilots just do not run the numbers.

https://aviation-safety.net/wikibase/wiki.php?id=219098
https://aviation-safety.net/database...?id=20091222-0

Then let it be FDM and HR. Give the pilots a railing they can hold on to and not fall over the cliff of their own importance. Otherwise, as very respectable non-pilot contributor posted elsewhere in the forums the last week(my re-phrase): As long as pilots keep crashing airworthy aeroplanes, future of that profession is deservedly grim.

[Uplinker]

Very good post, Flightdetent

Not saying it applies here, but I have been in CRM courses where a Captain lounges back arrogantly and tells the young cabin crew how difficult it is to fly the plane, and by implication what a hero the Captain is. Completely missing the point that CRM is mainly to tell Captains to : Use their team, Listen to their team, and Don't be autocratic.

[vilas]

As long as pilots keep crashing airworthy aeroplanes, future of that profession is deservedly grim.

Piloting errors along with the human factor which only seems to serve as an obituary is the biggest incentive to replace humans. Everyone knows about Somatogravic illusion and yet now and then we loose an aircraft because someone tried to fly by his ears and not instruments.

[parkfell]

Would Fix Based Simulators reinforce that message better about using the instruments and not other senses?
RTO probably best in a FFS.....?

[FlightDetent]

Questionable. Training against the overwhelming effect of a physiological phenomena at its absence.

The number of pure SGI crashes after a failed upset recovery is not overwhelming compared to the usual suspects of illegaly executed landings and CFITs.

You train for C at the expense of having to train less for B. More training has its upper limits too, you can only learn certain much and actively keep the skill on the line.

Besides the economical cap on training amount is coming down with more and more automation to claim its role in the upcoming aircraft design.

[Tee Emm]

In an effort to prevent re-occurrence, the investigators will need to answer why no G/A from a misadjusted approach and what can be done in the future to ensure the landing is not continued.

In another era I was a simulator instructor training students who in their own country were strongly subject to cultural mores. One of which was unquestioning obedience to authority or higher status. One of the questions I asked of them was how would they take over control from a captain when it was obvious the approach was so badly unstable that an over-run was inevitable.

I explained I was asking the question for a good reason and that was sometime in their career as a pilot there was a good chance they would be faced with such an event. The universal reply, apart from a verbal warning, was along the lines of they would never attempt to take physical control from the captain - that it was unthinkable in their culture.

There had to be a way of changing that cultural mindset. I asked them to watch me demonstrate an example of a typical badly unstable approach and to note the end result. The simulator was placed n the landing configuration on a five mile ILS final in fully visual conditions. I then deliberately flew 30 knots above Vref and that was after I had entered a tailwind of 20 knots. Inevitably we got very high on glide slope and attempted to regain glide slope by 200 feet AFE by closing the throttles and .
increasing the rate of descent. All the time I pattered the approach including saying aloud " We are badly unstable but we can make this OK".

Ignoring sink rate GPWS auto warnings, we passed high over the fence at 25 knots beyond Vref plus the tailwind so that we had an impressive ground speed which was duly pointed out. We then deliberately floated a long way to achieve a smooth touch down on the wet runway.

It doesn't take much imagination to guess what happened next. With full reverse thrust and maximum manual braking we went off the far end of the runway at 60 knots. I had "arranged" a gear collapse and the noise was impressive.

I then pointed out that what they had witnessed was the result of a grossly unstable approach even though I had said "We can make it OK." The whole demonstration took five minutes. Opinions will vary but as far as I was concerned it was good value for money.

A picture is worth a thousand words and simulator instructors should have the confidence to walk the walk as well as talk the talk. They need to cut through political correctness and not be afraid to where necessary demonstrate a sequence to get a point across to the student. The students I was teaching were rote learners and they could recall perfectly all the elements of an unstable approach. But to actually witness these elements right through to its logical conclusion I hoped would fixate the result in their mind, regardless of cultural mores.

Apart from timorously warning the captain the approach is unstable, most culturally afflicted students would have no idea how to physically take over control from a captain intent on "making it OK". . As a last resort the PM could call "GO-AROUND - GEAR UP" and select the gear up without waiting for a reply from the captain. That should really focus his attention and force a go-around without the dangers inherent in a physical intervention.

[fdr]

Originally Posted by hans brinker

From AVHerald. Not on plan B myself, so don't want to guess what the pilots were doing based on this.

That is a sad image to see. Perhaps the resultant cross country ride resulted in the repositioning of some levers through mechanical linkage feedback, but the speed brake is in the down detent, which is not going to happen all by itself. The auto stow doesn't get it to the detent.

Indian conditions in the monsoon are interesting, and the runways are singularly compromised in heavy rain conditions. The lack of RESA/EMAS makes any off catastrophic.

[fdr]

Originally Posted by vilas View Post
There was a documentary by Al Zajeera on making of B737 800 in which Boeing workers had made serious allegations on NG fuselage which breaks on RW excursions. ​

Originally Posted by AuroraAustralis

I've seen the documentary. It alleges that manufacturing defects are to blame to the break ups; I don't think that is the case, although those complaints should be heard and investigated, but it may be simply the way the 737 fuselage was designed in an era of different standards. I agree with the other posters that it is not fair to expect IX1344 to survive in one piece after going off the "cliff" (see TACA in 2008 or Pegasus this year). But take a look at history and there is an apparent trend.

The NG AMM was predicated on the application of CNC machining of critical parts, which happened to include the joints of the fuselage barrels, which were expected to reduce stress and cracking, giving improved maintenance overhead. 3 Boeing QA engineers audited the supplier of the joints, to find they were not using the CNC, there was none in the plant, and the units were being formed by hand. Boeing ended up sacking the QA engineers who reported the non-conforming manufacturing practice. FAA did nothing much. The litigation for unfair dismissal was about as effective as one would assume from individuals taking on a giant run by lawyers. About as effective as Roger Boisjoily trying to get justice for Challenger. That is the world we have, and under the pumpkin king, it is not getting better anytime soon.

a number of the fuselage breakups on impact have occurred in the area of the joint, a correlation of the supplier's non-compliant parts with MSN and bingles and tube integrity would be interesting, but as the WAWKI fell off a cliff this year, not sure it makes much difference in the end.

[George Glass]

Tee Emm

Garuda GA200 in 2007 is a favourite.
As a sim exercise on unstable approaches, we were put at 2000’ in the configuration they were at and asked to continue. It made the hair stand up on the back of your neck. The CVR is gobsmacking.