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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. |
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 |
Sounds like the Captain should have been found in the Hotel Room :E 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, :ok: |
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..." :ugh:
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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. |
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. |
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. :ugh: |
...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. :ugh: 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. :yuk: |
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. |
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!:eek: You will spare us of another BORING Abs x Boeing thread, for God sake! |
Okay than , no A vs B.
KBROCKMAN: OH NO! You will spare us of another BORING Abs x Boeing thread, for God sake! 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. |
flaps were oversped during the recovery (since there was no Autothrottle protection). |
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. |
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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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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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. |
I am not familiar with the 777 so I'm relating the incident to my own aircraft (737)
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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 |
bleeds off;
The automation reduced the power to idle so as not to exceed the max flaps speed. On this type of a/c is it normally an acceptable reflex to disconnect only the autothrottles while keeping autopilot engaged like he did. 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 |
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. |
cheers for that PJ2 :ok:
Would have been interesting to know what actually was the automation target speed during that early level off and what exactly made the capt doubt about the validity of the autothrottle reaction. |
faheel;
For my part I fully comprehend the rapidity with which these operations can occur. That's why the departure briefing is critical and the full use of the automation is required. I gave up hand-flying London departures years ago simply because the autoflight system did it better and more accurately. There is a time for manual flight and departing Heathrow is most definitely not one of them. While not quite the silliness of the DEL SID, the Compton departure off 23R often levels at 6000ft - a trap for young players or a crew that isn't on top of the game as that is also the transition altitude and one must remember to set standard pressure immediately upon being cleared higher. It can be even much busier elsewhere and I know you'll have experienced exactly that. The fact that this pilot is having to resort to sharing information here on an anonymous aviation forum is not good, it is shameful and a condemnation of Air India's flight safety system and operational culture. I still have no responses to the questions I have asked and that, at this stage of the thread where it is certain that people in the know would have the answers but haven't said anything, is revealing. PJ2 |
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. HOWEVER, I have no experience in using the autopilot with such a low level-off altitude. I do not know for sure how well the 744 would handle it, so I tend to fly those manually at least until the airplane is stable at the level-off altitude. There are those in the 744 community who would recommend going directly to FLCH after 400' AGL in similar situations -- especially if VNAV ALT was not captured) to reduce the rate of climb and ensure the Autopilot/FD and autothrottles exit TO/GA. I would not disagree with that technique. Frankly, in that situation the flap limit speed would be among the LEAST of my worries. Keeping above V2 and VERY close to the target altitude would be my primary concerns. ACARS WOULD immediately report the flap overspeed. A couple hundred people were VERY lucky that there was a 3rd pair of eyes AND a 3rd brain at work on this flight. In the US we at least have the NASA ASRS reporting program to use without fear of retribution. Many airlines have the ASAP program as well, but it's not confidential like ASRS is. It's too bad the situation is so bad over there in India... |
The current flap limit speed is set by the FMS as the limit speed, so flap overspeed protection IS provided. Such an early capture brings up another latent problem: The "Alt*" (altitude capture) characteristic, which, while first demonstrated tragically by the A330 at Toulouse, applies equally to Boeing. I wonder if this is what occurred here? It depends upon how much the flap speed was exceeded by and what flap setting was out. I suspect more than a few here have exceeded flap speeds by a few knots for a few seconds. While not good for the slats/flaps and mainly for the flap support structure, a catastrophic failure of the flap system is not normally the result. In other words, such infrequent excursions aren't likely to damage them and in my view such an excursion wouldn't necessarily result in a decision to dump fuel and return to the airport. However, only the on-board crew can make that call, especially if the overspeed was substantial or for an extended period of time. Anyway, all this is beside the point and off-topic. The main point here is very clear to all - a possible loss-of-control almost-certainly fatal accident avoided due to quick thinking. Now what? PJ2 |
While I now fly the 777 and am in awe of the control/thrust/autopilot systems, this crew did something a DC-8 or B-727 crew would never had done.
They didn't control airspeed. Plain and simple. It's happening with increasing frequency these days - as our MD-10 in the high holding pattern showed a few years ago. Open the speed edit box, set it at 200 knots, let the damn thing stabilize, see what you can do about cleaning up. Fly the damn airplane. |
A salutory tale.
It seems we are off on a few incorrect tangents, however? 1) Reading 'Lesson f' suggests the Captain was not an ex-pat, so some of the comments here may not be applicable 2) It does indeed sound like the 'alt*' event which I know from the 737 well. A low-level level off is by no means unusual and needs to be carefully briefed due to this. It can be common in Tel Aviv. It is easily handled as a crew. 3) The 'CVR download' in JFK would be a waste of time unless our poster had pulled the CB which would, it seems, have been a death sentence. 4) The intitial reaction of the Captain in disconnecting the A/T is understandable but not excusable. The Captain should have expected, briefed and known what would happen. It is "Lesson 1" in how to deal with automation - if it appears to be malfunctioning turn it off and revert to basic flying skills The latter part did not happen. The demonstrable existence of such fear of reporting is of serous concern. Surely an FDR would be fitted and that could have been downloaded? If we are in yet another 'culture/status' driven area of operations then some international body needs to wake up. |
What actually happened here is that the AFDS captured the low leveloff very early (evidence FMA VNAV ALT). The AFDS sub-mode (not displayed on modern Boeings or Airbusses) is V/S. In this sub-mode the AFDS tries to follow a parabolic arc to level off at the captured altitude using pitch control. The A/THR has speed but is respecting only the low speed limit. VFE is ignored in this submode.
As suggested, the best way (but not the only way) to handle a low level off with automation is revert to FLCH. This puts the A/THR back in charge of the speed, not guarding it. I too have been given the low level off at DEL. I rejected it and sat on the runway until I was given a more reasonable level off. Like PJ2 I wonder about the SMS at AI. :* |
3-wire - do not fly to Nice - you'd be there all day waiting on 04:ugh:
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I am not saying all automation is bad, quite the contrary, it is great to have, however it seems that a lot of crew simply slip 'out of the loop' accidently with the fixed mindset of letting the AP fly - especially near the ground.
What happened to hand flying to 10000ft, or at least the initial portion of the SID? Maybe it's just me, but in a two-man flt deck there should be plenty of capacity for one the hand-fly and the other to run checklists and radios. I am not saying people should hand-fly in crap weather conditions for the sake of it, but they should certainly be prepared to do so at any time. If both get preoccupied with checklists or the autopilot, none is monitoring the actual flying. Think about it this way... we'd have probably read about this in the papers wouldn't it have been for the SIC on the jump. :ouch: |
What actually happened here is that the AFDS captured the low leveloff very early (evidence FMA VNAV ALT). The AFDS sub-mode (not displayed on modern Boeings or Airbusses) is V/S. In this sub-mode the AFDS tries to follow a parabolic arc to level off at the captured altitude using pitch control. The A/THR has speed but is respecting only the low speed limit. VFE is ignored in this submode. PJ2: The autothrottles don't "see" anything on their own. They are controlled and limited by the FMC. In FLCH the speed is controlled by the MCP window, since it opens automatically when FLCH is selected. IIRC, flap limit speeds are not honored when the MCP speed window is open. |
Few years back, i was on descent into Mumbai and cleared to 11000ft. Indian Airlines Airbus was cleared to climb to 9000. To cut the story short, he climbed through it and hell broke loose. Hard RA and we climbed out of the way. Whew!
I filed a report and rang the chief pilot, who begged me not to file the report. Something about having an ace up the sleeve, next time the authorities did an audit on the compay. I resigned and had left India within the week! When i left India, the number was up to 35 near misses a year. I sometimes wonder how many WERENT reported! |
<<the Compton departure off 23R often levels at 6000ft >>
Now there's a man who hasn't been to Heathrow for 50 years as 23R simply does not exist. "Often levels at 6000ft"?? If I recall correctly all except one of the the Heathrow SIDs level at 6000ft and that has been the case for donkeys years. |
Im gonna deviate abit....
ITS been a coupla years since i flew the big bird, but I vaguely remember that the B777 A/Ts are never really off...and at Vls(low speed) they kick in just enough to maintain speed at or slightly above Low speed Buffett irrespective of their posn ie off or armed....any to clarify? |
if it appears to be malfunctioning turn it off and revert to basic flying skills The latter part did not happen. Concerning reverting to basic skills, now there's a thing that scares me most. I've seen too much absence of such skills recently as to believe in coincidence. We will never have automatics that are fool proof, we will never completely and continuously be aware of all modes and features of automation. We should, at least for the foreseeable future, still be able to revert to basics and reengage automatics once stabilised. This beeing neglected in basic and enhanced training, and thus lost forever, will lead to such incidents happen more often. The perpetuous call for even more protections and automatics will always only cure some symptoms, but not aviations malaise -> lack of skill and experience. |
If the airline doesn't have Flight Data Analysis (FOQA) don't fly with it or on it.
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Having flown the 777 for the company involved I can believe something like this could have happened, however some things need clearing up in regard to 777 operations. After T/O after acceleration height, FMA changes from TOGA to THR REF/LNAV/VNAV SPD ie. A/Ts set reference thrust on the engines, LNAV captures and VNAV speed is maintained by pitch attitude through the A/P or F/D which at this point is 230 knots (flaps 5 speed minus 5 knots) this speed is indicated as the target airspeed above the ASI (speed window is closed). If at this point FLCH is selected, again THR REF and LNAV unchanged, and FLCH is engaged, speed window opens indicating a target airpseed of 250 knots (below 10,000') and A/P or F/D maintains airspeed throught pictch angle.
There is no need to hand fly low level hold downs, the A/P has logic to anticipate this in FLCH or VNAV, and in fact at heavy weights close to the ground automation makes sense (even more so in that part of the world where manual proficiency is not maintained). The 777 does have low speed protection even with the A/Ts selected off, and they would have enagaged automatically to prevent speed decreasing to near Vs (which even at heavy weights would be closer to 100 knots than 200 knots with flaps 15 still set). When the aircraft was accelerated using manual thrust and still climbing in FLCH the A/P would have mainted 250 during the climb, and any overspped condition would have been prevented by the load relief system. To suggest pulling a CVR CB at the begginng of a 15hr flight is probably not prudent, as anything could happen after this point that could need to be recorded (ie. incident on approach), and the FDR would record all the parameters and selections anyway. A valuable lesson learned hopefully for the crew involved, and I would expect that someone would notify the airline so that they can prevent it happening again. |
Safety
Just a thought, but shouldn't the best and more experienced crews be those selected for operations such as B777 Delhi-JFK? The report suggests a combination of incompetence and inexperience in the front 2 seats of this particular near-disaster. With a consequent cover-up to boot.
I fear that nepotism over-rules ability-based qualification for "good" jobs in many countries like India and in many airlines similar to Air India. I am being direct and politically incorrect here, but am by no means having a pop at AI specifically. I just believe that the democratic systems in place in major US/North European/Antipodean carriers have little or no place for nepotism. Their safety records reflect this. |
"Often levels at 6000ft"?? If I recall correctly all except one of the the Heathrow SIDs level at 6000ft and that has been the case for donkeys years. DEL, on the other hand, is obtuse in the extreme with ATC demands...expect the unexpected. Par for the course. |
On a B777 you can not pull the CVR circuit breaker.
It is not located in the cockpit, the CB is in the electronics bay below the cockpit. You need to open a hatch in the floor at door 1L and don't forget to bring your portable oxygen when you go in there during flight. Frankly I don't understand WHY the CVR CB is located THERE. beats me. Ask Boeing. |
Furthermore, it's against of the SOPs on majority of the airlines to go manual at will. There are situations, as described in this low altitude level-off, in-a-turn, fast-moving scenario, where the automatics may not have been set properly, or for whatever reason may not deliver the required profile. A common mistake I have noticed by many new pilots is their obvious hesitation in disconnecting the automatics and going manual. Their first impulse is always an attempt to correct the flight profile with more automatics. After the THY B738 stall and crash at AMS, Boeing has clearly stated: "When the automatic systems do not perform as expected, the PF should reduce the level of automation to ensure that proper control of the airplane is maintained. The PF should not attempt to restore higher levels of automation until after aircraft control is assured." Practical reality suggests that pilots should not be trained to have an aversion of hand flying the machine at will. :ooh: |
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