(cvr) Tape Transcript Of Alliance Air B-737 Aircraft
 

This is the actual cvr transcript released by the investigation board ... go through it carefully a lot of things to learn from such an incident .. specially for all the young pilots like , low on the hours mistakes made should not be repeated in aviation

happy landings



RELEVANT COCKPIT VOICE RECORDER (CVR) TAPE TRANSCRIPT OF ALLIANCE AIR B-737 AIRCRAFT VT-EGD WHICH MET WITH AN ACCIDENT AT PATNA ON 17TH JULY, 2000


Seconds From Impact
Time (GMT)
From
To
Text
1166
01:43:35
7412
VEPT
Patna Allied 7412
1163
01:43:38
VEPT
7412
7412 Patna go ahead
1157
01:43:44
7412
VEPT
Namaskar maintaining flight level 260, estimating arrival at 0206
1148
01:43:53
VEPT
7412
Request estimate Sarek.
1144
01:43:57
7412
VEPT
Say again
1141
01:44:00
VEPT
7412
Estimate Sarek
1138
01:44:03
7412
VEPT
We checked Sarek at 41
1133
01:44:08
VEPT
7412
Allied 7412, Roger, maintain flight level 260 in co-ordination with Calcutta Cleared to PPT ILS DME ARC approach runway 25 transition level, flight level 55. Met. Report Patna 0120 wind calm, visibility 4000 meters, weather haze, cloud broken 25000 feet , temperature 29, dew point 27, QNH 996 HPa, No sig.
1104
01:44:37
7412
VEPT
996 copied
1101
01:44:40
VEPT
7412
QNH correct
1091
01:44:50
Intra

Lot of moisture around
947
01:47:14
VEPT
7412
Allied 7412 .
945
01:47:16
7412
VEPT
Go ahead.
942
01:47:19
VEPT
7412
Report for descent. Please check up descent traffic with Calcutta control.
938
01:47:23
7412
VEPT
Calcutta reported negative.
904
01:47:57
Intra

(Approach briefing) DME ARC approach
899
01:48:02
Intra

Approach briefing
855
01:48:46
7412
VEPT
Calcutta 7412 requesting descent clearance
846
01:48:55
VEPT
7412
Roger 7412, Patna confirm negative traffic with Calcutta
842
01:48:59
7412
VEPT
Say again
839
01:49:02
VEPT
7412
Confirm negative traffic with Calcutta
838
01:49:03
7412
VEPT
Affirm Sir
835
01:49:06
VEPT
7412
Roger Sir, descent to flight level 75. Report 25 miles.
832
01:49:09
7412
VEPT
75, call you 25 miles.
810
01:49:31
Intra

Approach briefing ---- pressurisation set for landing at Patna--- etc. Go around EPR set
Approach briefing completed --- Descend checks completed.
798
01:49:43
Intra

(Mike head set disturbance sound)
793
01:49:48
Intra

Set (disturbance sound)
593
01:53:08
Intra

(Mike head set disturbance sound)
565
01:53:36
Intra

News paper hai (in Hindi)
562
01:53:39
Intra

Chahiye (in Hindi)
415
01:56:06
Intra

25 miles
412
01:56:09
7412
VEPT
25 miles 7412
406
01:56:15
VEPT
7412
---- 7412 Roger, descend to 4000 feet. QNH 996 HPa, transition level, flight level 55. Report 13 DME for ILS-DME ARC approach runway 25.
398
01:56:23
7412
VEPT
4000, 996 HPa. Call you commencing the ARC.
367
01:56:54
VEPT
7412
Allied 7412, latest QNH 997 Hpa
363
01:56:58
7412
VEPT
997 copied
361
01:57:00
VEPT
7412
QNH correct
320
01:57:41
Intra

(whistling) Passing 55, 997
317
01:57:44
Intra

Set
301
01:58:00
Intra

13 miles, joining the Arc
299
01:58:02
7412
VEPT
Commencing the Arc 7412. Call you established localiser
291
01:58:10
VEPT
7412
Descend to 2000 feet QNH 997. Report crossing lead radial 080 PPT
281
01:58:20
7412
VEPT
Will do
252
01:58:49
Intra

Cabin crew
249
01:58:52
Intra

At your station please
201
01:59:40
Intra

Flaps 1
200
01:59:41
Intra

Speed good. Flaps 1 selected. Moving
199
01:59:42
Intra

(Landing gear unsafe warning horn)
184
01:59:57
Intra

Flaps 5
179
02:00:02
Intra

Gear down
147
02:00:34
Intra

Gear down
145
02:00:36
Intra

(Gear coming down sound)
143
02:00:38
Intra

Flaps 15
141



To


129
02:00:40






02:00:52
Intra

Landing checklist
Start switches
Low ignition
Recall
Checked
Altimeter
Checked, 997 set
Speed brakes
Armed green
Landing gear
Down three green
Flaps
15 on gauge
95
02:01:26
7412
VEPT
412 crossing lead radial and coming up on localiser
90
02:01:31
VEPT
7412
Descend to 1700 feet, QNH 997 HPa. Report establishing localiser.
83
02:01:38
7412
VEPT
Will do
79
02:01:42
Intra

Flaps 40
37
02:02:24
Intra

Horn (altitude alert)
36
02:02:25
Intra

Left hand down ---
35
02:02:26
7412
VEPT
Patna Allied 7412
34
02:02:27
VEPT
7412
Flight 7412 Patna
31
02:02:30
7412
VEPT
I would like to do one 360 due to high on approach Sir
25
02:02:36
VEPT
7412
Confirm aerodrome in sight.
23
02:02:38
7412
VEPT
Affirm. Sir affirm. Field in sight.
21
02:02:40
VEPT
7412
Roger, report final Runway 25 after carrying out 360.
16
02:02:45
7412
VEPT
Roger
10
02:02:51
Intra

Stall warning stick shaker sound (continued till the end of the tape)
7
02:02:54
Intra

Gear oopar lelo (in Hindi).
5
02:02:56
Intra

(Gear unsafe warning)
3
02:02:58
Intra

GPWS pull up warning
1
02:03:00
Intra

Noooooo………. Loud voice.
0
02:03:01
Intra

Crash (click sound)

I've only seen pilots do this in Asia .. a 360 degree orbit on final when the approach is too high. :rolleyes:

Whatever happened to doing a proper go around when the approach is unstable? Isn't that how all of us were trained to deal with such circumstances?

The '360 degree turn' or 'orbit on final' has since ben rendered illegal and banned unless the landing aerodrome is positively identified.The "commander" of the flight was shortly being upgraded to check pilot and the F/O was due for a commander's upgrade.The FO was doing the sector (illegally) from the LHS and the Capt was "instructing" from RHS.Both were drinking till 3 AM in their hotel room for a 6 AM departure.No breathalyser was conducted,but this was ascertained from the PM reports and the hotel queries and investigations.Pure CFIT,this one!

CFIT? The stick shaker would suggest they stalled whilst doing the orbit.

What else is Cfit my friend......:cool:.
The stick shaker was on for 23 seconds before they hit the ground.Lowest registered speed......97 kts.....!!!

The DGCA report says that instead of responding to the "Stick shaker" stall-warning..... a Go-around was initiated( wrong sequence--L/G up then Flaps 15 to silence L/G unsafe warning horn)
Also increase in power,even for the "Go-Around" was very slow.....hence the rapid transition from excess energy situation to running out of airspeed.(moving flaps from 40 to 15 made a bad situation,worse)
The Turkish 737 Amsterdam accident is somewhat similar( do i hear cries of "cultural" issues"?)
All the other factors apart,an A/C with "envelope protection" like the A320 prevent this kind of accident.
However even these can be flown into terrain/sea due disorientation, as happened in Bahrain just a month or so after the Patna one,and again at Sochi.
The Obvious next step is to rig up the EGPWS to an alpha floor kind of protection(that would also knock the wind out of 911 scenerios!)

Both were drinking till 3 AM in their hotel room for a 6 AM departure
 

With due respect to all the members here at PPRuNE, I would like to request you not to allege someone without strong proofs of Drinking till 3 A.M (with his Co-pilot) for a 6 A.M departure, specially when that person is no more. And moreover talking about my personal view about it, I dont think that a Captain (about to be a check-pilot) with around 4000 odd hours would sit with his Co-Pilot (to get the Command soon) with around 4000 hours as well would be drinking at 3 A.M for a 6 A.M flight.

Here is the Official Report of the accident issued by the D.G.C.A.

AIRLINE OPERATION-1

1. AIRCRAFT:
Type : Boeing 737
Registration : VT-EGD
2. DATE AND TIME : 17.07.2000, at 0734 Hrs.
3. LOCATION : Gardani Bagh, Patna.
4. TYPE OF OPERATION : Scheduled Flight.
5. PERSONS ON BOARD : Crew : 06, Passengers : 52
6. INJURY INDEX : Fatal : 55+5 Serious 2+5 : Minor/None 1

7. DAMAGE TO AIRCRAFT : Destroyed
8. PILOT-IN-COMMAND : Licence : ALTP-2089
Age : 35 Yrs approx.
Total Hrs. : 4316:15 Hrs.

SUMMARY:

Boeing 737 aircraft VT-EGD, owned by Indian Airlines Ltd. and operated by
Airlines Allied Services Ltd. took off from NSCBI Airport Kolkata at 0615 hrs on
17.07.2000 for Patna – Lucknow - Delhi. The aircraft was under the command of Capt.
Sohan Pal and there were 58 persons, including six crewmembers, on board. At approx 0713
hrs, the aircraft informed Patna ATC, estimated arrival time at Patna at 0736 hrs. The
aircraft informed Patna ATC at 0732 hrs that it would like to do a 360-degree due to being
high on approach. The ATC informed the aircraft to report final for R/W 25 after carrying
out a 360-degree turn and the pilot acknowledged the same. This was the last
communication recorded between the aircraft and the ATC. During the approach, for R/W
25 at Patna, the aircraft turned steeply to the left, losing height, and collided with the tree in
the approach funnel and crashed in the Gardani Bagh area near Patna Airport.
The aircraft
was totally destroyed due impact with the ground and post impact fire.
The probable cause of the accident: The cause of the accident was loss of control of the
aircraft due Human Error (Aircrew). The crew had not followed the correct approach
procedure, which resulted in the aircraft being high on approach. They had kept the
engines at idle thrust and allowed the air speed to reduce to a lower than normally
permissible value on approach. They then maneuvered the aircraft with high pitch
attitude and executed rapid roll reversals. This resulted in actuation of the stick shaker
stall warning indicating an approaching stall. At this stage, the crew initiated a Go
Around procedure instead of approach to Stall Recovery procedure resulting in an actual
stall of the aircraft, loss of control and subsequent impact with the ground.

Factor: Pilot: Non-adherence to standard operating procedure.

Both were drinking till 3 AM in their hotel room for a 6 AM departure
 

Just to further point out, if someone is intrested, and i think one should must go through the complete report on the accident :

REPORT ON

ACCIDENT TO ALLIANCE AIR BOEING 737-200
AIRCRAFT VT-EGD ON 17Th July 2001 AT PATNA BY

THE COURT OF INQUIRY
AIR MARSHAL P. RAJ KUMAR, PVSM, AVSM, VM
PROGRAMME DIRECTOR (FLIGHT TEST)
AERONAUTICAL DEVELOPMENT AGENCY, BANGLORE

GOVERNMENT OF INDIA
MINISTRY OF CIVIL AVIATION
GOVERNMENT OF INDIA

MINISTRY OF CIVIL AVIATION

Link to the report:
http://civilaviation.nic.in/coi-fin/report.PDF


"AND CLEARLY ON PAGE 51 OF THE OFFICIAL REPORT CONTAINING THE MEDICAL REPORT OF THE CREW STATES THAT ALL THE CREW TESTED NEGATIVE FOR THE BREATH ALYSER."

A stall isn't exactly "controlled flight" my friend. :)

CFIT
 

I wouldnt definately call this a CFIT ( Controlled Flight into Terrain).

Primarily the reports suggest that the accident has taken place because a go-around procedure was initiated instead of recovering from the stall procedure.

RIP Capt. Sohanpal & Capt. Bagga.....

That's right , this cannot be defined as a CFIT as the flight was not in a "controlled" state when it impacted the ground.This is more the case of an aircraft going out of it's envelope , the low speed regime.On the B 7372s if you are not aggressive with thrust management you can go on the wrong side of the drag curve very quickly with Gear Down / Flap 30 even in level flight so you can imagine what it would be like in a turn.It is true that Capt. Bagga was on the LHS while Capt.Sohan Pal was on the RHS.Capt.Bagga had completed his Captain's training but was awaiting the endorsement from the DGCA.However that said I think it is important for us aviators to respect their memory and the sentiments of their respective families and not accuse them of acts committed, of which there is no proof but only hearsay..:ok:

This is from the report which you quoted aviator_hyd;

I don't think it was CFIT. The stick shaker was going all the way until they hit the ground suggesting they stalled whilst doing the orbit at idle thrust.

As someone said earlier, this accident has very close parallels with the Turkish Airlines 737 accident at Amsterdam earlier this year. Now if only the CVR transcript for that accident could be released to the public so that we can all learn from it.

lets define CFIT as a lot of people are having some misunderstanding about this .
Controlled flight into terrain (CFIT) describes a collision whereby an airworthy aircraft, under pilot control, inadvertently flies into terrain, an obstacle, or water. The term was developed by engineers at Boeing in the late 1970s. The pilots are generally unaware of the danger until it is too late.

this particular accident is purely pilot error , since they were high on approach and wanted to loose height while doing a 360 on final , well nothing wrong in that ofcourse not a published procedure , but at places like patna where there is not much traffic can be done , but during the maneuver they both might concerened about losing height and no one noticed the airspeed dropping as the two might also be looking out for the runway so that they can roll out . The thing is that the very basics of flying went wrong along with poor CRM .

we respect the feelings of the families of the crew , hoping that such fatal errors wont be repeated in future .:=

happy landings :ok:

@leftseatview
 

just read the analysis of the bahrain A 320 crash which is so similar to this one!...ofcourse the 360 orbit during final approach is a complete no-no in the SOP of almost every airline..

but the findings of that investigation show some more interesting data..

1. the age/experience difference in the flight crew..the fo was low time ( training reports showed him as a slow learner...)..the capt was experienced...as a result of which blatant violations of the sop met with no reaction from the fo. infact the capt reviewed a few sys with him earlier so that must be weighing on the fo's mind and he probably thought the capt knew what he was doing!

2. the weather was not a factor yet again

3. atc approved the orbit ( its no longer an approved manoeuvre )

4. crm was not a mandatory part of the refresher for flight crew at gulf air then...

the study further concluded by making CRM part of the refreshers so that a vauable resource like the FO is just not used to do PNF work..

inclusion of GPWS recovery procedure at sim checks

strict adherence to "stabilised approach"...

and last but not the least...no punitive action ( or questions asked ) against pilots initiating a go-around...for most its like a challenge to land come what may( EGO )..going around is like embarassing especially with a new low time FO..but of late that perception has changed thanks to the thrust on following sop's...

scorpilot - "...ofcourse the 360 orbit during final approach is a complete no-no in the SOP of almost every airline.." well at that time many many airlines did not have a 360 degree policy. Alot do now, and they are not a no no, but have a definite policy.

This Captain did the 360 at night, starting it at 500 above the water, autopilot off and for good measure, no Flight Directors!!! The trouble with doing a 360 is that if you have not thought it out, you often end up in exactly the same place as when you started it!! Another point in this accident was the captains ego. It was huge, and this was not helped by the fact that, although he had just gotten his command, he considered himself to be on the most senior captains in the airline. This because GF changed thier seniorority system, from date of check out as a captain, to the date of joinging the airline. This chap joined the airline as a ground engineer, then went to flight engineer, got his flying licence and moved to the right seat. So when he got his command he had spent nearly 20 years in the airline!!

The Fo on this flight had been given more than a hard time by the captain - the landing runway was changed in the decent to a strait in VOR/DME shortening track miles by approx 20. The cpatian inserted the approach into the FMC, commenting " see little boy, I done it before you can blink". The Fo was totally behind the aircraft!!

MOd for automatic F/Ds on G/A
 

The modification for Flight Directors to come on automatically when Thrust Levers are moved to TOGA came after the Bahrain accident.
Though it could not prevent the Sochi accident 6 years later.....not sure if it was a pre mod A/C or the pf/Capt did not follow F/D commands on the Go-Around.

"C"fit is CONTROLLED flight into terrain..hardly imagine a stalled aircraft is under control at impact

I was sent to Cal for 4 weeks (since we always had shortage of crew at the Calcutta base then), 5 of us sat for Dinner at about 8PM, Capt. Sohanpal had a splitting headache and went up to his room right after dinner, Capt. Bagga's wife was in Cal for some personal work and they went up to their room too at the same time.

It was the 2 of us (rookie first officers) later joined by 3 cabin crew who were drinking, the bill was sent up to Capt. Sohanpal since he was the seniormost of all of us and crew respect was that he had instructed the hotel staff to bill it to his room.

If any ex Alliance Air people are on this forum, you know the tricks Capt. Javed did on this one.

It was sad when we flew the relief aircraft into Patna the next day carrying the relatives of the deceased.

I WOULD REQUEST FELLOW FLIERS TO NOT DRAG THE TWO DEAD MEN INTO THIS ... PLEASE.

IN MY PERSONAL OPINION - two very experienced fliers in the cockpit sometimes can take the aircraft and procedures for granted at times, which is what I believe happened here. It was common fact that we were flown like dogs in those days. Since you keep repeating the same thing over and over again (like when we'd do 471/472 early mornings, 4 landings) sometimes when preparing the aircraft for the next leg I'd be like "ummmm did i do this in this sector or the last sector" it took a lot at times to just look straight back into the check-list to confirm.

I find it hard to believe that a B777 TRE and Boeing test pilot (as per boeingdream787's profile) can not distinguish between CFIT and a stall! :hmm: :rolleyes: