Airplane Boeing
737-8HG, registration VY-AXV, serial number 36333 manufactured in 2007.
The ACCIDENT
On 22 May 2010,
Air India Express Flight 812 takes off from Dubai at 0630 local time to
Mangalore*1.
The Directorate General of Civil Aviation (DGCA) ordered an inquiry into the crash, which began the
day of the crash. The National Transportation and Safety Board (NTSB) is also assisting the investigation with a team of
specialists including a senior air safety investigator, a flight operations
specialist, an aircraft systems specialist and technical advisers for Boeing
and the Federal Aviation Administration (FAA).
Weather-
The (non-aviation) weather station in
Mangalore reported the weather as partly cloudy, no precipitation, humidity 80%, visibility 4000 metres,
temperature at 28 degrees Centigrade, dew point at 25 degrees Centigrade and
calm winds at the time of the accident and 3 hours prior to the accident. Three
hours after the accident the weather station reported light drizzle, humidity
90%, temperature 28 degrees C, dew point 26 degrees Centigrade, visibility of
2000 meters, winds calm.
Transcripts from the Air Traffic Control (ATC)-
According to audio transcripts obtained
from the ATC, Captain
Zlatko Glušica, reported “established on ILS approach*” at 15 km (8 NM) from touchdown and was
given clearance to land at 7 km (3.8 NM) from touchdown, however, he aborted the attempted landing seconds
after touchdown (the spoilers, or air brakes are deployed to full extended
position immediately after touchdown) and tried to takeoff. The throttle of the
aircraft was reported to have been found in the forward position, confirming
that the pilot had attempted to abort the landing and proceeded to go around
(take off) with a short remaining runway length still available. According to
unnamed ATC sources at
Mangalore, the First Officer Ahluwalia was said to have warned his
commander more than once to go around instead of landing, and also that this
warning had come at a height of 800 ft, well before the aircraft attempted landing.
Retrieved
Data-
The Cockpit
Voice Recorder (CVR)was recovered on 23 May, and the Flight
Data Recorder (FDR) was recovered two days later. The
recorders were sent to New Delhi
by the Directorate General of Civil Aviation (DGCA) of India for data acquisition and analysis and were
sent to the USA to the National Transportation and Safety Board (NTSB) for investigation. DGCA official Zaidi claimed "better data
protection" while unnamed officials mentioned heavy damage to the devices.
In direct response
to this accident the Government of India decided to set up an independent air
accident enquiry board called the Civil Aviation Authority (CAA) would function independent of the DGCA. Effectively this means the DGCA will be
the regulator and the CAA
the investigator. The Director General of the DGCA said that it would be set up though a legislation, and would
comply with the recommendations of the International Civil Aviation
Organization (ICAO).
Official Inquiry-
On 8 September
2010 the details of the CVR and FDR were
presented to the COI.
The CVR analysis
reveals that one of the pilots was asleep in the cockpit (during cruise
flight-not exactly relevant information). For a duration lasting 110 minutes
the CVR picked up no
conversation from the pilots, with the report adding that the sound of nasal
snoring and deep breathing was picked up during this recording (information is
not related to the accident itself). The FDR analysis indicated that the flight started descending
from its flight path at an altitude of 4400 ft instead of the normal 2200 ft. The
aircraft also touched down at the 4,638 feet mark thus remaining only 3,402 ft
of available runway length*4 (see Figure 3). After rolling 2602 ft the pilot decided to go around with barely
800 ft of
the runway length still remaining resulting in the crash. Both pilots had
been aware of the non-stabilized flight path since they were both heard saying
"Flight is taking wrong path and wrong side", additionally the
aircraft warning systems had given repeated warning regarding this through the
GPWS-Ground Proximity Warning System*2
On 3 June 2010 the Government of India set
up a Court of
Inquiry (COI) to investigate the air crash. Former Vice
Chief of Air Staff, Air Marshal Bhushan Nilkanth Gokhale, was appointed to head
the inquiry. Named the Gokhale inquiry, it has to investigate the reasons
behind the crash and was originally mandated to submit its findings by 31
August 2010, this was later extended by a month to 30 September 2010. The
Government has also appointed four experts into this COI to assist in the investigation. The COI started its investigations by visiting the
crash site on 7 June 2010, it also visited all the eight survivors for
information.
Aircrash Consultants Considerations
Weather related
phenomena do not appear to have any influence in the accident as the weather
report clearly describes.Non stabilized
approach (too high & too fast) resulting in a touchdown way beyond the
touchdown zone (lack of Standard Operational Procedures – SOPs adherence). Too late attempt to abort an already
very long landing with only short runway length still available. The distance
to bring a Boeing 737-800 to a full stop on its maximum landing weight
-assuming the flight was carrying its full load and using manual brakes is 1310 metres (4,300 ft).
Bottom Line:
Air India Express negligence on implementing and enforcing a safety oriented
operation based in strict adherence to Standard Operational Procedures and CRM
implementation appear to be the initial link that triggered the chain of events
that lead to the accident.
A serious
investigation into Air India Express crews training and policies, SOPs and CRM would be strongly advisable at this moment.
Unfortunately,
pilot misjudgment and mistakes played a fundamental role for this accident. The
reasons for that pilot to have made his errors rely somewhere else and that is
what we need to peruse.
As any other
aircraft accident, this one was caused by a linked chain of events.
Air India
Express might have an SOPs
Manual (every 121 carrier-meaning Airlines in the world is enforced by law to
have one). Also every crew member must have his or hers CRM training up to date, within one to two
years of its last recurrent training, depending on company's policy.
It's crystal
clear to me that the deceased pilots were not examples of SOPs followers nor CRM abiding individuals. Let me explain:
1) Regarding the SOPs adherence routine:
The approach was
clearly a non stabilized one. Most serious Carriers SOPs have similar rules regarding stabilized
approaches. Usually on an ILS approach the airplane must be stabilized on the glide path, with gear
down and flaps in the landing configuration when passing the ILS Outer Marker (usually 1,500 ft above field
elevation and 5 Nm from the threshold). Under VMC (visual meteorological conditions) some SOPs allow the pilot to have his aircraft
stabilized at 1,000 ft. This rule is different if you are flying a visual
pattern when you may turn the base leg (90º degrees to the runway) at 1,000 ft
and the final approach at 750 ft, but that was not the case. The flight 812
was on an ILS approach, 2,200 ft above the glide path (see Figure 1 for the required altitude
information during Final Approach-red under line) and employing an excessive rate of descent (and
speed) in order to try to reach it! That lead to airplane touching down faster
and way beyond the touch down zone (see Figure 2 and 3).
The remaining
involuntarily reckless (too late attempt to go around) maneuver ended up
aggravating the already bad situation.
2) Regarding the CRM procedures adherence:
The First
Officer noticed the completely non stabilized approach and ushered
(unsuccessfully) the Captain to Go Around when they were still at 800 ft. His
shy response allied with the Captain's excess of self confidence (arrogance?),
ignorance of basic Airplane’s landing distances information were responsible
for the unsuccessful landing attempt and further consequences that ended in a
perfectly avoidable tragedy.
Here I emphasize
Air India Express responsibility:
1) Air India
Express apparently does not enforce SOPs strict adherence regarding stabilized
approaches procedures. The Captain's actions clearly show his lack of SOPs
knowledge and the company's disregard in enforcing its use. His apparent
ignorance of the airplane flying characteristics, meaning landing distance data
information also appears to have played a role.
2) Air India
Express does not appear to implement standard CRM techniques behavior towards
its crews. This is very clear by both pilots (captain-dictatorial, first
officer-submissive) actions and behaviors during the attempted approach.
Appendix: Notes on procedures and
Figures
Go Around
Procedure description:
A maneuver
initiated after a discontinued final approach phase (the actual flight path that the
airplane might fly in the final phase of the flight just before landing is
called FINAL APPROACH) due to
the following reasons:
1. Lateral
deviation from the runway centerline or ILS Localizer beam.
2. Vertical
deviation from the glide path of the ILS (above or below the glide path).
3. Excessive rate of descent.
3. Excessive rate of descent.
4. Approach speed
in excess of specified values for the approach. Typical example is more than 20
KT above the established approach speed for the actual weight.
5. Wind Shear.
6. Loss of visual conditions after reaching the D.A. - decision altitude.
7. Loss of visual conditions after reaching a Circling Approach D.A. or any time during a Circling Approach.
6. Loss of visual conditions after reaching the D.A. - decision altitude.
7. Loss of visual conditions after reaching a Circling Approach D.A. or any time during a Circling Approach.
6. Any abnormal
situation that might deviate or require deviation of the flight path from the above mentioned parameters.
Figure1
Figure 2
Figure 3
* ILS-Instrument
Landing System
*2 The GPWS provides alerts for potentially hazardous flight
conditions involving: excessive descent rate, excessive terrain closure
rate, altitude loss after takeoff or go around, unsafe terrain clearance when
not in landing configuration, excessive deviation below or above an ILS glide
slope.
References
- The WALL STREET JOURNAL, 21 June 2010
- Government of India DIRECTORATE GENERAL OF CIVIL AVIATION, 8 July 2008
- THE TIMES OF INDIA, 10 February 2011
© Antonio Carlos Arantes De Biasi
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