Friday, September 16, 2011

Boeing 737-8HG (WL), Air India Express, VT-AXV: Fatal accident occurred May 22, 2010 at Mangalore-Bajpe Airport (IXE), India

NTSB Identification: DCA10RA063
Accident occurred Saturday, May 22, 2010 in Manglaore, India
Aircraft: BOEING 737, registration:
Injuries: 158 Fatal, 7 Serious, 1 Uninjured.

The foreign authority was the source of this information.

On May 22, 2010 at about 6:10 am local time (0040 UTC), Air India Express flight 812 (VT-AXV), a Boeing 737-800 equipped with CFM56 engines, overran the runway into a valley during landing at the Mangalore International Airport, Mangalore, India. Of the 166 passengers and crew on board, there were 158 fatalities and 8 survivors. The airplane was substantially consumed by post-crash fire. The flight originated in Dubai, United Arab Emirates.

The investigation will be conducted by the Indian Director General of Civil Aviation (DGCA), and the NTSB has designated a U.S. Accredited Representative to assist the DGCA as the State of design and manufacture.

All inquiries should be directed to:
Office of the Director General of Civil Aviation
DGCA Complex, Opposite Safdarjung Airport
New Delhi 110003  India
E-mail: das@dgca.nic.in







More people could have lost their lives in June 2010, in a replay of the events that led to India’s worst air crash in a decade in Mangalore last year that killed 158 people.

On June 25, an Air India Express flight (IX-208) from Mumbai landed deep into the table-top runway located on a mountain in Mangalore.

The captain decided to take off and land again after circling the airport, but the co-pilot overruled him in the nick of time and applied the brakes, bringing the aircraft to a stop at the edge of the runway. A 300-ft gorge stared below.

“It was actually a miracle that they survived,” said Mohan Ranganathan, an air safety expert and a member of the government-appointed Civil Aviation Safety Advisory Council. “If the runway was even slightly wet there was no way they could have stopped before the runway ended. But if they had tried to take off they would have certainly ended up like the last Mangalore crash.”

The Directorate General of Civil Aviation (DGCA) is investigating the incident, said two government officials familiar with the matter, declining to be identified.

Air India Express, the low-fare arm of Air India Ltd, continues to run without a qualified chief of flight safety even a year and four months after the ill-fated crash in Mangalore.

Incidents such as the ones described earlier are increasing.

One of the government officials mentioned above said the landing of the IX-208 flight was of a magnitude of 2.9 G (acceleration due to gravity).

The maximum allowed for a Boeing 737​ aircraft, like the one Air India Express was flying, is 2.1 G.

A 2.9 G magnitude means landing an aircraft weighing 70 tonnes would be like landing an aircraft of 200 tonnes. The impact could have broken the belly of the aircraft.

An Iberia A 340-600 made a similarly hard landing of 3 G magnitude in 2007 in Quito, Ecuador. Its landing gear sensors got damaged, and that prevented normal deceleration of the aircraft due to the failure of thrust reversers and spoilers. The aircraft was damaged beyond repair.

The Air India Express IX-208 was operated by commander Saravjit Singh Hothi, 62, and co-pilot Manish Chimurkar, 34.

Air India Express chief operating officer S. Chandrakumar confirmed the incident.

“After the Mangalore crash, the standard of co-pilot training has been improved; so the co-pilot (Chimurkar) was more aggressive in taking over control of the situation,” he said. “Hothi has been grounded.”

In the Air India Express flight that crashed in May 2010, the co-pilot could not overrule the commander’s decision to land. The co-pilot had wanted to go around and land again, according to investigation reports. The flight overshot the runway and crashed.

Ranganathan said Air India Express has not learnt lessons from the Mangalore crash and the latest incident shows poor training standards.

The incident was not the only one in recent months. On 28 August, another Air India Express flight that took off from Kochi suffered a tail strike because its commander R. Sobti chose a speed suitable for an aircraft 20,000 kg lighter than the one he was flying.

In a tail strike, the rear end of the aircraft hits the ground druing take-off.

“Instead of take-off weight he used zero-fuel weight to calculate take-off speed,” said the first government official mentioned earlier. “Worryingly, the investigation shows that the ex-Indian Air Force pilot had a tendency to have a tail strike. Why did Air India Express ignore this?”

Sobti, too, has been grounded, Chandrakumar said.

Till an audit is done, DGCA should ground Air India Express and let Air India run those flights, said Ranganathan and the second government official.

Air India is certified by International Air Transport Association’s IATA Operational Safety Audit (IOSA), the global benchmark for airline safety; but Air India Express, despite committing to go through an IOSA audit last year after the Mangalore crash, hasn’t done so.

The aviation regulator has, meanwhile, started a base inspection of the airline.

“The situation is so bad at the airline that you can’t imagine,” said the second government official.

Air India Express Boeing 737 aircraft met with an accident 22nd May 2010 at Mangalore. The accident was investigated by the Court of Inquiry appointed by the Government and the report made available in April 2011.The accident shook the aviation industry and led everyone to undertake a look at safety oversight system of DGCA, aerodrome, air navigation, airlines, flight operations, training of pilots and all other related areas. While efforts to build and strengthen a robust civil aviation safety oversight system in DGCA were already underway, which Federal Aviation Administration of USA had confirmed during their audit of DGCA in 2009, immediate steps were taken after the accident to instil and restore confidence of the traveling public. Some of the immediate actions included a reassurance drive in the areas of aerodromes, airworthiness and operations which included inspections of all critical airports, confirmation on adherence to approved maintenance programs by airlines, availability of approved documentation and assurance on following of regulations by the airlines. Intensive spot checks on the tarmac, checks on maintenance hangars/ stores and night inspections were undertaken during the period. Special Operations surveillance drive was undertaken wherein emphasis on adherence to SOPs, ALAR/ Monsoon Circulars, Stabilized approach for safe landing, review of missed approach – ‘Go around’ policy, presence of Cabin crew in cockpit in case of one pilot leaving the cockpit, FOQA and CRM was ensured.

A Civil Aviation Safety Advisory Council (CASAC) was formed on May 28, 2010 with the mandate to strengthen aviation safety environment through synergization of available expertise in areas of airlines, airworthiness, operations, air navigation, aerodromes, aircraft engineering, human performance. Special invitees to the Council include FAA, ICAO Experts, IATA, Airbus, Boeing, Bombardier etc. This is an ongoing initiative under the Chairmanship of Secretary (Civil Aviation). The Council gets its technical inputs from working groups covering Operations (Fixed wing and helicopter sub-Groups), Aerodromes, Air Navigation Services, Airworthiness General Aviation and Helicopters. Based on the reassurance drive several issues in the three areas of aerodromes, operations and airworthiness came up. Immediate actions to address the deficiencies have been taken up during the past one year. Several safety related circulars have been issued and implementation ensured. These include presence of Cabin crew in cockpit in case of one pilot leaving the cockpit, Cabin Crew to interact with pilots on intercom during period of lean cockpit activity, in the event of incapacitation of PIC, copilot to take over control and in the event of PIC not responding to calls of copilot regarding ‘go around’, assertiveness by copilot to be encouraged. Regulatory provision for penal action for reporting for duty with alcohol consumption has been made. Pilots are being subjected to Breath Analyzer test prior to flights. License are being suspended for three months in case of first BA positive and on second BA positive instance, the license is cancelled.

In a move to step up the quality of training Captains, the period of Instructorship/ Examiner-ship has been restricted to 5 years with proficiency check every 2 years. Increased oversight for selection of trainers, quality of training imparted by trainers, integrity of simulator training have been introduced. Breath Analyzer Test has been mandated for approval of Training Captains and Pilots with BA ‘positive’ report have been debarred from becoming Training Captains. Existing Training Captains if found BA ‘positive’ are debarred from training Captain list for three years.The process for approval of foreign pilots has been made stringent wherein background checks are being done to ensure that these pilots have accident free record. The experience requirements for the foreign pilots have been enhanced and the pilots are subjected to Proficiency Checks before approval is granted by DGCA. These pilots are being subjected to same medical standards as the Indian pilots.



Many of the issues relating to condition and facilities at aerodromes which came up during the reassurance drive of critical aerodromes have been taken up with Airports Authority of India as well as Defense authorities for immediate corrective action. These relate to Friction test for condition of the runway, markings, location of Precision Approach Path Indicator (PAPI) for realignment with aiming point marking, adequacy of runway end safety area (RESA), Installation of localizer antenna frangible structures at identified airports of AAI, calibration of equipment such as ILS and VOR/DME In order to smoothen the licensing process, an Aerodromes Directorate has been set up in AAI with support staff. DGCA has undertaken a special drive for licensing of AAI airports. As on date, 42 airports for public use have been licensed by DGCA as against 29 in January 2011 of which 32 are AAI airports. There were 6 AAI licensed airports in November 2010. The Committee set up by the Government to examine the Flight Duty Time Limitations (FDTL) of crew members has submitted its report to the Government in September 2010. The report has been accepted and based on the recommendations of the Committee, a draft regulation has been prepared and comments invited. These comments are being reviewed for finalization of the regulation.

Review of the recommendations made by the Court of Inquiry of the Mangalore crash has revealed that action has already been initiated by DGCA on the issues raised in the report by DGCA during the last one year and the organization and the Government is sensitive to safety of aircraft operations. Government and DGCA are committed to sustain and enhance safety oversight system through proactive regulation making and its compliance by approved organizations. The real challenge today is to manage phenomenal growth of air traffic with safety.


Mangalore crash report, Cockpit Voice Recorder (CVR), Captain Zlatko Glusica, EGPWS

New Delhi:

Co-pilot (6:03:35):

It’s too high!

(6:03:42): Runway straight down.

Captain (6:03:43):

Oh my God

Okay

Co-pilot (06:03:54):

Go around?

Captain (06:03:56):

wrong loc.. localizer

Co-pilot (06:04:06):

Go around

(06:04:07): Captain

(06:04:12): Un-stabilised

(06:04:38): Go around Captain

(06:04:44): We don’t have runway left

Captain (06:04:54): Oh my God

(06:04:59): awwww. Big One!

(06:05:00): Ohhhh

At this point, 6:05:00 am on May 22, 2010, the Cockpit Voice Recorder (CVR) went blank. The Captain, soon after touchdown, attempted to take off again against air safety norms and failed. Few minutes later, Air India Express IX 812 overshot the tabletop runway at Mangalore’s Bajpe airport, its right wing hit a concrete structure supporting the antennae, crashed into the boundary fence and fell into the gorge below.

Within seconds, the flight from Dubai was a ball of fire, claiming 158 lives on board. Eight passengers survived.

The final investigation report has held the Captain’s failure to execute a safe landing as ‘the direct cause of accident’. The report, which has been accepted by the government, said Captain Zlatko Glusica, who was in command during take-off from Dubai and landing at Mangalore, carried on with the “unstabilised approach” during landing and ignored both the first officer’s (HS Ahluwalia) three calls to ‘go around’ and several warnings to ‘PULL UP’ and ‘SINK RATE’ from the Enhanced Ground Proximity Warning System (EGPWS).

Being at an altitude much higher than mandatory, the aircraft lost considerable runway length during descent, left with little to brake. EGPWS alerts the pilots in case the aircraft is in danger of flying into the ground or an obstacle. Unstabilised approach means the aircraft did not follow the prescribed speed, descent rate or vertical/lateral flight path parameters at the time of landing.

Despite adequate rest period prior to the flight for him and the co-pilot, the Captain was found sleeping for the first one hour and forty minutes out of the total two-hour and five minutes recorded on the Cockpit Voice Recorder (CVR), the report said. “As a result of relatively short period of time between his awakening and the approach, it possibly led to impaired judgement,” the report said.

The “sleep inertia” coincided with another phenomenon, often said to be a nightmare for pilots, Window of Circadian Low (WOCL) which refers to the period between 2 am and 5.59 am, when body temperature, alertness and ability to be awake is lowest. The report observed that a mandatory pre-flight medical check was not conducted for the flight crew before they departed from Mangalore. However, the report ruled out intoxication or self-administered drugs by the flight crew.

Another contributory factor, as per the report, was the incorrect landing instructions received by the flight as the Mangalore Area Control Radar (MSSR) was out of order and a notice to this effect was given in advance to all flights operating into or out of the airport. There was lack of communication between the flight crew, and the CVR recordings show that first officer was not assertive when he made a call for ‘go around’, even though he had read incorrect parameters during landing. He said to the Captain, “Radar not available, but I do not know what to do.”


Giving its recommendations, the court of inquiry — headed by Air Marshal (rtd) BN Gokhale—has said that Air India Express should be allowed to function as in independent organisation, and its training and flight safety should be accorded due priority. It also noted the airline’s simulator, on which training is conducted, suffers from maintenance problems and frequently breakdowns. It has asked the AAI to avoid downward slopes near the runway, as was the case in Mangalore, and instead bring them to the same level as the runway surface, especially in tabletop runways. The regulator, Directorate General of Civil Aviation (DGCA), should formulate guidelines on controlled rest in the cockpit, the report said.

5 comments:

  1. Almost exactly like the recent (8/6/20) crash. Guess no one took any of the lessons learned from the previous crash to heart. Too bad.

    ReplyDelete
  2. This airport is a good candidate for an EMAS system. The article's graphic mentions a "sand pit" but EMAS might prevent a similar accident from occurring again. Of course, training and CRM is first and foremost.

    ReplyDelete
  3. Waterlogged runway and ineffective braking for IX 1344.

    ReplyDelete
  4. Tabletop runways = No room for errors.

    ReplyDelete
  5. Training issues of foreign pilots seems to be a recurring theme among airliners crashing.
    Rumors have been rampant for years of healthy payoffs to pass check rides at these foreign carriers. Time to investigate?

    ReplyDelete