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Air India Express Crash: Update  
User currently offlinerishikesha From India, joined Sep 2010, 2 posts, RR: 0
Posted (4 years 3 months 1 week 6 days 22 hours ago) and read 12306 times:

Indian newspapers today cite recordings released by the court of enquiry into the May 2010 crash of an Air India Express B737-800 to suggest that a series of pilot errors led to the crash:

http://timesofindia.indiatimes.com/i...s-blunders/articleshow/6521963.cms

If true, these reports reiterate several important points of air disasters:

1. They rarely happen due to a single mistake.
2. Co-pilots have a critical role to play in taking charge when the pilot-in-command makes serious mistakes.

Rishi

17 replies: All unread, jump to last
 
User currently offlineCBPhoto From United States of America, joined Dec 2003, 1572 posts, RR: 6
Reply 1, posted (4 years 3 months 1 week 6 days 22 hours ago) and read 12188 times:

Sounds almost disturbing to me. One thing that I may never understand with this one, is why after he had already touched down, reversers deployed, would only guess the spoilers had come up at this point, would the captain then initiate a go around? Yes, he did land long and we all know that. But even if he applied full breaks, he might have been able to stop in time, give or take a few tires, or it worst came to worst, they would have overshot the runway by a bit. Surly a more desirable outcome then overshooting the runway at full power and increasing speed. The only thing I can think of, is that in the heat of the moment, he panicked and made a fatal mistake.



Quoting rishikesha (Thread starter):
2. Co-pilots have a critical role to play in taking charge when the pilot-in-command makes serious mistakes.

Unfortunately they are still Captains out their that have the old mindset that he/she is the boss, and the co pilot is just their for the radios. Unfortunately some cultures seem to harbor these people more then others, whether it is through training or following examples by their leaders and check airman. Once again, a break down in CRM has lead to more deaths, something that, while it is not common, is sure not unheard of!

Thanks for posting the follow up!



ETOPS: Engines Turning or Passengers Swimming
User currently offlineNASBWI From Bahamas, joined Feb 2005, 1320 posts, RR: 0
Reply 2, posted (4 years 3 months 1 week 6 days 22 hours ago) and read 12170 times:

I take it that Capt Ahluwalia was the FO? The media report doesn't specify.

Quoting rishikesha (Thread starter):
If true, these reports reiterate several important points of air disasters:

1. They rarely happen due to a single mistake.
2. Co-pilots have a critical role to play in taking charge when the pilot-in-command makes serious mistakes.

You're absolutely right. Unless there is a single cause to a catastrophe (such as an uncontained explosion onboard), there are many factors that lead to an incident. However, not all of those factors are necessarily attributed to the pilot(s).

As far as interaction between CA and FO...well, if what the CVR revealed was true, then this incident is yet another painful reminder to any naysayers that CRM is not only helpful, but crucial in the safe operation of an aircraft.



Fierce, Fabulous, and Flawless ;)
User currently offlineCBPhoto From United States of America, joined Dec 2003, 1572 posts, RR: 6
Reply 3, posted (4 years 3 months 1 week 6 days 21 hours ago) and read 12089 times:

Quoting NASBWI (Reply 2):
I take it that Capt Ahluwalia was the FO? The media report doesn't specify.

Yeah, I think the article has it wrong. Capt is usually the abbreviation for captain, which I have no idea why they would put in front of the FOs name! Zlatko Glusica was the captain of the flight and I am pretty sure H S Ahluwalia was the FO. Glad we got that figured out.



ETOPS: Engines Turning or Passengers Swimming
User currently offlineha763 From United States of America, joined Jan 2003, 3671 posts, RR: 5
Reply 4, posted (4 years 3 months 1 week 6 days 19 hours ago) and read 11918 times:
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Quoting CBPhoto (Reply 3):
Quoting NASBWI (Reply 2):
I take it that Capt Ahluwalia was the FO? The media report doesn't specify.

Yeah, I think the article has it wrong. Capt is usually the abbreviation for captain, which I have no idea why they would put in front of the FOs name!

The article is correct. The crew list from Air India lists H.S. Ahluwalia as Capt. H.S. Ahluwalia.

http://home.airindia.in/SBCMS/WebPages/list-of-crew.aspx


User currently offlinerfields5421 From United States of America, joined Jul 2007, 7607 posts, RR: 32
Reply 5, posted (4 years 3 months 1 week 6 days 11 hours ago) and read 11029 times:

Quoting CBPhoto (Reply 1):
One thing that I may never understand with this one, is why after he had already touched down, reversers deployed, would only guess the spoilers had come up at this point, would the captain then initiate a go around? Yes, he did land long and we all know that. But even if he applied full breaks, he might have been able to stop in time, give or take a few tires, or it worst came to worst, they would have overshot the runway by a bit. Surly a more desirable outcome then overshooting the runway at full power and increasing speed. The only thing I can think of, is that in the heat of the moment, he panicked and made a fatal mistake.

Panic - maybe. But more likely a bad decision.

My read of the first link and your question both point to the Captain believing that beyond any doubt the plane was not going to stop on that runway. A key element I would like to know is the speed of the aircraft when he tried to initiate a go around. Did the attempt to go around increase the distance off the runway where the aircraft eventually stopped? Did it actually increase the speed going off the runway, and if so by an estimated how much?

If there was only 800 feet of runway remaining when he made that decision, was stopping on the runway or overrun even remotely possible at the speed of the aircraft at that time?

While they say there was only 800 feet of runway remaining, where did the aircraft touchdown? How fast was the aircraft when it touched down?

Certainly the decision to go around was completely contrary to any airline regulations after deploying the thrust reversers - but panic?

I'm not sure. Maybe a bad decision when the pilot and co-pilot had already put the aircraft into an unsurvivable situation.


User currently offlineCBPhoto From United States of America, joined Dec 2003, 1572 posts, RR: 6
Reply 6, posted (4 years 3 months 1 week 6 days 11 hours ago) and read 10668 times:

Quoting ha763 (Reply 4):
The article is correct. The crew list from Air India lists H.S. Ahluwalia as Capt. H.S. Ahluwalia.

My apologies, did not realize both were captains. If that is the case, H.S. Ahluwalia had no excuss not to interact and tell the captain he was in an unstable approach. He should have known better, as should have any FO but even more so if he was a Captain.

Quoting rfields5421 (Reply 10):
Certainly the decision to go around was completely contrary to any airline regulations after deploying the thrust reversers - but panic?

Well...it is certainly plausible. If you were a pilot in a similar circumstance, you land very long and the nose comes down on the runway only to realize you only have 500 ft left. Certainly we would all react differently to the situation, but I am sure a good percentage of pilots would panic and possibly try to take off again.

Quoting rfields5421 (Reply 10):
My read of the first link and your question both point to the Captain believing that beyond any doubt the plane was not going to stop on that runway. A key element I would like to know is the speed of the aircraft when he tried to initiate a go around. Did the attempt to go around increase the distance off the runway where the aircraft eventually stopped? Did it actually increase the speed going off the runway, and if so by an estimated how much?

Some interesting questions you pose, but I am still going to stick to my original thought. If you have landed the plane, spoilers are deployed and the reverse thrust has been engaged, imo you are committed to landing the aircraft. Forget about any policy or procedures, just sheer physics come into play. Unless you have a 16000ft runway, they just don't add up. Imagine how many precious seconds were wasted from the engines going from reverse to full power. Heck, even from idle to full power the spool up time can be near 3-5 seconds. All of this happening while they are still rolling down the runway at a 100+ kts. They should have just committed to the landing, that would have been the best option. Then again, hind sight is 20/20!



ETOPS: Engines Turning or Passengers Swimming
User currently offlinetharanga From United States of America, joined Apr 2009, 1867 posts, RR: 1
Reply 7, posted (4 years 3 months 1 week 6 days 11 hours ago) and read 10523 times:

Quoting CBPhoto (Reply 11):
They should have just committed to the landing, that would have been the best option.

Maybe, but this is still an interesting question:

Quoting rfields5421 (Reply 10):
when the pilot and co-pilot had already put the aircraft into an unsurvivable situation.

When they touched down that long, was a disaster already inevitable, regardless of what they did afterwards? Does it become a question of, is it better to overrun down a cliff while trying to slow down?


User currently offlineAesma From France, joined Nov 2009, 6933 posts, RR: 12
Reply 8, posted (4 years 3 months 1 week 6 days 10 hours ago) and read 10357 times:

With the cliff, the crash most likely would have happened anyway, but slower. That could lead to a better (or less worse ?) outcome.


New Technology is the name we give to stuff that doesn't work yet. Douglas Adams
User currently offlineBoeing747_600 From United States of America, joined Oct 1999, 1295 posts, RR: 0
Reply 9, posted (4 years 3 months 1 week 6 days 10 hours ago) and read 9818 times:

Quoting ha763 (Reply 4):
The article is correct. The crew list from Air India lists H.S. Ahluwalia as Capt. H.S. Ahluwalia.

Both the article nor the crew list from AI appear to be wrong. The crew list seems to have been put out by AI's PR department and may not be accurate. For one thing in the picture, H.S. Ahluwalis is shown wearing only 3 stripes, so he may have most likely been a senior F/O and not a captain,


User currently offlineJBirdAV8r From United States of America, joined Jun 2001, 4491 posts, RR: 21
Reply 10, posted (4 years 3 months 1 week 6 days 10 hours ago) and read 9793 times:

Quoting CBPhoto (Reply 3):
Yeah, I think the article has it wrong. Capt is usually the abbreviation for captain, which I have no idea why they would put in front of the FOs name!

1) Pilots in the right hand seat are not always "First Officers"

2) Even if they are, in many countries the entire flight crew is referred to as "Captains"



I got my head checked--by a jumbo jet
User currently offlineCBPhoto From United States of America, joined Dec 2003, 1572 posts, RR: 6
Reply 11, posted (4 years 3 months 1 week 6 days 6 hours ago) and read 7348 times:

Quoting tharanga (Reply 7):
When they touched down that long, was a disaster already inevitable, regardless of what they did afterwards? Does it become a question of, is it better to overrun down a cliff while trying to slow down?
Quoting Aesma (Reply 8):
With the cliff, the crash most likely would have happened anyway, but slower. That could lead to a better (or less worse ?) outcome.

One would think so. At least the chances that the crash will be become a survivable crash will increase. The same scenario could be used with a car. If you are going off the road, down an embankment, is it better to continue hitting the breaks while going down, or to hit the gas pedal and speed up. Either way you are going down, but the outcome could be vastly different if you are slowing down rather then speeding up.

Quoting JBirdAV8r (Reply 10):
1) Pilots in the right hand seat are not always "First Officers"

Yes, thank you! I corrected myself above!

Quoting CBPhoto (Reply 6):

My apologies, did not realize both were captains
Quoting JBirdAV8r (Reply 10):
2) Even if they are, in many countries the entire flight crew is referred to as "Captains"

That is true, and I have have been referred to as a Capt, even though I am a first officer. However, for purposes of an investigation it should be known whether the person in the right seat is a captain or a first officer. This clues us in on experience, type ratings and additional information on that specific individual. After all, two captains up front SHOULD mean a more experienced and seasoned crew.

Quoting Boeing747_600 (Reply 9):
For one thing in the picture, H.S. Ahluwalis is shown wearing only 3 stripes, so he may have most likely been a senior F/O and not a captain

Interesting, maybe he was a FO then. They just gave him the title as captain. Thanks for the info!



ETOPS: Engines Turning or Passengers Swimming
User currently offlinetguman From Canada, joined Apr 2001, 431 posts, RR: 1
Reply 12, posted (4 years 3 months 1 week 6 days 6 hours ago) and read 7050 times:

Quoting Aesma (Reply 8):
With the cliff, the crash most likely would have happened anyway, but slower. That could lead to a better (or less worse ?) outcome.

That would depend on the depth/breadth of the cliff.

I bring up the case of TACA 390 which crashed May 30, 2008, at TGU. The aircraft (Airbus 320) landed long on the 6,132ft runway and overran the end of the runway. Given the aircraft speed when reaching the end of the runway and entering the cliff, the pilot was able to pull the nose up slightly in order to allow the aircraft to settle into the gorge on its belly. This resulted in three deaths on board (the captain and two passengers) and two deaths on the ground. Previously, in an accident involving a C-130 hercules had a similar incident, all onboard perished because when reaching the cliff the aircraft went nose first and burst into flame.

So in this case, if it was a skinny/deep gorge, more speed would lead to the aircraft being able to "jump" the gorge, and a slower speed would be catasphrophic. Conversely, with a shallow/wide gorge, a slower speed would allow aircraft to stop "nicely" in the gorge, while a faster speed could tear the plane apart.

There are many factors to consider with regards to the gorge.

tguman



Life is a Mine Field.
User currently offlineyellowtail From United States of America, joined Jun 2005, 6349 posts, RR: 2
Reply 13, posted (4 years 3 months 1 week 6 days 4 hours ago) and read 6019 times:

Quoting CBPhoto (Reply 6):
Some interesting questions you pose, but I am still going to stick to my original thought. If you have landed the plane, spoilers are deployed and the reverse thrust has been engaged, imo you are committed to landing the aircraft. Forget about any policy or procedures, just sheer physics come into play. Unless you have a 16000ft runway, they just don't add up. Imagine how many precious seconds were wasted from the engines going from reverse to full power. Heck, even from idle to full power the spool up time can be near 3-5 seconds. All of this happening while they are still rolling down the runway at a 100+ kts. They should have just committed to the landing, that would have been the best option. Then again, hind sight is 20/20!

Another case is the AA overrun on the beach in KIN.....adding power would have probably ended it up in the ocean which would have surely led to loss of life.



When in doubt, hold on to your altitude. No-one has ever collided with the sky.
User currently offlineGolfOscarDelta From India, joined Feb 2008, 169 posts, RR: 0
Reply 14, posted (4 years 3 months 1 week 6 days 3 hours ago) and read 5383 times:

The CVR transcripts are here

The entire CVR audio used to be here with the timestamp, but looks like they've pulled it now.

From when i heard the audio before it looks like the FO was handling all the radio calls, and all the voices you hear in the flightdeck (and see on the transcript) are his.

Quoting CBPhoto (Reply 11):
Interesting, maybe he was a FO then. They just gave him the title as captain

Happens all the while in India in PR pieces and the media.

CRM and this:

Quoting rishikesha (Thread starter):
Co-pilots have a critical role to play in taking charge when the pilot-in-command makes serious mistakes

From when i heard the audio and the transcript you can see the FO urging the captain to go around hoping he will do it even before touch down.

Also i think most of the CRM breakdown here is mainly due to the eastern culture of deferring to authority/seniority.


User currently offlineCBPhoto From United States of America, joined Dec 2003, 1572 posts, RR: 6
Reply 15, posted (4 years 3 months 1 week 6 days 2 hours ago) and read 5043 times:

Quoting GolfOscarDelta (Reply 14):
From when i heard the audio and the transcript you can see the FO urging the captain to go around hoping he will do it even before touch down.

At that point, after telling the captain a few times to go around, he should have demanded or forcefully taken over the controls and executed a go around him self. He might have gotten in trouble, even fired, but he would be alive today. CRM is only CRM if both crews practice it!

Quoting GolfOscarDelta (Reply 14):
Also i think most of the CRM breakdown here is mainly due to the eastern culture of deferring to authority/seniority.

   Unfortunately in this and many parts of the world, CRM still has a long way to come!

Quoting yellowtail (Reply 13):
Another case is the AA overrun on the beach in KIN.....adding power would have probably ended it up in the ocean which would have surely led to loss of life.
Quoting yellowtail (Reply 13):
Another case is the AA overrun on the beach in KIN.....adding power would have probably ended it up in the ocean which would have surely led to loss of life.

Exactly. In my limited crash investigation experience, I honestly cannot think of a situation where going off the runway faster is less dangerous then slower.



ETOPS: Engines Turning or Passengers Swimming
User currently offlineJBirdAV8r From United States of America, joined Jun 2001, 4491 posts, RR: 21
Reply 16, posted (4 years 3 months 1 week 6 days ago) and read 4466 times:

Quoting CBPhoto (Reply 11):
Yes, thank you! I corrected myself above!

Sorry, I missed that.

I agree, it does get a little confusing when you talk about rank, title, pilot flying/pilot not flying, etc.  



I got my head checked--by a jumbo jet
User currently offlinerishikesha From India, joined Sep 2010, 2 posts, RR: 0
Reply 17, posted (4 years 3 months 1 week 5 days 22 hours ago) and read 3658 times:

Other press reports in India clearly established that Ahluwalia was the first officer though he was due for promotion shortly as captain. However, Ahluwalia had more experience with the Bajpe airport at Managalore having landed there 66 times compared to somewhere between 15 and 20 for the captain.

Details of the crew are available at
http://civilaviation.nic.in/COI/COI%20for%20Web%20site%20290610.pdf


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