[1lokesh]

Hello folks,

So after long chain of tedious follow ups with the DGCA, I have been able to get the final accident report from them, as prepared by the AAIB. The same is attached herewith. I am not a pro in deciphering such reports, however there are some understandings which I have construed from my read. Basis my previous experience (on this forum and otherwise as well), I will not jump on to conclusions as of yet.

Notwithstanding, may I request learned members of this forum to help me understand this better.

Note: As of now this report is not available on DGCA website. It was sent to me from the DGCA offices directly through an email. As far as I know, they were planning to update it on the site in the first week of July '18, but I don't see it live yet.

Thanks,
Lokesh.

[AlphaKilo]

Originally Posted by 1lokesh

Hello folks,

Notwithstanding, may I request learned members of this forum to help me understand this better.

Note: As of now this report is not available on DGCA website. It was sent to me from the DGCA offices directly through an email. As far as I know, they were planning to update it on the site in the first week of July '18, but I don't see it live yet.

Thanks,
Lokesh.

Ouch! Good that no one was seriously hurt or lost their lives by the stupid mistake. Some points I notice from the report:

1. The Aircraft was fit and fine.
2. Sufficiently trained Crew (cockpit and cabin)
3. No external factors in play.
4. Simple cause: Human error - Neither the pilot flying nor the Pilot monitoring reacted to the asymmetrical power setting (left engine (engine 1) producing more thrust (power) than the right engine (engine 2))
5. The above caused the aircraft to turn towards the right, towards the side of the engine generating the weaker power.
6. Second mistake was while trying to correct the asymmetrical power, a constant opposite force using brakes(rudder) was used - No speed brakes were applied nor the right engine was allowed to reach its full potential.
7. While decelerating, the Pilot flying throttled down only one engine and hence, causing a even larger difference in thrust generated.

I hope this helps. Feel free to pen down your questions.

I have a few questions though, may other members can answer it.
1. What was the outcome of the previous such rejected take-offs? Were they too pilot errors?
2. If yes to above, then why did not the airline already react to this error that already happend once before!!! Why was their training not updated?
3. How can the airline be not held responsible for not acting to a mistake that has already happened?
4. What the Co-pilot/pilot monitoring doing at the time? why did he not callout for "Reject" when he should have noticed that both the engines were not at equal thrust?
5. How long were the crew already on duty? Were they tired? Report says they reported to duty at 2220 UTC, I assume they were resting until then.
6. Why was the flight delayed by 20 mins? Scheduled departure was at 23:10 UTC!

[saket77]

As far as I can understand this 44 page report, it is a pilot error. I am just an aviation enthusiast, not a professional hence would like to get the views of aviation experts and pilots of the forum to please come in and help us understand the circumstances & the series of events leading to this unfortunate accident. With my understanding, I couldn't find a fault in the aircraft or technology. This to me looks like a pilot error; feel free to correct me.

And I must thank Lokesh for bringing us this report, so that a meaningful discussion can take place further. Also hope that you have now recovered fully by the trauma caused by the incident.

Regards,
Saket.

[Jeroen]

Originally Posted by AlphaKilo

Ouch! Good that no one was seriously hurt or lost their lives by the stupid mistake. Some points I notice from the report:

I agree with your points. To add some thoughts/comments; I don't believe for a minute this has anythign to do with training. They will have been taught the correct procedure. Allowing engines to stabilitze prrior to pressing TOGA, effectiviness of rudder at slow speeds. This is rooky stuff!! As soon as you start flying twins as a student pilot you will be taught.

My opinion: These are just sloppy pilots that don't follow procedure. No amount of training will correct that. It is down to attitude. And these two characters have got bad attitudes in my opinion. They cut multiple corners on standard operating procedures. They did not abort the take off, which would have saved they day, but tried to muddle through their own ineptitude. Very poor performance.

Pilots that start cutting corners on normal operational procedures are the one that typically find themselves in these sort of reports! As I have been saying many times on the various aviation threads on our forum: Safety in aviation is about attitude, not about being the best stick and rudder guy.

Attitude gets you the thoughtfullness, preparedness for any eventuallity and the adherence to correct procedure. That is what makes aviation extremely safe. When shorts cuts are made, accidents happen. We discussed this before there is an element of culture in here as well: note that under recommendations states First officers must be more assertive. (?!) So he knew things were going south!!!

I did not see anything in detail about the voice recording, so it is unclear what they were saying in the cockpit. But based on the recommondentation it appears as if the FO was likely to have called out something to the captain who did not think it relevant to listen to his FO but still pressed ahead. (Reminds me of the Teneriffe disaster in which more than 500 people died because the KLM captain chose to ignore the FO)

Also, the blood and urine test was carried out approx 6 hours after the incident. Which is really way to late to be usefull to detect some casual drinking and drug effects.


Finally I noticed the FO held a CPL, whereas the captain has an ALTP. Is it common for FO only to have CPL. What is the minimum requirement to get an ALTP. These days in the USA it's 1500 hours and the FO doesnt even have half the hours. When I learned to fly you could get your ALTP at 250 hours only. So not quite sure how that works today and certainly not in India.

Jeroen
Jeroen

[AlphaKilo]

Originally Posted by Jeroen

...This is rooky stuff!! As soon as you start flying twins as a student pilot you will be taught.

+1 ! Even with a Single engine PPL, I was taught these stuff (as my Instructor was a fighter pilot and a Test pilot)

Originally Posted by Jeroen

My opinion: These are just sloppy pilots that don't follow procedure. No amount of training will correct that.

I think I didn't pen my question properly,

1. The Review committee addresses the issue at the end by saying, "This should be included in future training..." --> My question was if a similar incident already happened, why was this not included as an add-on training/SOP already?
2. Why was this not a part of their simulator training / Conversion testing procedure?

Originally Posted by Jeroen

It is down to attitude. And these two characters have got bad attitudes in my opinion.

True.

Originally Posted by Jeroen

...We discussed this before there is an element of culture in here as well: note that under recommendations states First officers must be more assertive. (?!) So he knew things were going south!!!

Was wondering the same. I was looking for more information on the investigation conducted with the pilots and the outcome of the cockpit voice recorder but it is sadly missing.

Originally Posted by Jeroen

Also, the blood and urine test was carried out approx 6 hours after the incident. Which is really way to late to be usefull to detect some casual drinking and drug effects.

Probably yes and no. But I was wondering whether they were sleep deprived or had a very short pause between two legs. Also as you pointed out, their experiences in general seem ok, I was also wondering about the FO being only a CPL and not an ATPL.
I remember from my selection agreement at the IGURA (Indira Gandhiv Rashtria Udan Academy), the premier pilot training institute in India that CPL --> ATPL was a part of the whole course and it lasted about 2.5 years with flying hours a lot higher than what you had mentioned. The only thing that was missing at IGRUA was the type rating, which usually the airline provides (in case of Air India, Indian airlines etc). Not sure about the policy of Jet Airways. I am not aware of the latest updates in the DGCA regulations though.

One issue that comes across is that the pilots could have graduated from elsewhere and did a conversion to Indian ATPL/CPL. In general, the Indian ATPL/CPL is quite tough to clear. Like in Europe, India has a lot many excess CPL holders who couldn't afford an type rating or couldn't manage to secure a job. They are doing the pay as you fly mode with Indian carriers. (for people wondering what this means: The Pilot/First officer, pays the airline a fee/rent to let him fly the jet so that he can gather flying experience and flying hours).

As far as the cultural aspect goes, I cannot comment on civilian flying as I have experience only with military instructors and there even with a very senior officer flying, junior most officer was always instructed to look for mistakes and make sure that it does not lead to any incidents. My instructor was an officer in the rank of a Wing commander with over 5000 hrs of combat and tactical flying and me being only a student trainee, he insisted that I should look for his mistakes and point it out to him and rectify them. His exact words were, both of us are equally responsible and if we end up in an accident due to our mistake, seniority does not count as to who dies first.

P.S: I got selected to do the Ab-initio till ATPL course but didn't join the academy due to personal reasons and hence remained only a PPL from NCC.

[Jeroen]

Originally Posted by saket77

With my understanding, I couldn't find a fault in the aircraft or technology. This to me looks like a pilot error; feel free to correct me.

Correct. Nothing wrong with the aircraft or anything else really. The aircraft was dispatched with one problem, but that was done in accordance with procedure and was not related to the incident at all

Originally Posted by AlphaKilo

+1 ! Even with a Single engine PPL, I was taught these stuff (as my Instructor was a fighter pilot and a Test pilot)
.

Same here. MInd you on a single engine (propellor) plane rudder authority comes into play much earlier in the take off roll as the propellor wash helps. On the down side you get all sorts of other effects that need to be countered by rudder (and aelerons).

When you go for your twin rating, the only thing that matters is to learn to fly and operate a twin engine on one engine across all flight regimes. So dealing with assymetric thrust under all circumstances is absolutely key to learning to operate a twin, be it prop or jet.

Originally Posted by AlphaKilo

1. The Review committee addresses the issue at the end by saying, "This should be included in future training..." --> My question was if a similar incident already happened, why was this not included as an add-on training/SOP already?
2. Why was this not a part of their simulator training / Conversion testing procedure? .

This is a bit more tricky. I dont see any evidence that the review committee actually reviewed what is being taugt in training and or on the simulator. But to my earlier point, my bets is on the fact that this is part of the training and the simulator already. And of course, you can't just put every eventuality in a training course or recurrent training.

Originally Posted by AlphaKilo

. Also as you pointed out, their experiences in general seem ok, I was also wondering about the FO being only a CPL and not an ATPL.
.

Well, at least they were in compliance with all formal Indian requirements it seems. Like you, I was just wondering how that works in India. Still 700 hours for a FO on a commerical jet would be considered quite low by many. You could argue how relevant flight hour is. (Depending on what report you want to believe it has no to a marginal affect on overall flight safety.

Fact remains that most large (Western Carriers) tend often to have at least everybody in the cockpit on the same formal certification level, so only difference would be hours. In countries such as the USA most commercial pilots clock up thousands of hours before getting into the cockpit of a commercial jet. But I do believe the USA is pretty unique and it would not surprise me if these days they have relatively low hour FOs in these sort of twin jets as well. And of course, every pilot at some point in time was a low hour pilot. You have to fly those hours to get the hours!

Jeroen

[TKMCE]

Not all incident/accident reports make it to the DGCA website , so a big thanks to the OP for the link.

I am not a pilot, but work in the industry and have tracked airline safety for about 3 decades. But I am not qualified to comment on technical issues.

My major observation after reading the report is this.


Both the Commander and the First Officer has an experience "on type" on of less than 500 hours? Isn't this pairing dangerous?

Agreed the Captain is an ATPL and has 5000 + hours, but he has directly transitioned as Commander from ATR 72 Turboprop where he has the bulk of his flying experience to Commander of B737. In such cases, should not Jet Airways have rostered him with a more experienced First Officer instead of another inexperienced (in type) FO? Do note the report also indicates a possible lack of CRM training for the FO.

If such low hour pairings on type are common rostering practices in India's airlines (let us hope not), then things don't augur well for India's aviation safety.

The USA requirement of 1500 hours for airline FOs came after the crash of a Colgan Air aircraft in 2009. In India to my knowledge there is there is no such stringent requirement. However it does raise a question of how assertive some of the these low hours FOs can be in case of a serous incident. ?

In August 2015, another Jet Airways B 737 aircraft with an experienced Captain (with more than 6000 hours on type, nearly half of it as Commander) with an inexperienced young FO (less than 600 hours on type) on a flight from Doha to Kochi made three attempts to land at Kochi in bad weather. The captain then decided to divert to Trivandrum despite the FO pointing out that a main landing aid (ILS) was unserviceable, made three more attempts to land in Trivandrum and finally landed "blind" on the SEVENTH attempt with no more fuel left to make another approach. The details of this incident which his available on the DGCA website makes horrific reading.


Some other accident/incident reports in the DGCA website also involving various airlines does raise serious concerns. Is Indian aviation growing too fast for its own good?

[Motard_Blr]

I am curious if there is a connection between these incidents where a lack of experience or negligence was a factor, and the publicly stated shortage of pilots and their pay. Could the situation be improved by airlines paying more? I have also read about Indian pilots complaining about the pay, restrictive regulations and contracts on notice period and duty hours.

It just seems to me that all these things are connected and cannot, should not be dealt with independently.

[AlphaKilo]

Originally Posted by Motard_Blr

I am curious if there is a connection between these incidents where a lack of experience or negligence was a factor, and the publicly stated shortage of pilots and their pay. Could the situation be improved by airlines paying more? I have also read about Indian pilots complaining about the pay, restrictive regulations and contracts on notice period and duty hours.

It just seems to me that all these things are connected and cannot, should not be dealt with independently.

No. There are more than enough pilots like more than enough engineers we are producing. The issue is with the quality. To get a CPL with ATPL takes atleast 2 years (with enough flying hours on real aircrafts). Further, the type rating is even harder. The most important of all for any commercial pilot is the CRM (Crew Resource Management) training and skills.

As Joeren rightly pointed out, being a good pilot is not enough, one should also be a good manager. This is lacking and no amount of money can buy this skill. Airlines themselves have a part to play. They want to cut operational costs and make more profit by investing less. You get what you pay for! Giving more salary will not solve the issue.

The money issue the pilots were fighting for were the difference between expat pilots and indian pilots. The expats get paid in dollar equivalent INR (i guess) whereas the Indian pilots are paid in INR only.

[Jeroen]

Originally Posted by TKMCE

Not all incident/accident reports make it to the DGCA website , so a big thanks to the OP for the link.

I have often commented on the fact that I find the Indian aviation lacking in transparency compared to their western equivalents. Why not publish everything? Why is there no transcript of the voice recorder included in the incident report?
Some of the conclusions in the DGCA report are not backed by factual information in the report. Their is nothing in the report that would suggest the FO needs to be more assertive. (I assume it might have become apparent if there had been a transcript of the voice recorder.)

Originally Posted by TKMCE

Both the Commander and the First Officer has an experience "on type" on of less than 500 hours? Isn't this pairing dangerous?

Dangerous is maybe to big a word. I am not aware of any formal requirements to this effect, but I do know that many carriers do have their own policies and would ensure that there is always one (1) very experienced cockpit member in the crew.

Originally Posted by TKMCE

The USA requirement of 1500 hours for airline FOs came after the crash of a Colgan Air aircraft in 2009. In India to my knowledge there is there is no such stringent requirement. However it does raise a question of how assertive some of the these low hours FOs can be in case of a serous incident. ?

Yes, and it was heavily criticised, because actually in this particular accident both pilots had lots of hours.

Originally Posted by Motard_Blr

I am curious if there is a connection between these incidents where a lack of experience or negligence was a factor, and the publicly stated shortage of pilots and their pay. Could the situation be improved by airlines paying more? I have also read about Indian pilots complaining about the pay, restrictive regulations and contracts on notice period and duty hours.

It just seems to me that all these things are connected and cannot, should not be dealt with independently.

The short answer I believe is no. I don’t think airlines in general have lowered their standards, even though they have lowered salaries. I can’t really speak for India, but in the western world pilot salaries are back on the rise again, due to the shortage. It is becoming a real problem, mostly for the more regional carriers. There is a definite lack of interest of young people in the west in becoming an airline pilot. In the USA fewer military pilots make it into commercial aviation (because there are a lot less military pilot than 20-30 years ago), adding to the problems.

You can see various “become a pilot, we pay for your training” adds starting to pop up again in the western world.

What is a safety concern are two aspect of the current terms and conditions of many pilots. The most prominent is fatigue and it is listed as a contributor in quite a few incident and accident reports. Pilots fly more, have fewer hours rest, often need to travel ridiculous distances in their own time. Especially in the USA I pilot could have been travelling for half a day (as a passenger) before he/she gets into the cockpit and conduct a flight.

The other aspect is how pilots are employed. These days many pilots are essentially self employed. Which very often means if they don’t fly they don’t get paid. The problem with that is that every pilot has to do a self assessment prior to a flight whether he or she is fit to fly. If you are not going to get paid, you might unconsciously, consider yourself fit, whereas really you ought to stay home. How bad needs a cold be, for a pilot to stay home. What if one of your parents just died? Messy divorce. Do you want people like that, who’s mind might be busy with other thins behind the controls.

Some carriers have partly sorted this by guaranteeing a minimum pay, regardless of flight hours. Obviously, this one is very tricky to measure. But when it comes to aviation the industry likes to quote better safe than sorry. Unfortunately, when it comes to fatigue and contract conditions other rules seems to apply.

Having said all of that, aviation safety is already at an astonishing level and is still improving!

Jeroen

[1lokesh]

Originally Posted by AlphaKilo

Ouch! Good that no one was seriously hurt or lost their lives by the stupid mistake.. [snip].
6. Why was the flight delayed by 20 mins? Scheduled departure was at 23:10 UTC!

It was a usual delay during the security, boarding, taxiing etc. Infact being used to huge delays, I didn't notice such a minor delay

Originally Posted by saket77

As far as I can understand this 44 page report, it is a pilot error. I am just an aviation enthusiast, not a professional hence would like to get the views of aviation experts and pilots of the forum to please come in and help us understand the circumstances & the series of events leading to this unfortunate accident. With my understanding, I couldn't find a fault in the aircraft or technology. This to me looks like a pilot error; feel free to correct me.

And I must thank Lokesh for bringing us this report, so that a meaningful discussion can take place further. Also hope that you have now recovered fully by the trauma caused by the incident.

Regards,
Saket.

Thank you Saket. It was a tedious, disappointing and painful exercise purely because of the fact that it took them 18 months to come up with this final report. But totally worth it!



Thank you everyone for your valuable comments, inputs and understanding of the report. I now feel more confident that I was not wrong in arriving at evident pilot error as the reason behind this incident. I am trying to figure out if there is any legal recourse available for me to seek damages from Jet Airways on this. Any feedback/suggestions on the same?

[libranof1987]

Thanks for pursuing this, Lokesh. And others for their studied analysis of the report.

While Indian aviation has enjoyed a good safety record (as has been frequently reported), this tremendous growth it has seen in the last decade or so can be a challenge, given the strain it has put on resources and infrastructure. And of course, a financially struggling airline industry.

Hope DGCA acts on this report and there is a public evidence of the actions recommended/taken. This is one industry where a chalta hai just cannot exist.

This is good then?

https://timesofindia.indiatimes.com/...w/64361299.cms

This Asian culture of respecting hierarchy/seniority has been already alluded to in past airline accidents (the Asiana crash in SF being a recent one).

Are the pilot/co-pilot de-rostered or do they continue to fly? I assume once a report assigns blame to the pilots, they lose their license/have it on their record?

Originally Posted by 1lokesh

I am trying to figure out if there is any legal recourse available for me to seek damages from Jet Airways on this. Any feedback/suggestions on the same?

The US has vulture-like lawyers that jump at such accidents and reach out to victims to form a civil suit against the offending party. Wonder if something like that exists in India. Perhaps you can reach out to other passengers and get a feel of what people are thinking. It could go on forever though.

[Jeroen]

Originally Posted by libranof1987

While Indian aviation has enjoyed a good safety record (as has been frequently reported), this tremendous growth it has seen in the last decade or so can be a challenge, given the strain it has put on resources and infrastructure. And of course, a financially struggling airline industry.
.

Well, in 2013 India's ICAO rating was downgraded to what is commonly known as sub-saharra like status. That is not something that should be taken lightly. Very simplistically put: The DGCA lacked the competence, skills and aptitude to provide adequate oversight and control.

Originally Posted by libranof1987

Hope DGCA acts on this report and there is a public evidence of the actions recommended/taken. This is one industry where a chalta hai just cannot exist.
.

Agree

Originally Posted by libranof1987

This is good then?

https://timesofindia.indiatimes.com/...w/64361299.cms
.

Yes, see my first remarkt. What happened in 2013 was extremely serious and you dont want to see a repeat.

Originally Posted by libranof1987

Are the pilot/co-pilot de-rostered or do they continue to fly? I assume once a report assigns blame to the pilots, they lose their license/have it on their record?
.

Not sure how it is done in India. In the end this was an incident, not an accident. So I assume the pilots will need to undergo training and prove proficiency in particular in the areas where they underpeformed. I assume it will be on their service record with the carrier. I doubt somehow they lose their license over this. I would not be surprised if they kept on flying during the investigations. It's typical with more serious incidents/accidents pilots are immediately relieved of all flying duties. Not sure how the carrier on the regulation in India deals with this particular incident.

Originally Posted by libranof1987

The US has vulture-like lawyers that jump at such accidents and reach out to victims to form a civil suit against the offending party. Wonder if something like that exists in India. Perhaps you can reach out to other passengers and get a feel of what people are thinking. It could go on forever though.

Well, it really depends probably on the Indian legal system. But irrespective of the legal system, personally I would always only look at my own incremental cost I might have incurred. This is me being very Dutch of course, because in the Netherlands you can only get compensated for real cost. Not like the USA where you can sue for ridiculous amounts of money whereas your actual cost could be peanuts.

These matters are not only a matter of legalities, but also of your own moral compass on what you believe is appropiate and fair. There is no absolute good or wrong, just personal belief/opinion

Jeroen

[V.Narayan]

1lokesh, getting into a court case will cost you a lot in money, time and peace of mind. In the end Indian law will entitle you to only direct damages for costs actually incurred. India and some European countries have balanced laws on such matters unlike USA where you can spill hot coffee on yourself and get the blame pinned on the coffee seller and get paid a few million $ for it.

With regard to DGCA I have not seen any fundamental change in attitude or processes since the downgrade. There are some decent folks there mind you but as an organization it is shoddy even by standards of a Govt body led by IAS who don't know the subject and keep changing every 18 to 24 months.

[TKMCE]

have often commented on the fact that I find the Indian aviation lacking in transparency compared to their western equivalents. Why not publish everything? Why is there no transcript of the voice recorder included in the incident report?

Indian accident reports rarely have the CVR transcripts. In many cases they do mention the salient points of the CVR transcript but in this report, even that is missing.

I still believe, a low hour (on Jet aircraft) Captain with a low hour FO has played a part here . Most of the captains PIC experience was on turboprops.

In August 2014 , an Air India A320 suffered an uncontained Engine failure soon after take off from Kochi. The crew managed to land the aircraft back safely. In this case both the crew were ALTP with P1 having 7000+ hour on type and the FO with 3500 hours. Defective maintenance practices was found to be the culprit (All observations are as per the enquiry report which is available in DGCA website). However with the break neck expansion of India's airlines, the probability of an inexperienced (on type) P1 paired with an inexperienced P2 as has happened in this Jet Airways incident, is higher than ever.

Are the pilot/co-pilot de-rostered or do they continue to fly? I assume once a report assigns blame to the pilots, they lose their license/have it on their record?

Can anyone confirm whether there is any statutory rules on this or it varies from airline to airline.? This particular occurrence is an accident (not an incident) as passengers were injured.

I am trying to figure out if there is any legal recourse available for me to seek damages from Jet Airways on this. Any feedback/suggestions on the same?

Interesting question. This is a domestic flight. However the airline is at fault as per the inquiry report. But your compensation claim is likely to be rejected because there is no "bodily injury" in your case. But the 16 passengers who received minor injuries (as per the report) may from my limited understanding of the subject definitely have grounds for a claim of some sort.

Do read through this - the relevant clause of interest is Rule 17.https://www.jetairways.com/en/bh/ter...s/general.aspx

However I am not aware whether there is any requirement that the claims have to be lodged before a certain time.

But as V. Narayan has mentioned, lodging a court case is certainly not going to be easy and will be both expensive and time consuming.

Just Google "Air India express Mangalore crash compensation" and you will find things are not easy on this count.


And another interesting point about accident investigation in India.

Yes the Jet Airways Goa Mumbai flight in question met with an accident. 16 people were injured (minor it may be) but it was an accident all the same. Did the CoI (Commission of Inquiry) take statements from the passengers as part of the investigation? Just wondering as it could not easily be ascertained from the report.

And finally what is shocking it took 20 minutes for the first responders to reach the accident site although it occurred within the aircraft boundaries. I think this is unacceptable. Not the first time this has happened either.