[TKMCE]

Waiting for the report of the Kozhikode accident to come out. Meanwhile a similar incident to another Air India Express aircraft on 30 June 2019 at Mangalore where the aircraft could not be stopped on the runway seemed to have escaped attention. Interestingly the Captain continued with the landing second time around despite the low hour copilot calling GO AROUND. Also in the report (page 38) it is mentioned about Pilot in Command telling Co Pilot that in case of second missed approach they have to divert. This last point I find interesting since a similar situation existed in the Kozhikode crash where also it was the second approach although from the other direction.

The Mangalore report came out on 24 April 2020 and you can read it on AAIB India website. Link is here.

http://https://aaib.gov.in/Reports/2019/SeriousIncident/VT_AYA_at_Mangalore_on_30Jun19.pdf


Looks like a study is badly needed on the work culture in Air India Express although it is unlikely to happen.

[Jessierider]

Is the investigation report pertaining to this accident published in the public domain. I couldn't find one. Please share the insights of the same if any one among us have it.

[TKMCE]

Not available yet in the public domain. But that means nothing, It may or not have been published

In fact an earlier incident (Jet Airways @ Goa) , the first copy of the report in the public domain came out in Team BHP.

Not a joke - one of our members was on the flight and since he was following up in parallel with the authorities, he was sent a copy which he was kind enough to share here. The upload in DGCA website came after some time

[balenoed_]

Good question, but doesn't look like has been published.

It was promised to be published by Jan'21 (see attached doc) but must have been delayed due to pandemic.

IIC_Order_VT_AXH_13_Aug_2020.pdf

[TKMCE]

Finally, the investigation report on the Air India Express crash at Kozhikode last year has been released in the public domain - the AAIB India website.

Here is the link.

https://aaib.gov.in/Reports/2020/acc...port%20AXH.pdf

From the report

****
3.2.1 PROBABLE CAUSE

The probable cause of the accident was the non adherence to Standard Operating Procedures by the Pilot Flying, wherein, he continued an unstabilized approach and landed beyond the touchdown
zone, half way down the runway, in spite of ‘Go Around’ call by Pilot Monitoring which warranted
a mandatory ‘Go Around’ and the failure of the Pilot Monitoring to take over controls and execute
a ‘Go Around’.
****

A sad, sad accident.

[padmrajravi]

Thank you for sharing this. So it was a combination of mechanical failure and clear violation of standard operating procedures by the captain. The wiper on his side was faulty and as per the report the crew seemed to be aware of it before hand. And to make matters worse, the captain ignored defenite calls from the first officer. Looks like he was was particular about landing at Calicut that day.

According to the report, the plane landed more than half past the runway that night. The initial eye witness reports had suggested landing at the one third mark of the runway. Landing after the half way mark in a wet runway would have resulted in no realistic chance of a recovery once it happened.

I think the junior-senior equation was also at play here. The report mentions the first officer not being assertive enough to take control when the captain violated operating procedures. It is not easy when there is a celebrated ex IAF pilot at the other end.

[fhdowntheline]

It is sad that the seniority culture still pervades in the era of CRM. Why in the world did they not divert to BLR/TVM ? Why did the company Ops not inform them to go for alternate ? Was there some pressure to have crew presence in CCJ for Vande Bharat flights ?

[balenoed_]

Originally Posted by fhdowntheline

Why in the world did they not divert to BLR/TVM ?

Coimbatore and Kochi were the alternate locations identified.

Originally Posted by fhdowntheline

Was there some pressure to have crew presence in CCJ for Vande Bharat flights ?

The same crew (PF) was to operate a flight next day morning from Calicut to Doha. Hence probably he wanted to settle in Calicut to avoid a delay to attend that.

[RedTerrano]

Originally Posted by TKMCE

...and the failure of the PM to take over controls and execute
a ‘Go Around’.

Could be because of this:

As per SOP of Air India Express, three airfields at Mangalore, Kozhikode and Pune qualify as ‘critical airfields’. These airfields are, therefore, cleared for operations by experienced flight crew and take off and landings have to be carried out by the pilot in command (PIC) only,” said the report.

[Source]

[TKMCE]

If I am not wrong (please do correct if I am) , after the Air India Express Mangalore crash, DGCA had amended the rules to allow Co pilots to take over controls to go around n emergencies. Not sure about this, may be he/she (P2) is allowed to take over controls, go around and then as per company SOP give the controls back to the captain to make another attempt/divert etc. That could be the only reason why P2 also got the share of blame.

In theory the finding of P2 (co pilot) to be also responsible for the accident is correct. But in reality what would have happened is while precious lives would have been saved, most likely knowing our aviation culture, the poor P2 would have had a tough time within Air India Express for over ruling a senior captain.

[TSIboy]

Really strange why the pilots decided to land on runway 10 for the second approach when runway in use was 28 and 10 had tailwind & crosswind. Seems they were influenced by the takeoff of the other Air India flight from 10 who probably chose to do that for a shorter backtrack(?).
Changing runways at this phase of the flight is a lot of work for pilots. Always requires a proper briefing always especially when the airport had two warnings for thunderstorms & wind active which they dint perform according to the report.

Originally Posted by padmrajravi

Thank you for sharing this. So it was a combination of mechanical failure and clear violation of standard operating procedures by the captain. The wiper on his side was faulty and as per the report the crew seemed to be aware of it before hand. And to make matters worse, the captain ignored defenite calls from the first officer. Looks like he was was particular about landing at Calicut that day.

The wiper wasn't working for the first approach, if I'm right this itself warrants a diversion to alternate according to adverse weather SOP!. It worked on the second approach albeit at a lower speed setting than selected. Not favorable as these wipers are not as good as the ones we have on cars even at full speed with heavy rain, the whole outcome would have been different if crew decided to stick with SOP.

Originally Posted by padmrajravi

I think the junior-senior equation was also at play here. The report mentions the first officer not being assertive enough to take control when the captain violated operating procedures. It is not easy when there is a celebrated ex IAF pilot at the other end.

Originally Posted by RedTerrano

Could be because of this:


[Source]

Originally Posted by TKMCE

In theory the finding of P2 (co pilot) to be also responsible for the accident is correct. But in reality what would have happened is while precious lives would have been saved, most likely knowing our aviation culture, the poor P2 would have had a tough time within Air India Express for over ruling a senior captain.

The second approach was unstable, the FO pointed this out twice. The flare was botched and the plane floated on the runway (report says for 16sec which is a very very long time!), FO made two attempts to point out the worsening situation and finally just before touchdown he made the GA call which was ignored. He should have done that much earlier & taken over controls if it was not executed. That was his mistake and it cost his & a lot of innocent lives. At the end of the day he was just a child of circumstances with a conditioned mindset which probably we all have in us.

This a big problem in countries with a high power distance culture. Young or inexperienced FO's rarely challenge the captain even when its plain obvious that safety is being compromised as in this case & the Mangalore crash. In this case the captain being ex IAF just made it worse. I don't know if its the right way to put it but with all due respect to him, we tend to put certain people on pedestals. We need to start seeing people as humans who can mistake rather than gods.

Another thing I've seen in among my colleagues & other pilots is the macho attitude which a lot of us pilots more so those from these countries have. Performing a go-around is seen like something shameful, something only pilots who cant fly a proper approach does. It seems to made a dent in the ego. One go-around would be bad enough imagine performing two! All this latent factors turn out to be dangerous, making the holes in James Reason's Swiss Cheese model. Aviation is a very safe and it takes many many big & small factors coming together for an accident like this and unfortunately it doesn't end up well. Rest in peace all the souls.

[dragracer567]

Originally Posted by TKMCE

If I am not wrong (please do correct if I am) , after the Air India Express Mangalore crash, DGCA had amended the rules to allow Co pilots to take over controls to go around n emergencies. Not sure about this, may be he/she (P2) is allowed to take over controls, go around and then as per company SOP give the controls back to the captain to make another attempt/divert etc. That could be the only reason why P2 also got the share of blame.

You are right and the conditions for the crash in Mangalore was the same if I remember correctly - the pilot decided to land instead of going around despite the pleas of the co-pilot. The DGCA had indeed amended the rules but the power-dynamics at play in the cockpit (as in any other workplace) is such that the co-pilot may be hesitant to defy the pilot who might be much more senior (sometimes decades). Its horrifying that two crashes over a span of 10 years took place with the same airline, in similar circumstances, similar geography & type of runway and similar issues with cockpit power dynamics. The DGCA really needs to have a look at the work culture in Air India Express as this problem hasn't been faced by Air India, Indigo or Jet airways who probably have flown many more flights in airports with difficult terrain in the North-East and the Himalayas.

[fhdowntheline]

Originally Posted by dragracer567

The DGCA really needs to have a look at the work culture in Air India Express as this problem hasn't been faced by Air India, Indigo or Jet airways who probably have flown many more flights in airports with difficult terrain in the North-East and the Himalayas.

May be a bit OT, but I fail to understand why this airline (AIE) even came to being in the first place. What exactly did it do that parent AI couldn't do in the normal course of operations, other than some sort of international LCC operating model? Its accident/incident record is perhaps the worst of all the Indian carriers in the past 15 years or so.

[airbus]

Originally Posted by dragracer567

Its horrifying that two crashes over a span of 10 years took place with the same airline, in similar circumstances, similar geography & type of runway and similar issues with cockpit power dynamics. The DGCA really needs to have a look at the work culture in Air India Express as this problem hasn't been faced by Air India, Indigo or Jet airways who probably have flown many more flights in airports with difficult terrain in the North-East and the Himalayas.

While most of us are aware about these two fatal crashes, there was another incident involving Air India Express Flight 611 in 2018 at Tiruchirappalli International Airport.

The aircraft consumed the full length of the runway, rolled past the paved surface and its tail struck the soft ground on lift-off. It did a sluggish climb, downed antennas of a ground-based navigation aid, hit the airport boundary wall and sustained a gaping belly wound. The aircraft functioned satisfactorily and the pilots of flight IX-611 of October 12, 2018, with 130 passengers on board, continued their journey, the report said.

The flight had reached Muscat airspace when the Air India Express team instructed the pilots to divert the flight to Mumbai, where it landed safely. As the flight duration exceeded the two-hour capacity of the cockpit voice recorder, the conversations between the pilots during the take-off and climb were not available to the investigators.

The AAIB released the final report 33 months later, well beyond the 12-month deadline set by International Civil Aviation Organisation. The report listed the probable cause of accident as “delayed takeoff due to reduction of take-off thrust from 98% to 77%” , breakdown of crew coordination and loss of situational awareness. Among the contributory cause was the commander’s reclined seat during during the take-off roll at 210 kmph when he moved back the throttle levers inadvertently.

Source.

Take off and landing are toughest part of any flight, is there something lacking with Air India Express in cockpit resource management?

[TKMCE]

Originally Posted by fhdowntheline

May be a bit OT, but I fail to understand why this airline (AIE) even came to being in the first place. What exactly did it do that parent AI couldn't do in the normal course of operations, other than some sort of international LCC operating model? Its accident/incident record is perhaps the worst of all the Indian carriers in the past 15 years or so.

The airline came into being to counter the likes of Jazeera, Air Arabia etc which was taking away a chunk of the price sensitive India Middle East market. Soon after AI Express was set up, Fly Dubai had joined the fray.

The problem with parent AI is its heavily unionized crew and their high pay scales and most of the crew is based in Mumbai and Delhi. Same was the case with Indian Airlines before it got merged with Air India. In the 1980s, the then Indian Airlines chairman tried to base an aircraft in Trivandrum to reduce costs and better scheduling, but it flopped in a few months due to the pressure from the Pilots/Engineers. Air India Express employees including senior management personnel and flight and cabin crew are on short to medium term contracts and with the exception of a few (mostly Commanders) and some senior management personnel, the rest are based at Trivandrum, Kochi, Kozhikode and now I think Mangalore. Pay Scales are also much lower than those in the parent airline

In fact not many are aware that Air India Express head office is in Kochi and not Mumbai. It is also the reason why court cases against insufficient compensation in the accidents at Mangalore and now Kozhikode have to be filed at the High Court of Kerala at Kochi and not Bombay High Court.

Originally Posted by airbus

While most of us are aware about these two fatal crashes, there was another incident involving Air India Express Flight 611 in 2018 at Tiruchirappalli International Airport.

Source.

Take off and landing are toughest part of any flight, is there something lacking with Air India Express in cockpit resource management?

I read the original report in this case as well. Here the P1 was much younger . The deplorable thing about this one was that the crew never bothered to return back or divert to TRV , COK or BOM despite being alerted multiple times by the TRZ Air Traffic Control. Finally it was the airport management at Trichy who were alarmed by the damage on the ground that the crew eventually diverted to Mumbai. In fact they had almost reached Muscat before they were ORDERED back by the Air India Express operations. By that time the relevant CVR conversation of the take off had got erased.

Interestingly, a little - OFF TOPIC - an Emirates A340 had a take off incident at Melbourne in 2009 (reason were different), damaged some navigation equipment on the ground, had a tail strike , barely cleared the perimeter fence and somehow climbed away. However the crew dumped fuel and returned back to Melbourne. The crew were interviewed by Australian investigators and returned to Dubai on another passenger flight and were met by Emirates HR with the acceptance of their resignation letters and were out of UAE in no time! No waiting for enquiry reports etc etc as the reason was clear even before the damaged aircraft landed back- wrong take off performance calculations. Any one wants to know more, you can read the Wiki article on Emirates Flight 407.