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Category Archives: ANALYSES ACCIDENTS/INCIDENTS : LESSONS LEARNT

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Analysis of Serious Incident- B 737-800 at Cochin on 18/08/2015

Analysis of Serious Incident- B 737-800 at Cochin on 18/08/2015

This Serious Incident is a classic example of how one gets into a situation from which it is impossible to get out. In our opinion, it was an act of kindness of God and also a miracle of some sort that the Pilot was able to land under such totally unfavourable conditions without siting the runway, almost till the end.

Aim of the analysis by ASMSI is not to find faults or criticise but to make efforts towards prevention of similar incidents in future, through, learning valuable lessons. Analysis by ASMSI and lessons which can be learnt are covered in subsequent paragraphs.

Situational Awareness and Decision Making.

In our opinion, the main cause of this serious incident was lack of situational awareness and poor decision making by the Captain.

During the month of August, it is a known fact that the Monsoon is at its peak. However, it appears that the crew did not take the peak season of the monsoon into consideration. The crew had received the weather of Cochin and Bangalore which was of time 0900 hrs. UTC whereas the aircraft took off at 1947 hrs UTC. The weather report with the pilots was almost 11 hours old, at the time of Take Off. Why the Pilots were satisfied with 11 hours old weather report and did not make any efforts to obtain current weather, should be a matter of concern. In this age of good communication, it should not be difficult to get the latest Weather and trends. This lapse clearly displays lack of involvement by the pilots in preparation for the flight.

The weather changes take place very rapidly during peak monsoon season and this aspect seems to have escaped the pilot’s attention. One has to remain abreast with the changes in weather conditions, particularly, during monsoons.

The surface winds at the time of landing were Nil Winds at Cochin and very light at Trivandrum. The winds can give a fair idea whether the visibility and cloud conditions will improve. It is easy to interpret from the Nil or very light winds that visibility and clouds are likely to remain unchanged or deteriorate further without any chance of improvement. This aspect was not appreciated by the pilots.

Adverse weather and night conditions are deadly combination and pilots should have been very alert and knowledgeable, to factor this aspect in their planning and pre-flight briefing. The Pilots even after going round on first approach at Cochin, did not bother to obtain Coimbatore and Bangalore weather, in spite of the fact that Bangalore was their first alternate and Coimbatore second alternate.

From the abovementioned facts, it is concluded that the Pilots were not situationally aware about the weather conditions. They should have kept in mind the peak monsoon season and night conditions for landing at Cochin.

The pilots should have obtained the weather conditions and trends at Cochin, Bangalore, Coimbatore and Trivandrum as soon as they came in contact with Cochin which would have enabled them to be situationally aware about the weather conditions at destination, first and second alternate and even the possible third alternate, Trivandrum. This would have helped them to take correct decision to divert to most suitable alternate, in time.

During the first approach at Cochin, the Pilot went around at 256 Ft since at decision ht of 320 Ft, the runway was not visible. When the Pilot was preparing to make second approach, Air India aircraft making approach at Cochin went round since he could not site the runway. However, the Go around of Air India flight was ignored or not taken into consideration by the Captain who continued to make second approach at Cochin.

The Captains inability to site the Runway during first approach, Air India aircraft going around due weather and Cochin reporting deterioration in visibility should have rung the bell in the mind of Captain but he did not seem to have factored these into his situation awareness.

The Pilot carried out second approach which also resulted in go around, as the pilot could not site the runway. After the Captain went around second time, the Kuwait airways aircraft on approach to Cochin went round due unable to site the runway. This aspect of Situational awareness was also ignored by the Pilot and instead of diverting to Bangalore or Coimbatore, he persisted in carrying out third approach at Cochin, hoping to make a landing on third approach. In the process, he even re designated his alternate as Trivandrum from the planned alternate which was Bangalore.

The co-pilot seemed to be more situationally aware since he expressed his opinion stating that Trivandrum has only VOR available and visibility may reduce at Trivandrum also. However, Captain ignored the advice of the Co-pilot and seemed confident of making a landing at Trivandrum with only VOR.

Both Cochin and Trivandrum which are separated by around 65 NM, are along the Coast line. The Captain should have known that if Cochin has bad weather and deteriorating visibility, same may also be the situation at Trivandrum. Trivandrum had reported 3 Kts wind speed which is not conducive to improvement in visibility and dispersion of low clouds. Also the time was nearing sunrise and it is known fact that visibility invariably deteriorates at around sunrise time. Thus lack of knowledge about weather phenomenon appears to have led to poor situational awareness.

The visibility and cloud base reported by both Cochin and Trivandrum also seem to be suspect. Three aircraft including the one being discussed here went around at Cochin even though cloud base and visibility reported by the ATC was well within the minimum of the pilots landing at Cochin. Same is true for Trivandrum which had reported 3000 metres visibility and cloud base 1500 Ft. but the pilot could not site the runway during all four approaches.

By the time, the Captain, who was very hopeful of making landing at Cochin in second or third attempt, decided to divert to Trivandrum, he must have become quite stressed as can be expected from any normal pilot under this kind of situation. Stress is quite evident from the fact that the pilot was not situationally aware and did not plan his decent in time to be at correct altitude for landing at Trivandrum and had to request for 360 degree turn to loose height.

In subsequent approaches also, the Captain was not able to align with the runway and was high on approach to land. When a person is stressed, his decision making is likely to be poor and he is more likely to commit errors which happened during all the approaches at Trivandrum.

One can easily appreciate the frustration and highly stressed mental state of the Captain who was under tremendous psychological pressure in the face of such challenging situation. During this period, all kind of thoughts must have been going through the mind of the Captain, about the safety of the crew, passengers, his family, guilt and even his own professional reputation.

The credit should be given to the Captain who did not break down, lost his cool, did not panic under such critical situation and finally managed to land even when he was not able to site the runway almost till the end of approach.

Similarly, the Co Pilot also must have felt very helpless and stressed thinking of the likely accident situation and all kind of thoughts crossing his mind about the impending doom. Going around in six approaches with fuel just for one more approach and runway not in site for last ditch approach before crashing, would have taken heavy toll of any Pilot.

Another aspect of lack of Situational Awareness, is that the crew did not have adequate knowledge of the Company policy which has no provision of changing the alternate airfield in flight. The decision to change alternate from Bangalore to Trivandrum after second approach, conduct of third approach at Cochin in the face of deteriorating and poor visibility, low clouds, proved to be bad decisions.

CRM.

Crew Resource Management during this flight appears to be below expected standards. There was authority gradient due to large difference in the experience and even age between Captain (40 Yrs. Age, ATPL, around 6000 hrs Experience) and F/O (25 Years age, CPL, around 600 hrs experience) on type.

Although the F/O did give the valuable inputs regarding availability of only VOR at Trivandrum and likelihood of deterioration of visibility to the Captain but was not assertive enough in his communication. The Captain did not seriously consider the inputs given by the F/O and appeared confident of landing at Trivandrum with only VOR since reported visibility was 3000 mtrs at Trivandrum.

The Captain, who was under tremendous stress, could have been helped by the F/O if the F/O was closely monitoring the progress and parameters of the flight when the aircraft was on way to Trivandrum. The close monitoring of the flight parameters by the F/O would have ensured the aircraft being at correct altitude for a VOR approach to Trivandrum without, any need for 360 degree turn to loose altitude and wasting of precious fuel. Possibly, even the Co Pilot must have been quite stressed due to overall uncertainty, grim situation and hence his ability to assist his Captain, was missing.

There appears to be no communication between Captain and Co Pilots before Top of Decent for Trivandrum airport. No approach briefing seemed to have been carried out for approaches at Cochin and Trivandrum.

The lack of involvement of the ATC,   Met during such crisis situation, is not conducive to safety of the aircraft. The lackadaisical attitude of the ATC and Met is quite evident in this situation. As per ATC tape transcript and CVR readout available, the change of visibility in Trivandrum was not broadcast by Cochin ATC to the Captain who was diverting to Trivandrum. Trivandrum ATC had informed Cochin on Direct Speech circuit to inform the Captain of the aircraft about the deteriorating visibility.

Another important aspect which needs highlighting is that the crew were operating during Window of Circadian Low which is known to adversely affect the performance and alertness of the crew.

It is also pertinent to mention here that someone from the Operator like COO, Chief of Flight Safety, Base Manager and Manager Operations etc. should be following the flight and under such unusual serious conditions, be in a position to give some professional advice to the Captain. In this incident, the pilots were on their own with no help from the Operational Staff of the Operator, ATC or Met.

Lessons Learnt.

Number of valuable lessons can be learnt from this serious incident.

  1. There is a need for thorough planning, preparation of the Flight by the Pilots and they should obtain and be provided latest weather. Pilots should be fully involved in obtaining the current weather and expected changes in weather. Operations Department, Dispatch staff of the Company should be sensitive to the requirement for intimating the pilots about the latest, accurate and expected weather.
  2. All Weather Operations, Monsoon Training should lay emphasis on the aspect of knowledge about the Monsoon Climatology, typical weather phenomenon in different areas and intelligent interpretation of weather. Better the knowledge of the pilots about the weather and its professional interpretation, better will be the situational awareness of the pilots.
  3. It is an established fact that when some Pilots gain experience and seniority, they do not go deep into the analysis of weather and are satisfied with whatever is fed to them by the ATC, Met and Company dispatch, without applying their mind. This tendency need to be curbed and pilots should not take the weather interpretation in a casual manner since most of the accidents around the world occur due to weather.
  4. Monsoon weather along the coast during night is definitely a challenging situation. Calm winds, high humidity, thick of monsoon season and location of runway in Coastal area should be cause of concern to the pilots since these are conducive to adverse weather conditions. Hence, the pilots must pay special attention to the weather, its interpretation and unpredictable changes.
  5. The ATC and Met staff should be sensitised to the need of accurate and timely reporting of the weather and should get fully involved in providing all possible assistance to the pilots under conditions which obtained during the conduct of the flight under discussion.
  6. Situational Awareness (SA) is one of the most critical and important area, particularly, in aviation. Any lack of situational awareness on the part of aircrew can lead to catastrophic consequences.
  7. SA can be enhanced through planning, preparation, having knowledge about the weather,terrain,disorientation,illusions,aircraft,its systems, nav aids, Weather Radar, Flight management system, SOP’s, Check List including Emergency Check List, charts etc. and applying the knowledge intelligently to maintain good situational awareness at all times. Alertness, vigilance and not being complacent at any time during flight are essential to remain Situationally Aware.
  8. The Pilots should have taken the weather of Bangalore, Coimbatore and Trivandrum as soon as they came in contact with Cochin or area control. This would have helped them towards an overview of entire weather situation and timely better decision.
  9. It is very important to analyse the situation in a pragmatic manner taking into account the various developments taking place during the flight. When one has been forced to go around due to weather, other aircrafts also have gone around due to same reason and the ATC is also cautioning you about the deterioration of weather, one should not be persisting with making more approaches, hoping to land. Such warnings and deteriorating situation should not be disregarded.
  10. Landing Operations during Window of Circadian Low, in adverse weather conditions, after a long flight, demands high standards of knowledge, preparedness, SA and full alertness.
  11. Pre Flight briefing should cover various aspects related to the flight particularly weather and terrain conditions, diversions and contingency plans in the event of deterioration in weather conditions.
  12. The approach briefing should be carried out in a professional manner. Awareness of risk factors for the approach is an important aspect and must not be ignored.
  13. It is essential to take decision to abandon approach and divert in time. Decision delayed can be dangerous.
  14. The Pilots should be aware of their Company SOP and should not change the alternate airport in flight unless the situation at the first alternate is unsuitable for safe landing. In this particular incident, the Pilot had adequate fuel even after second failed approach at Cochin to divert to Bangalore which had better weather and ILS.
  15. Crew Resource Management Training should lay adequate emphasis on problems associated with Cockpit/Authority Gradient and how to address this serious problem which has led to number of accident/incident. We should get rid of this wrong impression that Captain alone is best judge and he cannot make errors. The inputs from the F/O should not be ignored or taken lightly. It is also essential that the F/O’s are assertive in such situations and Captain should accept such assertiveness, in a sporting manner.
  16. Inconvenience to passengers,crew,company,expenditure on facilitation of passengers like transportation, hotel accommodation, administrative problems, bad press, questions by Company ,DGCA, ATC etc. are some of the important factors which play heavily on the mind of the pilot and his decision get influenced by these factors.
  17. DGCA in its All Weather Operations CAR has clearly highlighted that carrying out missed approach or diversion does not reflect on the performance of the pilot and DGCA, ATC and Operator will not ask the Pilot any questions related to these. Hence, there should be no hesitation on the parts of the pilots to divert to a suitable place in time and they should always place the safety of the aircraft and passengers uppermost in their mind.
  18. The effect of stress on human performance should be given due considerations. The pilots under stress, which was immense in this incident, are prone to poor decision making and their chance of making error increases. This aspect is abundantly evident in this particular incident.
  19. Overconfidence, complacency are hazardous attitudes and the Pilots should be conscious of this fact and not get carried away by overestimating their capability.
  20. Presently, none of the aerodromes in the Southern Region has Cat II/ Cat III ILS installed. Deterioration of weather on account of monsoons and/or fog/low clouds is a regular phenomenon in the Southern region and even Bengaluru experiences daily fog during winters. One centrally located aerodrome viz Bengaluru can serve to be a safe diversion under the circumstances. With construction of Second Runway underway at Bengaluru, it is recommended to consider installation of Cat II/ Cat III ILS at Bengaluru.
  21. There is a need to include the number of Missed Approach/Go Around due to weather in the Ops Manual and Company SOP. This would make the decision making conservative and aid the timely recovery from an impending situation.
  22. During Recurrent Training, there is a need to lay adequate emphasis on all aspects of Visual Approaches from Set Up to Execution. This would enhance the proficiency and confidence of operating crew to carry them out whenever the need arises.
  23. Operators should have a system to provide necessary assistance and guidance to the pilots towards management of critical situations as was obtained during this Serious Incident. The Base Managers, Chief of Operations, Chief of Flight Safety and Chief Pilot of the Company need to be fully involved to offer timely help. They should rise to the occasion to offer flight related professional inputs and advice, which can go a long way to assist the Pilot, who is likely to be under tremendous stress in such a situation, to make appropriate decision.

Sign-in Safety Investigation Report: Malaysia Airlines Boeing B777- 200 ER (9M- MRO) 08 March 2014

This Safety Investigation Report builds on the previous Factual Information Report recognising that at the time of issue of this Report, the main aircraft wreckage, including the aircraft’s Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) have not yet been located, this Report will necessarily be limited by a significant lack of evidence.

Based on the available evidence, the analysis of factors considered relevant to the disappearance of MH370 include:

• Diversion from Filed Flight Plan Route;

• Air Traffic Services Operations;

• Flight Crew Profile;

• Airworthiness & Maintenance and Aircraft Systems;

• Satellite Communications;

• Wreckage and Impact Information;

• Organisation and Management Information of DCA and MAS; and

• Aircraft Cargo Consignment.

Other factors examined by the investigation and not considered relevant include the aircraft weight and balance, the amount and quality of fuel on-board and meteorological conditions.

Significant Issues and Safety Recommendations

In the analysis of the above factors, several significant issues were identified that could affect the safety of international commercial aviation, including the lack of effectiveness of certified Emergency Locator Transmitters (ELT) if a large commercial aircraft ditches or crashes into the ocean.

While this issue is currently being addressed by ICAO and the international aviation industry, the Team is of the view that work needs to be expedited in this area to implement effective changes to enhance aviation safety into the future.

Additionally, a number of issues were identified that could affect the monitoring and timely initiation of search and rescue of commercial aircraft in Malaysian airspace by the Air Navigation Services provider. Issues were also identified in the Airline Operations. They include the following:

• Malaysian and adjacent air traffic management;

• Cargo screening;

• Flight crew medical and training records;

• Reporting and following-up of crew mental health;

• Flight following system;

• Quick reference for operations control; and

• Emergency locator transmitter effectiveness.

As a result of the issues identified in the investigation and in accordance with para. 6.8 of Annex 13 which states that: “At any stage of the investigation of an accident or incident, the accident investigation authority of the State conducting the investigation shall recommend in a dated transmittal correspondence to the appropriate authorities, including those in other States, any preventive action that it considers necessary to be taken promptly to enhance aviation safety”, a number of safety recommendations (Section 4 – Safety Recommendations), have been made to the Department of Civil Aviation (DCA), Civil Aviation Authority of Viet Nam, Malaysian Airlines Berhad (MAB, formerly MAS), the Malaysia Airports Holdings Berhad (MAHB) and the International Civil Aviation Organization (ICAO) to enhance aviation safety.

Click Here to View Full Report


Analysis of Accident-BEECH-CRAFT KING AIR B200 AIRCRAFT at CHANDIGARH AIRPORT, ON 27 Mar 14.

 

Analysis of Accident-BEECH-CRAFT KING AIR B200 AIRCRAFT at CHANDIGARH AIRPORT, ON 27 Mar 14.

Sequence of Events

VIP Flight on 27.3.2014. In addition to the pilot and co-pilot, there were 8 passengers.

On clearance from ATC the take-off roll was initiated and all the parameters were found normal. As per the pilot just before getting airborne, some stiffness was found in rudder control as is felt in yaw damper engagement. The aircraft then pulled slightly to the left which as per the Commander was controllable. As per the pilot, the rotation was initiated at 98 knots.

As per the DATCO the aircraft had lifted up to 10-15 feet AGL. The Commander has stated that after lift-off, immediately the left rudder got locked in forward position resulting in the aircraft yawing and rolling to left.

The pilots tried to control it with right bank but the aircraft could not be controlled. Within 3-4 seconds of getting airborne the aircraft impacted the ground in left bank attitude.

Findings (Investigating Agency).

PIC was not having 5 hrs of PIC experience in the preceding 30 days.

No checks were carried out by the crew for the flight.

The Pilot had not reported any abnormality of aircraft parameters.

During the take-off roll, the pilot observed stiffness in the rudder control and the aircraft pulled slightly to the left.

On observing that the yaw damp was ON, both the crew members tried to put off the yaw damp & in the process yaw damp first got off and then on.

There was failure of CRM and the emergency of stiff rudder was not handled as per the checklist.

The crew failed to reject the take-off.

 Probable cause of the accident (Investigating Agency)

Failure on the part of the crew to effectively put off the yaw damp so as to release the rudder stiffness as per the emergency checklist.

Checks not being carried out by the crew members.

Not putting off the Rudder Boost.

Speeds call outs not made by co-pilot.

Not abandoning the take-off at lower speed (before V1).

Failure of CRM in the cockpit in case of emergency.

Early rotation and haste to take-off.

Analysis by ASMSI.

The Captain and Co Pilot were experienced.

Captain, 58 years old, ex Airline Pilot, almost 10000 hrs. of experience (B 200 -2200 Hrs.)

Co Pilot, 42 Years Old, around 2200 hrs. of Experience (B 200 – 1383 Hrs.)

Flying during last 30 Days-02:30 hrs. both the Pilots. Minimum as per Regulatory requirement 5 hrs. Violation of DGCA CAR.

Having gone through the Investigation Report of the Accident, ASMSI has arrived at the following conclusions.

  • The steep Cockpit Authority Gradient is quite evident which appears to be one of the major contributory factor to the occurrence of this accident. The Pilot was highly experienced whereas the Co Pilot was relatively less experienced. Thus the Power Distance (Authority/Cockpit Gradient) between the cockpit crew prevented the Co Pilot to speak up or assert for rejecting take off when the aircraft had started going to the left.
  • In case of large authority or cockpit gradient, most of the less experienced pilots have total faith in the ability of the Captain, who is highly experienced, to handle any situation with ease. They don’t think that the Senior Pilots also can make errors. This misplaced confidence has led to number of accidents. The less experienced pilots need to appreciate that senior, highly experienced pilots also can make mistakes. Therefore, they need to be much more alert, vigilant, knowledgeable and situationally aware so that they can correct the Captain if he or she makes mistakes.
  • Lack of knowledge related to the aircraft, its systems, Emergency actions. Complacency, casual, unprofessional attitude, poor CRM, situational awareness and decision making on the part of the Captain and Co Pilot has been contributory factors for this accident.
  • It is an established fact that most of the senior and experienced pilots  become complacent and do not believe in following SOPs, check list and other rules,regulations.This aspect has been clearly brought out in the All Weather Operations CAR issued by the DGCA where it has been brought out that 76 %  pilots did not follow SOP’s during operations. In this accident also, the Capt. being highly experienced did not follow the Checklist and SOP.
  • It has been found that number of Pilots flying with State Govt tend to take it easy and become casual due inadequate supervision.
  • It is a known fact that the Civil Aviation Departments in most of the states are headed by Bureaucrats who are handling the Civil Aviation Department (CAD) as an additional charge. They hardly have any time, inclination and knowledge to get involved to effectively manage the CAD. Obviously in the absence of effective command, Control and supervision, the flight crew operate as per their own whims and fancy since there is no one to check or question them.
  • The Accountable Executive particularly in the Civil Aviation Department of the State Govt.is seldom questioned by the regulatory authority and not held accountable for the lapses on Safety front. Hence, they do not get involved to ensure proper supervision, enforcement of rules, regulations and continuity training standards. This is a serious flaw in the system which needs to be corrected.
  • There is a need to lay much more emphasis on the professional standards (Knowledge and Training), supervision, monitoring and audits by the regulatory authorities in respect of the Civil Aviation Department of the State Govt. since they undertake VIP flying.
  • No lessons seem to have been learnt from the accidents of CM of Andhra Pradesh, Arunachal Pradesh and CM of Maharashtra.

 

 

 

 

 


Lessons to be Learnt from the Accident to B 200 Aircraft at Delhi Airport on 22 Dec 15.

Lessons to be Learnt from the Accident to B 200 Aircraft at Delhi Airport on 22 Dec 15.

Beechcraft Super King Air B-200 aircraft was involved in an accident on 22.12.2015 while operating a flight from IGI Airport, New Delhi to Ranchi. The flight was under the command of a CPL holder with another CPL holder as Second in Command. There were ten persons on board including two flight crew members. The aircraft was loaded with spare parts and equipment for the rectification of a Helicopter at Ranchi.

The weather at the time of accident at Delhi was foggy with visibility reported as 800 meters and winds of 3 knots. The previous METAR which was available with the flight crew mentioned visibility of 600 meters. The visibility was marginal and it is inferred that the marginal visibility was a contributory factor to the accident.

The aircraft was given take-off clearance from runway 28. Shortly after take-off, the aircraft progressively turned left with simultaneous loss of height. Finally it impacted terrain and came to final rest in the holding tank of the water treatment plant of the airport. There was post impact fire and the aircraft was destroyed. All passengers and flight crew were fatally injured.

It is learnt that the accident was caused due to engagement of the autopilot without selecting the heading mode by the flight crew just after lift-off (before attaining sufficient height) in poor foggy conditions and not taking corrective action to control the progressive increase in left bank; thereby, allowing the aircraft to traverse 180° turn causing the aircraft to lose height in a steep left bank attitude followed by the aircraft impacting the ground.

It appears that the flight crew were not confidant in their ability to operate this flight due to the poor foggy condition prevailing at the time of planned departure. With an understanding that immediately after take-off, autopilot will be engaged and the aircraft will fly away on the autopilot, the crew cancelled the taxi clearance and carried out the serviceability checks of the operation of (engagement/ disengagement) of the autopilot. The flight crew during discussion among themselves regarding the conduct of flight had decided to rotate after 120 knots (additional 10 knots) considering tail wind component of 06 knots. The take-off roll and rotation of the aircraft was carried out as discussed. Their decision to increase the rotation speed by 10 knots to allow for the tail wind of 06 knots itself shows that they were ignorant of the fact that the tailwinds do not affect the rotation speeds of the aircraft at all.

Just after lift-off, even without retracting the landing gear, the crew engaged the autopilot but did not engage the Heading Mode ‘of the autopilot. This hurried and non-standard action by the flight crew by engaging the auto-pilot immediately after lift-off reveals their eagerness to let the aircraft be flown by autopilot and underlines their inability to fly the aircraft manually until autopilot engagement height was achieved.

As per the Pilot Operating Handbook procedure, after lift–off and establishing of positive rate of climb, the landing gear is retracted. Thereafter the climb power is set and the autopilot should be engaged only after attaining the height of 500 feet AGL. Engagement of the autopilot without engaging the Heading Mode resulted in the aircraft turning left probably due to the existing left bank or inadvertent manual input by the flight crew at the time of engagement of the autopilot. The bank angle increased progressively and beyond 45 degrees, a situation the flight crew could not decipher because of their disorientation. After disengagement of the autopilot, probability exists that the flight crew had further increased the bank instead of taking corrective action to decrease the bank. This allowed the bank angle to increase beyond 45degree’s resulting in multiple altitude warning and stalling of the aircraft. The aircraft crashed after turning almost 180 Degrees from the direction of the take-off.

From the analysis of the accident Investigation Report, following lessons can be learnt:-

  • Involvement of Accountable Manager, Chief of Flight Safety.

As mentioned above, though in the Organisation chart it is specifically indicated that there will be Chief of SMS & Chief of Flight Safety with a full-fledged Department of Flight Safety, none was existing. From the discussions with the Officers who were designated as the Chief of Flight Safety in the present and past, it was noted that as and when any regulatory requirement arose, an Officer was nominated for the purpose. At times Officers have conveyed their unwillingness to the Accountable Manager & Alternate Accountable Manager on the work load grounds and not being trained on Flight Safety. The Chief of Flight Safety was interviewed by the DGCA officials for the post of the Chief of Flight Safety and the aspect of lack of training on flight safety was brought out. Approval was accorded for the Chief of Flight Safety for 06 months on the precondition of Flight Safety training.

The Organisation seems to suffer from Complacency which can be described as a loss of awareness of potential dangers. In the present case flying undertaken by the flight crew wherein both, the PF and the PM, were neither possessing adequate flying experience nor could mutually add or impart quality flying experience in the real sense of the terms. The combination of this flight crew was continued over other Type qualified Pilots in the Organisation. Therefore, though the numbers of flying hours flown by this flight crew were increasing, but whether it added to qualitative improvement in their flying skills is questionable? All this while, the highly experienced Examiner was meagrely rostered for the flights.

To conclude, there was non-existence of safety culture, non-existence of SMS and nil supervision of the operations at ground level.

The Safety & Quality Policies were existing on paper, but no documentary evidence existed to prove that effective procedures for implementation of these policies were followed.

 

Lessons Learnt.

  • Aviation is a serious business which has no place for complacency, casual and careless attitude. A proper Risk assessment must be carried out before undertaking any flight.
  • Lack of skill and knowledge about the aircraft, its systems, equipment , Manuals, SOP’s, Checks and procedures, Emergency Procedures , various charts, Spatial Disorientation and  Situation awareness  have led to many accidents. Hence, it is essential to address these areas of knowledge and skill.
  • Proper supervision and close monitoring of the performance and competence levels of the pilots is of paramount importance. The role of Supervisors, who should be knowledgeable, involved and competent, to ensure safety of operations, cannot be over emphasised.
  • It is the duty of the supervisors to ensure that the man, machine and mission are matched in a professional manner particularly during adverse weather conditions. The Supervisors should be held accountable for any lapses.
  • Ignorance or violation of SOP’s have caused number of accidents/incidents. SOP’s must be followed meticulously at all times.
  • Safety Management System is a proven process of managing risk and building Safety culture in an organisation. Hence, it must be implemented by all Operators in letter and spirit. The Accountable Manager/Executive should be held accountable for lapses in the sincere implementation of Safety Management System and any compromises on safety.
  • Proper training and competency of Accountable Manager, Chief of Operations and Chief of Flight Safety can go a long way in ensuring safety and efficiency of Aviation Operations.
  • The lack of proper Crew Resource Management was evident in the accident. It is imperative that Crew Members apply the knowledge about the CRM intelligently during flying operations and remain vigilant and situationally aware during conduct of Take Off and Approach, landing, particularly, since the margin of safety is low, during these phases of operations.

 


HELICOPTER NAVIGATION EXPERIENCED MAGNETIC INTERFERENCE

What happened?

On a normal (passenger) crew change flight in an AW169 helicopter, crew noticed a “1-2 AHRS FAIL” caution displayed in the crew alert system shortly after departure from the offshore installation.  With this caution message, electronic helicopter heading information was completely lost.

What went wrong?  What were the causes?

After disembarking, the passengers were asked if they had any ferrous or magnetic parts in their luggage, which was initially denied.  After becoming aware of certain products possibly containing magnets, one of the passengers realized and admitted that he had two medium size stereo speakers in his luggage.

The cause of the instrument failure was found to be due to the presence of magnetic elements (speakers) in the luggage hold.

In bad weather conditions, navigation errors due to loss of orientation could have resulted in a far more serious outcome.

What actions were taken?

  • The helicopter equipment involved in the occurrence was checked for damages and for correct function. No damage nor discrepancies were found; the helicopter was released for service;
  • Check-in personnel now inform passengers that stereo speakers are not permitted on board helicopters;
  • Check-in personnel now inform passengers that stereo speakers are not permitted on board helicopters;
  • Check-in personnel make random checks of passengers’ luggage (as approved by customer/passenger) for items not to be transported onboard helicopters;

What lessons were learned?

  • There is poor awareness amongst helicopter passengers as to what could constitute hazardous goods; information on such potentially hazardous items needs to be made more readily available;
  • Offshore facilities (helicopter departure lounges) are not displaying adequate lists or images of items which are not permitted on board helicopters; this needs to be addressed and rectified.

Analysis of Helicopter Accident on 04 Aug 15 – Arunachal Pradesh

On 04 Aug 15, a Helicopter belonging to an NSOP Operator, flying for Govt of Arunachal Pradesh ,met with an accident killing two crew members and one passenger.

The helicopter was on a mission to pick up three Deputy Commissioners (DC) of Districts in Arunachal Pradesh to Dibrugarh Airport.  The prevailing weather was quite bad which is expected during thick of monsoons in the month of August. The helicopter landed at the first Helipad in the hills and picked up the lone passenger (DC) and got airborne for the next destination.

During the investigation, it was found that the helicopter took off with the first DC in bad weather with low thick clouds. The pilot on finding very low clouds and rain on the standard route to the next helipad of landing, appeared to have decided to follow alternate route which may have looked somewhat better as compared to weather on the standard route. As per the witnesses on ground, the helicopter vanished in the clouds soon after take-off. Flying in clouds in the hilly terrain, the pilot could not see the hill in front, and crashed.

It has been observed by the Inquiry team that the pilot might not have been familiar with the terrain on alternate route as is evident from the decision of the Pilot to climb to 6000 Feet only when the height of the hill where he crashed was 6500 Ft.

The Inquiry Team during their investigation observed the following which may have contributed directly or indirectly to the occurrence of this accident:-

The PIC had a total flying experience of 6000 hers and the co-pilot had a total flying experience of around 800 hrs.

There was no Operational supervision on the Pilots on day to day flying at various levels.

The training of individuals on SMS across the whole organisation had not been carried out as per the requirement and as such the SMS Manual just remained a document on paper without performance of functions at working level.

The Supervisors were not aware of their duties related to Safety as defined in SMS Manual. It was found that for a period of almost a year prior to the accident, actions such as review of Flight Safety Manual, Safety Management System Manual and record keeping on key performance indicators, training of Supervisors, pilots, AMEs and other staff were not conducted though it was required as per regulations.

The SMS manual has not been revised since initial issue in 2014, in spite of the fact that various changes in organisation setup had taken place. Neither there was any Risk Assessment carried out for any of these changes.  No Safety circulars or bulletins had been issued by the Operator during last 2 years.

Safety training is required to be provided to all staff with refresher each year. However, it was found that even initial training had not been completed for all the employees as mentioned in the Manual.

It was revealed from the perusal of the recommendations which were made by the inquiry team in the past, after conducting investigation in some of the accidents which occurred with the helicopters of same Operator that the operator must ”establish a strong safety department”. However, it was observed that the Operator had not established the safety department in true letter and spirit and was found to be continuing on ad-hoc basis.

Brief Analysis by ASMSI.

 From the Committee of Inquiry report, it becomes abundantly clear that the Operations by the Operator were being carried out without adequate supervision and in an ad hoc manner. General safety culture appeared to be missing and Pilots were operating on their own accord without any involvement of the supervisory staff. It is learnt that the Pilot was highly experienced in the conduct of operations in the North Eastern Region, which might have led to his possible, overconfidence and complacency. The same is evident from his continuing the flight in adverse weather conditions, over hilly terrain, during highly active month of monsoon.

There was a steep Cockpit Gradient owing to the large difference in the age, seniority and experience levels between the crew members, which could have been a  contributory factor in this accident besides adverse weather and hostile terrain. Lack of adequate Crew resource Management, Situational Awareness and timely decision making ability of the crew could have been instrumental in causing this accident.

Lessons which can be learnt from this accident are covered in succeeding paragraphs.

  1. Operation Risk Assessment must be carried out before undertaking any operations particularly in adverse weather and hostile terrain conditions. Matching the Man, Machine and Mission must be given due consideration.
  2. Hilly Terrain and Adverse Weather conditions, are deadly combination. Be very meticulous in planning and Preparing for your flight keeping in mind the weather, Terrain and other safety related aspects of the flight.
  3. Thorough Planning, preparation of the flight, pre-flight briefing, Weather briefing, comprehensive terrain awareness, knowledge of Minimum Safe Altitude, Minimum Enroute Altitude and Minimum off Route Altitude, correct altimeter setting, cross checking of altimeters, obstructions in the area of Helipad, is  of paramount importance and should not be neglected.
  4. Poor visibility, drizzle, rain, clouds particularly in Hilly Terrain are likely to lead to Spatial Disorientation, Visual Illusions, Loss of Situational Awareness and Controlled Flight into terrain (CFIT) with disastrous consequences.
  5. Knowledge about Spatial Disorientation, Situational Awareness and factors leading to CFIT is very essential. Be aware of these inherent dangers in flying and take no chances with safety.
  6. Pilots must learn to respect Weather and be situationally aware at all times. GO/NO GO decision must be taken in time after evaluation of the prevailing situation in its entirety. A decision without proper evaluation of the situation and delayed decision can be catastrophic.
  7. Do not fly visually in IMC conditions. Fly with reference to instruments. Trust your instruments, disregard your body sensations, use your Eyes rather than head and use Auto Pilot, if available, to fly in poor visibility conditions.
  8. Co Pilot should be fully invoved,knowledgeable,situationally aware at all times and should be good at monitoring the weather, terrain, obstructions and other hazards ahead of the Helicopter, monitoring the instruments and the actions of his Captain inside the cockpit particularly during critical phases of the flight and should not be a laid back member of the crew.
  9. The Captain must brief the Co Pilot about his duties and responsibilities with special emphasis on the role of the Co-Pilot to be aware and vigilant in the cockpit. The Co Pilot must be given the freedom to speak up, advised and encouraged by the Captain not to hesitate to advise his Captain if he finds the Captain violating SOP’s, appearing disorientated, making wrong control inputs and taking unsafe or delayed decisions.
  10. Plan and prepare for contingencies i.e. what to do if you inadvertently get into unforeseen Situation due to loss of visual clues. Remember to:
  • Control-Fly the Helicopter with reference to instruments, Wings Level and Don’t Turn Immediately.
  • Climb– Climb Power, Climb Attitude, Speed and gain height above minimum safe altitude keeping the terrain and altimeters errors in mind. Take Off –Go around Switch can be used as per SOP of your helicopter.
  • Communicate with the Air Traffic Control for any Assistance.
  1. Do not hesitate to divert, return to base or find a suitable place to land (as per the provisions of Air Safety Circular 09 0f 2013) if you are unable to continue the flight due weather.
  2. Proficiency and IR Test should be conducted in a professional manner and there should be no hesitation to provide additional training if required to rectify the weak areas observed during these tests.
  3. The CRM, SMS, Specific Ground Training, Safety and Emergency Procedures Training of the Pilots and other crew members need to be result oriented rather than tick the box syndrome to meet regulatory requirements.
  4. Pilots need to be Safety Conscious and learn to say NO if situation demands without any hesitation or apprehension. Erring on the positive side should always be kept in mind.
  5. There is no mission so important that cannot be undertaken on another day.
  6. Over confidence, Complacency, Macho Attitude have led to number of fatal accidents. Pilots with extensive experience of flying in the particular area of operations tend to become overconfident and complacent. The mere fact that they have been able to negotiate and fly in similar bad weather conditions on earlier occasions with success, they tend to take chance again. This attitude must be curbed and there is a need for self-discipline among pilots.
  7. Good CRM and Good (Knowledgeable and Professionally Competent) Co Pilot can make difference between life and death. The Co Pilot should be fully involved, vigilant, situationally aware at all times and should not prove to be a dead weight in the cockpit. He should be assertive if situation demands and not be a mere spectator to the happenings in the cockpit.
  8. It needs to be mentioned that during this accident and similar accidents in the past of the same Operator, there was large Cockpit gradient in terms of the authority, age and flying experience between the Captain and the Co Pilot.
  9. It is an established fact that large Cockpit Gradient leads to creation of an atmosphere in the cockpit where the Co Pilot is unable to speak up to correct the Captain if required with the mistaken belief that what his Captain is doing is right and the Captain is capable of handling the situation. The Co Pilot may also not correct the Captain or speak up to give his inputs, for fear of offending his Captain. Such situations are not at all conducive for safe operations and should be addressed.
  10. Awareness must be created among all the pilots about the safety threats posed by Cockpit gradient. Open atmosphere in the Cockpit where the crew members are free to give their considered inputs to the Captain without any reservation, fear and apprehension, must be given a serious thought. It is the responsibility of the Captain who needs to create an environment which encourages the Co Pilot to speak up without any fear.
  11. The aircrew which tends to display hazardous attitudes like Anti Authority, Invulnerability, Impulsivity, Macho and Resignation must be identified, counselled, kept under close watch, supervision and monitoring.
  12. The SOP’s must be reviewed, updated, approved and followed meticulously. Violation of SOP’s must be taken seriously.
  13. The Supervisors must be competent, well trained, involved and committed to promote safety and efficiency of operations. It is pertinent to mention that the supervisors must be responsible and held accountable for any safety related occurrences.
  14. There is a definite need to learn lessons from past accidents/Incidents and the recommendations of Inquiry Committee must be implemented with the seriousness it deserves.
  15. Safety Management System is a proven process of managing safety through identification of hazards, Safety Risk Management and Safety Assurance to ensure that risk control measures introduced are effective.
  16. It is the moral duty of the Top Management to implement Safety Management System in letter and spirit and create safety culture in the organisation. Any lapse on the part of the Management on this subject must be viewed seriously.
  17. Job Demands, Monetary considerations, Commercial/ VIP / passenger/Management/peer/self-inflicted pressures have led to serious compromise on safety leading to large number of fatalities. It is the duty of the management to address these issues on priority.

 


B 200 Accident at Delhi Airport on 22 Dec 15- Lessons to be learnt.

Beechcraft Super King Air B-200 aircraft was involved in an accident on 22.12.2015 while operating a flight from IGI Airport, New Delhi to Ranchi. The flight was under the command of a CPL holder with another CPL holder as Second in Command. There were ten persons on board including two flight crew members. The aircraft was loaded with spare parts and equipment for the rectification of a Helicopter at Ranchi.

The weather at the time of accident at Delhi was foggy with visibility reported as 800 meters and winds of 3 knots. The previous METAR which was available with the flight crew mentioned visibility of 600 meters. The visibility was marginal and it is inferred that the marginal visibility was a contributory factor to the accident.

The aircraft was given take-off clearance from runway 28. Shortly after take-off, the aircraft progressively turned left with simultaneous loss of height. Finally it impacted terrain and came to final rest in the holding tank of the water treatment plant of the airport. There was post impact fire and the aircraft was destroyed. All passengers and flight crew were fatally injured.

It is learnt that the accident was caused due to engagement of the autopilot without selecting the heading mode by the flight crew just after lift-off (before attaining sufficient height) in poor foggy conditions and not taking corrective action to control the progressive increase in left bank; thereby, allowing the aircraft to traverse 180° turn causing the aircraft to lose height in a steep left bank attitude followed by the aircraft impacting the ground.

It appears that the flight crew were not confidant in their ability to operate this flight due to the poor foggy condition prevailing at the time of planned departure. With an understanding that immediately after take-off, autopilot will be engaged and the aircraft will fly away on the autopilot, the crew cancelled the taxi clearance and carried out the serviceability checks of the operation of (engagement/ disengagement) of the autopilot. The flight crew during discussion among themselves regarding the conduct of flight had decided to rotate after 120 knots (additional 10 knots) considering tail wind component of 06 knots. The take-off roll and rotation of the aircraft was carried out as discussed. Their decision to increase the rotation speed by 10 knots to allow for the tail wind of 06 knots itself shows that they were ignorant of the fact that the tailwinds do not affect the rotation speeds of the aircraft at all.

Just after lift-off, even without retracting the landing gear, the crew engaged the autopilot but did not engage the Heading Mode ‘of the autopilot. This hurried and non-standard action by the flight crew by engaging the auto-pilot immediately after lift-off reveals their eagerness to let the aircraft be flown by autopilot and underlines their inability to fly the aircraft manually until autopilot engagement height was achieved.

As per the Pilot Operating Handbook procedure, after lift–off and establishing of positive rate of climb, the landing gear is retracted. Thereafter the climb power is set and the autopilot should be engaged only after attaining the height of 500 feet AGL. Engagement of the autopilot without engaging the Heading Mode resulted in the aircraft turning left probably due to the existing left bank or inadvertent manual input by the flight crew at the time of engagement of the autopilot. The bank angle increased progressively and beyond 45 degrees, a situation the flight crew could not decipher because of their disorientation. After disengagement of the autopilot, probability exists that the flight crew had further increased the bank instead of taking corrective action to decrease the bank. This allowed the bank angle to increase beyond 45 degree’s resulting in multiple altitude warning and stalling of the aircraft. The aircraft crashed after turning almost 180 Degrees from the direction of the take-off.

From the analysis of the accident Investigation Report, following lessons can be learnt:-
Involvement of Accountable Manager, Chief of Flight Safety. As mentioned above, though in the Organisation chart it is specifically indicated that there will be Chief of SMS & Chief of Flight Safety with a full-fledged Department of Flight Safety, none was existing. From the discussions with the Officers who were designated as the Chief of Flight Safety in the present and past, it was noted that as and when any regulatory requirement arose, an Officer was nominated for the purpose. At times Officers have conveyed their unwillingness to the Accountable Manager & Alternate Accountable Manager on the work load grounds and not being trained on Flight Safety. The Chief of Flight Safety was interviewed by the DGCA officials for the post of the Chief of Flight Safety and the aspect of lack of training on flight safety was brought out. Approval was accorded for the Chief of Flight Safety for 06 months on the precondition of Flight Safety training.

The Organisation seems to suffer from Complacency which can be described as a loss of awareness of potential dangers. In the present case flying undertaken by the flight crew wherein both, the PF and the PM, were neither possessing adequate flying experience nor could mutually add or impart quality flying experience in the real sense of the terms. The combination of this flight crew was continued over other Type qualified Pilots in the Organisation. Therefore, though the numbers of flying hours flown by this flight crew were increasing, but whether it added to qualitative improvement in their flying skills is questionable? All this while, the highly experienced Examiner was meagerly restored for the flights.

To conclude, there was non-existence of safety culture, non-existence of SMS and nil supervision of the operations at ground level.

The Safety & Quality Policies were existing on paper, but no documentary evidence existed to prove that effective procedures for implementation of these policies were followed.

Lessons Learnt.

  1. Aviation is a serious business which has no place for complacency, casual and careless attitude. A proper Risk assessment must be carried out before undertaking any flight.
  2. Lack of skill and knowledge about the aircraft, its systems, equipment , Manuals, SOP’s, Checks and procedures, Emergency Procedures , various charts, Spatial Disorientation and Situation awareness have led to many accidents. Hence, it is essential to address these areas of knowledge and skill.
  3.  Proper supervision and close monitoring of the performance and competence levels of the pilots is of paramount importance. The role of Supervisors, who should be knowledgeable, involved and competent, to ensure safety of operations, cannot be over emphasised.
  4. It is the duty of the supervisors to ensure that the man, machine and mission are matched in a professional manner particularly during adverse weather conditions. The Supervisors should be held accountable for any lapses.
  5. Ignorance or violation of SOP’s have caused number of accidents/incidents. SOP’s must be followed meticulously at all times.
  6. Safety Management System is a proven process of managing risk and building Safety culture in an organisation. Hence, it must be implemented by all Operators in letter and spirit. The Accountable Manager/Executive should be held accountable for lapses in the sincere implementation of Safety Management System and any compromises on safety.
  7. Proper training and competency of Accountable Manager, Chief of Operations and Chief of Flight Safety can go a long way in ensuring safety and efficiency of Aviation Operations.
  8.  The lack of proper Crew Resource Management was evident in the accident. It is imperative that Crew Members apply the knowledge about the CRM intelligently during flying operations and remain vigilant and situationally aware during conduct of Take Off and Approach, landing, particularly, since the margin of safety is low, during these phases of operations.

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