Analyses Accidents/Incidents : Lessons Learnt

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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