M’lore crash report: Sleepy captain was just one of the reasons‎

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Indian Express

New Delhi, 21 April 2011:


Co-pilot (6:03:35):


It’s too high!


(6:03:42): Runway straight down.


Captain (6:03:43):


Oh my God




Co-pilot (06:03:54):


Go around?


Captain (06:03:56):


wrong loc.. localizer


Co-pilot (06:04:06):


Go around


(06:04:07): Captain


(06:04:12): Un-stabilised


(06:04:38): Go around Captain


(06:04:44): We don’t have runway left


Captain (06:04:54): Oh my God


(06:04:59): awwww. Big One!


(06:05:00): Ohhhh


At this point, 6:05:00 am on May 22, 2010, the Cockpit Voice Recorder (CVR) went blank. The Captain, soon after touchdown, attempted to take off again against air safety norms and failed. Few minutes later, Air India Express IX 812 overshot the tabletop runway at Mangalore’s Bajpe airport, its right wing hit a concrete structure supporting the antennae, crashed into the boundary fence and fell into the gorge below.


Within seconds, the flight from Dubai was a ball of fire, claiming 158 lives on board. Eight passengers survived.


The final investigation report has held the Captain’s failure to execute a safe landing as ‘the direct cause of accident’. The report, which has been accepted by the government, said Captain Zlatko Glusica, who was in command during take-off from Dubai and landing at Mangalore, carried on with the “unstabilised approach” during landing and ignored both the first officer’s (HS Ahluwalia) three calls to ‘go around’ and several warnings to ‘PULL UP’ and ‘SINK RATE’ from the Enhanced Ground Proximity Warning System (EGPWS).


Being at an altitude much higher than mandatory, the aircraft lost considerable runway length during descent, left with little to brake. EGPWS alerts the pilots in case the aircraft is in danger of flying into the ground or an obstacle. Unstabilised approach means the aircraft did not follow the prescribed speed, descent rate or vertical/lateral flight path parameters at the time of landing.


Despite adequate rest period prior to the flight for him and the co-pilot, the Captain was found sleeping for the first one hour and forty minutes out of the total two-hour and five minutes recorded on the Cockpit Voice Recorder (CVR), the report said. “As a result of relatively short period of time between his awakening and the approach, it possibly led to impaired judgement,” the report said.


The “sleep inertia” coincided with another phenomenon, often said to be a nightmare for pilots, Window of Circadian Low (WOCL) which refers to the period between 2 am and 5.59 am, when body temperature, alertness and ability to be awake is lowest. The report observed that a mandatory pre-flight medical check was not conducted for the flight crew before they departed from Mangalore. However, the report ruled out intoxication or self-administered drugs by the flight crew.


Another contributory factor, as per the report, was the incorrect landing instructions received by the flight as the Mangalore Area Control Radar (MSSR) was out of order and a notice to this effect was given in advance to all flights operating into or out of the airport. There was lack of communication between the flight crew, and the CVR recordings show that first officer was not assertive when he made a call for ‘go around’, even though he had read incorrect parameters during landing. He said to the Captain, “Radar not available, but I do not know what to do.”


Giving its recommendations, the court of inquiry — headed by Air Marshal (rtd) BN Gokhale—has said that Air India Express should be allowed to function as in independent organisation, and its training and flight safety should be accorded due priority. It also noted the airline’s simulator, on which training is conducted, suffers from maintenance problems and frequently breakdowns. It has asked the AAI to avoid downward slopes near the runway, as was the case in Mangalore, and instead bring them to the same level as the runway surface, especially in tabletop runways. The regulator, Directorate General of Civil Aviation (DGCA), should formulate guidelines on controlled rest in the cockpit, the report said.



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