Mayday! Mayday! Mayday!

Mayday is the word used around the world to make a distress call via radio communications. Mayday signals a life-threatening emergency, usually on a ship or a plane, although it may be used in a variety of other situations. Procedure calls for the mayday distress signal to be said three times in a row — Mayday! Mayday! Mayday!

24 Aug 1984, Hasimara, WB - Flaming Arrows: We had been operating a 4 aircraft detachment at Leh since April 1984, as the IAF fighter component of Op Meghdoot. I had returned to Hasimara for a short break, and was programmed to fly a 2 vs 1 air combat mission at around mid day. Bonny was the leader with Missy as his No 2, comprising the defender pair, and I was the lone attacker. The idea was to practice a few offensive/ defensive splits, in which the defender pair tries to present two distinct targets to the attacker, forcing him to choose, track and commit to one aircraft of the pair. The other defender of the pair then manoeuvres to position behind the attacker and get into a 'kill' situation, before the attacker can reach a kill situation with the other defender. Those were the days of guns and short range air to air missiles, where-in most air combat was in the visual range. Kill is when one is in a position to launch his weapon at his adversary; range, angle-off and tracking wise. All of this is filmed in the air, so as to effect a professional debrief on ground. A 2-minute combat in the air sometimes takes hours to debrief untangling the manoeuvres; and claims of kill.

Hunter Aircraft

Image Courtesy: Bharat Rakshak

The defender pair had positioned itself in fighting position, and I was positioned at about 2.0 to 2.5 kms astern, with a 50 knots overtake speed. Combat, combat, Go! I am trying to catch up while keeping both aircraft in contact. I can hear the leader call out the split, as we are all on the same channel, as this is not real combat. I decide to go for the lower of the two while trying to keep the other in contact. I am turning hard left behind the lower aircraft, slowly catching up with them, with my head turned fully to the left & upwards, looking well inside my turn to keep the aircraft in contact. I glance right for the other aircraft, and look back at the aircraft I am tracking. Something did not seem right, I tell myself and this time force myself to look right, inside the cockpit, at the fire warning light. 

I sensed right, my fire warning light is ON. I ease the turn, look down and check my jet pipe temperature (JPT) and engine oil pressure gauges. Both are off the clock. I immediately throttle back and ask my formation members to check my wake for smoke. Bonny responds, "Joe, you are trailing thick black smoke". Fire is confirmed. I now take the final action of pressing the fire warning light, to empty the fire extinguisher into the engine. The thick black smoke slowly dies out, and Bonny calls out that now the wake is clear of smoke. I am relieved and start to glide towards base. Mentally calculate my height and distance to base, get my speed to the best glide speed, settle down and make the call to ATC........... 

Mayday! Mayday! Mayday!

Fire in the Air; fire extinguished; Gliding towards base for a forced landing; 20 nms from base at 12000 ft.

I am now heading towards base, and can see the runway directly in-front. Suddenly the aircraft starts to roll to the left. I am in manual controls as the hydraulic power controls are lost. I try to stop the roll with the stick, by deflecting the stick to the right; aileron trimmer to the right, but the roll continues. As per the book, I jettison drop tanks, to rule out roll being caused due to unequal weight of fuel in the drop tanks. The aircraft continues to roll with increasing roll rate. As it gets into inverted position, I find that my nose has dropped about 60 degrees below the horizon, and the aircraft is no longer in my control. I decide to eject. This is a tough call, as one feels very secure in the cocoon-like structure of a fighter cockpit, where-in the pilot is more than familiar with every switch, instrument, and every other item. Getting out of this cocoon in the air is unthinkable, but this time there was no second thought needed.

Representative Image of an Ejection Seat firing from an Aircraft.

Image Courtesy: Google Images

I wait for the aircraft to come right side up, before pulling on the face blind ejection handle. As per the book, the canopy cartridges fire first and the canopy flies off due to the airflow lifting off the canopy from the front; the seat cartridges are supposed to fire after 0.75 seconds to give the canopy time to clear the aircraft tail. I am waiting, nothing happens; my entire life flashed in-front of eyes - my wife and 4 years old daughter ......... thoughts flash through my mind! 0.75 second looks like an eternity; no wonder it is said that time is our creation, and is relative. I am just in the process of moving my hands down to the seat pan handle, the alternate firing handle, as the aircraft roll and pitch rate have increased too much.

I hear a bang; I black out due to the g-forces. The first thing I do when I come back to my senses is, look up. Thank God; relieved to see the orange and white parachute deployed. I look around and see my squadron mates, both Bonny and Missy, orbiting around me. Comforted. Things couldn't get better than this, in this situation. I peer down. I am at about 12,000 feet and I can see the rivers Teesta, Toorsa and all the other tributaries going from the Himalayas to Bangladesh. I can see forests and high tension cables under me. It will take me about 20 minutes to hit the ground. I silently pray to God to spare me from falling onto high tension cables, the jungles or in the rivers. The ride down is slow; one does not have the mind frame to enjoy the beautiful view afforded by this unplanned slow descent towards the ground. It is comforting to have Bonny and Missy as company on the way down. I am sure they have informed ATC, and that a helicopter would be dispatched to pick me up.

As I keep coming down, I see huge crowds running down from all the villages around, from all directions, towards where I was likely to land. I see water all over. Monsoons in the East are unbelievable. As I approach the ground, I can see hundreds of faces looking up towards me, coming down strapped to a parachute. God had answered my prayers in His own graceful way; I land in the middle of a paddy field with knee deep water. People rush to help me, pick up my parachute and give me those bewildered looks. Language is a barrier; none of them speak Hindi or English; I do not speak Bengali/ Assamese; we are in an area on the West Bengal/ Assam border. I finally ask loudly, "Does any one understand Hindi". One young man comes forward. He is from the Army, on leave. Thank God. He speaks a little Hindi. I ask him to take me to a dry place, where a helicopter can land. He says that the village school playground is on raised ground and should be dry.

Our trudge to the playground commences with him in the lead, me following, with a huge crowd following thereafter along with my parachute and survival pack. As we approach the school play ground, I can see the chopper landing there. The chopper flight was in the process of packing up for the day, with the choppers already pushed inside the hangar. The hangar doors were being closed when the news of my ejection reached the Helicopter flight. Sqn Ldr Sengupta heard of it, ran down to the hangar and pulled out the chopper, with the others. They got airborne immediately. If I remember right, he was in uniform when he came to pick me up, as he did not waste time, on hearing about the ejection, to change into overalls. I got into the chopper and we were back in base in a short while. The squadron guys were all very happy to see me back, seemingly in one piece and fit. I requested them not to inform my wife, as she may get worried and that I would inform  her, after she had physically seen me in the hospital. I was taken to the Military Hospital to check out my spine for any injuries due to the ejection. I was admitted to the ward and another officer went home and fetched my wife to the hospital. She came down and was happy to see me hale and hearty, but was concerned about my mental well being, as I told her that I was now entitled to join the 'Caterpillar Club'. She told me later that my mental health was her biggest concern on hearing me discussing about joining caterpillars in a club.

I stayed in the Hospital for the mandatory X-rays and observation, after which I was discharged, fully fit. I went back to Leh, and returned with the squadron in September. 

I am grateful to Martin Baker, and all those connected with this event; people who made it possible for me to live to see another day. God is kind, and I am grateful. 

A court of inquiry was conducted. Hunters were on their last leg. Nothing conclusive came off the inquiry as the aircraft had burnt out. It was most likely a case of failure of the hydraulic pipelines, leading to a leak, fire, pipeline burst and loss of control. All is well that ends well. Hunters were slowly phased out in due course, one squadron at a time. Just over three months after my ejection, i.e. in December of 1984, our squadron was re-equipped with Jaguars. 

 

Military and Commercial Aviation - A View, Mine!

The last paragraph of an article that I have read so beautifully described everything that I too wish to state, based on my limited experience in commercial aviation, as also based solely on my perceptions. The paragraph is reproduced below.

At last I understood what true professionalism is. Being a pilot isn't all seat-of-the-pants flying and glory. It's self- discipline, practice, study, analysis and preparation. It's precision. If you can't keep the gauges where you want them with everything free and easy, how can you keep them there when everything goes wrong.

As a pilot with the IAF, I always considered the commercial licensed pilots as lesser mortals, who got the best of things, while we had to make do with what we had, even though, I felt that our job was more demanding. An example...

May 1984, Op Meghdoot, we were the 1st fighter sqn to land in Leh. We were put up, 2 to a room, with no running water in the bathroom, and with water stored in an empty tar drum outside the rooms & night temperatures of -6*C. We had a kerosene bukhari in the room but there was no legal supply of kerosene, as the supply was only authorised until 31 March. We were given 2 metal buckets to fill our washing needs from the tar drum outside, which was replenished twice a day by a bowser. Electricity was from a captive generator, if I remember right. We used to fill our bucket with water at night, and insert our bazooka (a wooden stick with a heater coil wrapped around it) in it at night, as the water would freeze at night. Get up in the morning, put the bazooka switch on & do all the ablutions/bathing with that 1 bucket. Life was good, we flew in the valleys, helicopter trip to Siachen glacier, with halts at Siala & Bilafondla, & being served warm orange juice laced with rum by our faujis on the glacier, at 17000'/ -55*C. However, we still envied the 5-star treatment of our commercial counterparts.

2006, I get my CPL and start my commercial flying with Blue Dart. I am sent to Johannesburg for my sim; boarding/ lodging in a 5-star resort & all travel plans, ticketing, etc done by the operations department. I feel like a son-in-law of the company. 3 weeks of ground school, and the sim session starts thereafter. I find that the instructor is being too fussy about the procedural aspects. Having 3200 hours on different types of aircraft as a pilot with the Air Force gives one an attitude of 'seen that, done that'. Finally clear the sim. Now the company wants me to fly some hours on the jump seat, followed by a few hours with a qualified co-pilot on the jump seat, while I fly as the u/t co-pilot. Finally, I get ‘released’ as a co-pilot. All I am initially permitted to do is walk around (external checks), checklist, get weather on ATIS, calculate speeds, set the speeds, R/T calls, and callout clear while taxiing, speeds on take-off, heights, checks & complete the navigation log. This seemed like pretty boring & mundane stuff for someone who had handled fast jets in varied terrains, heights & speeds in many different roles/ exercises, all demanding high levels of skill.

At Blue Dart, we operated only by night. As I commenced my line flying, I realised that there were no supervisors to brief/ see us off; a dispatcher would give us the weather, flight plan, fuel and communications briefing, handover two bags full of documents; the Captain was at liberty to ask for additional fuel, if he desired, depending on weather or congestion at destination. At the aircraft, the AME would be available for any queries. For any issues with the aircraft the Captain was required to consult the book on ‘go/ no go’ criteria. In short, it was the Captain who was required to take all decisions, and this becomes even more stark once the door is locked from inside; the Captain becomes wholly responsible for the duration of the flight of this living habitat, which has every possible thing that a mini township has; people, electricity, plumbing, galley, communications, sewerage, fire & safety systems, etc, in addition to the aircraft systems of hydraulics, engines, pneumatics, air conditioning, etc. In the ground classes you learn about regulations, weather, R/T, navigation, log keeping, CRM, technical, FDTL, etc. During the school, one aims to pass the exam, not realising that this is the only data that would be of help to take professional decisions, as there is no help available once the door is locked; it is just you, your crew, and your licence. This is much unlike the Air Force where the whole organisation is organised to provide backup to the launch, execution, and recovery of every sortie. Here there are multiple organisations; each with a professional, a licensed person, providing services, as per their licence, be it the flight crew, Met, ATC, AME, etc.

I started to fly in June; the monsoons had started to set in. Landing in to Mumbai at around midnight, with the aircraft wipers going at max speed, and the turbulence over the ghats never deterred the Captain to continue on the auto pilot coupled ILS, with me calling out the speeds and with nothing visible in front except blasts of rain hitting violently against the windshield. We flew the B-737-200, where-in the autopilot was cleared only upto and above 500’. The localiser and glide slope needles are stuck, right angles to each other. I callout 500’ – Captain disconnects autopilot and holds the needles at right angles while continuing with the approach to land. On my call ‘minimums’, he would call landing, if he had the visual cues to land, which are specified in the regulations, or plan a missed approach, briefing for which was already done prior to commencement of descent. Every flight was a steep learning experience for me; in spite of my 3200 hours of flying experience, there were many things that were new to me. Many a night we flew through a wall of towering Cbs, with lightening all around; the weather radar would help us find a gap, ATC would clear our detours, & we would squeeze through the gap. Latest weather at destination, weather at most likely diversions, as the route progressed were sought, fuel consumption/ fuel remaining were closely monitored. Flying to the absolute limits was the norm with balanced field length RTOW, V-speed calculations, before every flight.

I remember one night; I had a Captain who was in his mid-twenties, on a four leg flight from Chennai to Delhi, via Hyderabad, Mumbai, & Ahmedabad. We were rolling for take-off at about midnight, with full load; I had called 100 kts, and was in the process of calling out V1, when there was a loud bang on the windscreen and a burning smell in the cockpit. All I heard from the Captain was ‘Continuing’. We rotated, checked engine parameters, all was normal, and he decided to continue to Mumbai. Got the engine checked at Mumbai, and found no damage, as the bird had most likely gone through the fan stage, as generally happens. This incident highlighted the quick decision making required at that stage of flight, a delay of 1” to abort at that stage could have the aircraft about 220 yds in the overrun area, if I remember my calculations right, after about 14 years now.

Considering my experience, I had thought I would be ready to sit on the left seat after completing 100 hours as co-pilot, as required by the company Operations Manual. I did not feel competent to even ask my Chief Pilot for the same, on completion of the regulatory 100 hours in the right seat. The variables, monsoons, the total responsibility was all new and a bit disconcerting. Flying from 9 pm to about 8 am taught one the practical lessons on fatigue, window of Circadian low, and importance of following the FDTL, in letter and spirit. 5-star stays no longer looked like comfort, but a basic need to be able to perform in an environment highly dependent on good decision making by the crew, with minimal oversight from anyone else in the organisation; backups of SFS, Flt Cdr, Sqn Cdr, COO, ATC, Met, SUs, etc are not the norm. It is you and your licence. An example….

Our company bought an aircraft from China. A crew was detailed to go and fly it in. The Captain went up to the CEO and told him to change the crew, as both crew members had never been to China before. The CEO replied that no one in the company had been there, & so there was limited choice. Besides, he said that you have an ATPL, & you are well qualified to undertake this task. Matter ended. The crew brought the aircraft from China.

Having operated as a co-pilot only, in commercial aviation, I am sure there are better qualified commercial pilots in this group to comment on what I am going to say. My experience of about one year in commercial aviation taught me that as the name suggests commercial aviation is all about making money and is basically geared for that in terms of organisation. Being a public service, it is highly regulated and has licenced nearly every critical component that makes up civil aviation. Each person is a professional in his own field, and so are the flight crew. The Captain carries the can for each flight and for every decision made. Others assist him within the ambit of their licence; decision making rests solely with the Captain, with minimal supervisory oversight. The IAF on the other hand is a national asset; the whole nation pays for its upkeep, & also depends on it to provide national security. The Air Force organisation stands solidly behind every sortie that gets airborne; there are supervisory oversights at every stage, in peace. Risk is inherent, and is accepted as part of mission accomplishment. In commercial aviation, safety is paramount, and understandably so. In IAF, skills are paramount; commercial aviation is more procedural, not that skills are not important. Both have their strengths and are equally demanding in their respective ways. It took me an exposure to commercial aviation to understand this simple fact, which used to sometimes come up in our crew room conversations.

After having taught CRM and human factors, I can safely say that one’s reality is based on one’s perception, which is totally dependent on one’s ‘experiences’ & ‘learning’ in life. Looking at the same facts, two individuals will perceive the same situation differently because of the above. I am now convinced that each has a role and has created an organisation/ structure/ systems/ procedures to meet that role. Both are right and have their strengths. One is not better or worse. Commercial aviation has gained tremendously with the inflow of Air Force pilots in terms of developing good training ethos, teamwork, leadership – the strong points of the IAF. I am convinced that the Hudson river ditching was perfect, largely because Captain Sully was an ex-USAF pilot. His actions, communications, & decision making were exemplary, as were his skills, and after ditching, so was his concern for each of his crew and passengers. The IAF would gain equally if they interact more with the civil aviation in terms of procedures, rules, etc. The two are vital components of a nation’s airpower and would both benefit with closer interaction that will eventually lead to a healthy transfer of their inherent strengths.

Irony of Automation in Aviation

    

These statements are so true!

Computers do those things well that pilots already know how to do well, much better than pilots. But computers do not know how to do those things that a pilot would like to do well.

   In essence, the irony is that pilots are to oversee an automated system, which they do poorly, and take over when there are abnormal conditions, which they may not be very good at either.

-----------------ATPL Book 8 CAE Oxford Aviation Academy

PRESSURISATION SWITCH IN THE WRONG POSITION

HELIOS AIRWAYS FLIGHT 522: 14 AUG 2005: BOEING 737 – 300

SYNOPSIS

On 14 Aug 2005, Helios Airways international Flight 522 departed from Larnaca, Cyprus, at 06:07h for an intermediate stop at Athens, Greece on way to Prague, Czech Republic. The planned flying time was 1 hour and 23 minutes. While climbing through an altitude of 12040 ft, for FL 340, the cabin altitude warning horn sounded at 06:12h. The German captain and the Cypriot co-pilot tried to solve the problem but encountered some problems communicating with each other.

Helios' Boeing 737-300 5B-DBY underwent maintenance on the night prior to the accident. The pressurization system was checked, but after completion of the tests the Pressurization Mode Selector (PMS) was reportedly left in the "Manual" position instead of the "Auto" mode. In manual mode the crew had to manually open or close the outflow valves in order to control the cabin pressure. The outflow valves were one-third in the open position which meant that the cabin would not pressurize after takeoff. The PMS mode was apparently not noted during the pre-departure checks by the crew.

At 06:14h while climbing through an altitude of 15966 ft, the Captain contacted the Company Operations Centre (COC) and informed, “Take off configuration warning ON” and “Cooling equipment Normal and Alternate Offline”. Because of a lack of cooling air another alarm activated, indicating a temperature warning for the avionics bay. 

There were a few communications between the Captain and the COC during the period of 06:14h and 06:20h. On a query from the Captain, “where are my equipment cooling circuit breakers?” The engineer replied, “Behind the Captain’s seat”. These needed to be pulled out to turn off the alarm. The captain got up from his seat to look for the circuit breakers. At 06:20h, the Captain made his last communication, at which time the aircraft was climbing through 28900 ft.

During the communications between the Captain and the COC, at an altitude of approx. 18000 ft, the cabin altitude exceeded 14000 ft, leading to the deployment of oxygen masks in the passenger cabin, as per design.

The crew was not wearing their oxygen masks as their mindset and actions were determined by the preconception that the problems were not related to the lack of cabin pressure. As the airplane was still climbing, the lack of oxygen seriously impaired the flight crew. The captain probably became unconscious when he was trying to find the circuit breaker. The first officer was still in his seat when he also became unconscious. There were no further two way communications with the aircraft after 06:20h.

The aircraft continued to climb and leveled out at FL 340, as programmed. The aircraft continued on track maintaining FL 340 and eventually fed in to a standard instrument approach procedure for runway 03L at Athens International airport, while continuing to maintain FL 340. The approach was followed by a missed approach, and setting up of a holding pattern over KEA VOR, while continuing to maintain altitude.

All efforts by Greek air traffic controllers to contact the pilots were futile. Around 07:00h, two Greek F-16 fighter planes were scrambled to intercept the aircraft. The F-16s intercepted the aircraft on its sixth holding pattern, at about 07:23h. The F-16 pilots reported that they were not able to observe the captain, while the first officer seemed to be unconscious and slumped over the controls. Oxygen masks were reported to be dangling in a dark passenger cabin.

At 08:49h, the F-16's reported a person not wearing an oxygen mask entering the cockpit and occupying the captain's seat. The F-16 pilot tried to attract his attention without success. At 08:50h, the left engine flamed out due to fuel depletion and the aircraft started descending. At 08:54h, two Mayday messages were recorded on the CVR, in a very weak voice. At 09:00h, the right engine also flamed out at an altitude of 7084 ft. The aircraft continued descending rapidly and impacted hilly terrain about 33 kms northwest of Athens, close to Grammatiko village.

All 121 persons on board the aircraft, including 6 crew members and 115 passengers, were fatally injured during the accident.

DIRECT CAUSES

1. Non-recognition that the cabin pressurization mode selector was in the MAN (manual) position during the performance of the:

a) Pre-flight procedure;
b) Before Start checklist; and
c) After Takeoff checklist.

Image Courtesy: Google Images. Pressurisation Mode Selector in Manual Mode

2. Non-identification of the warnings and the reasons for the activation of the warnings (cabin altitude warning horn, passenger oxygen masks deployment indication, Master Caution), and continuation of the climb. (The initial actions by the flight crew to disconnect the autopilot, to retard and then again advance the throttles, indicated that it interpreted the warning horn as a Takeoff Configuration Warning). (At an aircraft altitude of 17 000 to 18 000 ft, the Master Caution was activated and was not cancelled for 53 seconds. The reason for its activation may have been either the inadequate cooling of the Equipment or the deployment of the oxygen masks in the cabin. Independently of the Master Caution indication, there are separate indications for both malfunctions on the overhead panel. The flight crew possibly identified the reason for the Master Caution to be only the inadequate cooling of the Equipment that was indicated on the overhead panel, and did not identify the second reason for its activation, i.e., passenger oxygen masks deployment, that was later also indicated on the Overhead panel. The crew became preoccupied with the Equipment Cooling fan situation and did not detect the problem with the pressurization system. The workload in the cockpit during the climb was already high and was exacerbated by the loud warning horn that the flight crew did not cancel).

3. Incapacitation of the flight crew due to hypoxia, resulting in continuation of the flight via the flight management computer and the autopilot, depletion of the fuel and engine flameout, and impact of the aircraft with the ground. (The incorrect interpretation of the reason for the warning horn indicated that the flight crew was not aware of the inadequate pressurization of the aircraft).

LATENT CAUSES

1. The Operator’s deficiencies in organization, quality management and safety culture, documented diachronically as findings in numerous audits.

2. The Regulatory Authority’s diachronic inadequate execution of its oversight responsibilities to ensure the safety of operations of the airlines under its supervision and its inadequate responses to findings of deficiencies documented in numerous audits.

3. Inadequate application of Crew Resource Management (CRM) principles by the flight crew.

4. Ineffectiveness and inadequacy of measures taken by the manufacturer in response to previous pressurization incidents in the particular type of aircraft, both with regard to modifications to aircraft systems as well as to guidance to the crews.

CONTRIBUTING FACTORS TO THE ACCIDENT

1. Omission of returning the pressurization mode selector to AUTO after un-scheduled maintenance on the aircraft.

2. Lack of specific procedures (on an international basis) for cabin crew procedures to address the situation of loss of pressurization, passenger oxygen masks deployment, and continuation of the aircraft ascent (climb).

3. Ineffectiveness of international aviation authorities to enforce implementation of corrective action plans after relevant audits.

SHUTTING DOWN THE ‘GOOD’ (WRONG) ENGINE

BRITISH MIDLANDS FLIGHT 092: 08 JAN 1989: BOEING 737 – 400

SYNOPSIS

Flight 092 left London for Belfast at 19:52h with a crew of 8, and 118 passengers on board. While climbing through FL283 moderate to severe vibration that was accompanied by ingress of smoke and fumes in to the flight deck were felt, as also fluctuations in the engine parameters of the No. 1 engine. Investigations revealed that these were the result of one of the outer panel of one of the no. 1 engine fan blades getting detached in flight, causing a series of compressor stalls that lead to airframe shuddering.

Believing the No. 2 engine had suffered damage, the crew throttled it back. The shuddering stopped, leading the flight crew to believe that their actions were correct, and they thus shut down the No 2 engine. The No. 1 engine operated normally after the initial severe vibrations, and during the descent in to East Midlands, the diversionary airfield.

The flight was cleared for an approach on to runway 27. The instrument approach on No. 1 engine continued normally, although with a high level of vibrations from the live engine. At 900 feet, 2.4nm from the runway, no. 1 engine suddenly suffered a reduction in power followed by a fire warning on this engine. Attempts to restart No. 2 engine were not successful. As the speed fell below 125 knots, the stick shaker activated and the aircraft struck trees at a speed of 115 knots. The aircraft continued and impacted the western carriageway of the M1 motorway 10 m lower and came to rest against the wooded embankment, 900 m short of the runway.

39 passengers died in the accident, and 8 more died later due to the injuries sustained. Of the remaining 79 occupants, 74 suffered serious injuries.

(Image Courtesy: Google Images: Aerial view of Crash site)

PROBABLE CAUSE

The operating crew shut down the No 2 engine after a fan blade had fractured in the No 1 engine. This engine subsequently suffered a major thrust loss due to secondary fan damage after power had been increased during the final approach to land.

The following factors contributed to the incorrect response of the flight crew

1. The combination of heavy engine vibration, noise, shuddering and an associated smell of fire were outside their training and experience.

2. They reacted to the initial engine problem prematurely and in a way that was contrary to their training. (Either pilot does not remember having noticed the engine parameters like N1, EGT, N2 or Oil Pressures of the engines before throttling back No. 2 engine).

3. They did not assimilate the indications on the engine instrument display before they throttled back the No. 2 engine. (The crew’s familiarity of the newly introduced EIS on the B 737-400 variant could have been a factor. The Captain had 23 hours and the first officer had 53 hours on the B 737-400. Both were given a 1day training session on the EIS, as there was no flight simulator available with the EIS. The variants before the B737-400 had the normal electro-mechanical engine instruments).

4. As the No 2 engine was throttled back, the noise and shuddering associated with the surging of the No 1 engine ceased, persuading them that they had correctly identified the defective engine. (The Auto Throttle system was disengaged while bringing No. 2 engine throttle back to idling. This led to manual control of the engines, and No. 1 engine fuel flow settled as per the prevailing engine conditions, rather than as demanded by the auto throttle to maintain flight parameters).

5. They were not informed of the flames which had emanated from the No.1 engine and which had been observed by many on board, including 3 cabin attendants in the aft cabin. (Inadequate communications between flight and cabin crew – a CRM issue that is greatly emphasised now).

Weak link in the Indigo Airline System

I recently traveled by Indigo from Chandigarh to Bangalore. The flight was perfect with everything that is expected of an airline, starting from check-in; customer service; boarding; in-flight; cabin crew; the flight and of course the hallmark of Indigo - punctuality.

Image: Courtesy - Google Images

However, there was one flaw that seems to stick out, and would stay with me unless something is done about it by the airline. Imagine booking this flight on the Makemytrip website, after having spent an inordinate time trying to book it on the Indigo website. The Indigo website is slow, and has many glitches that forced me to re-enter data and keep refreshing pages.

Probably it has not been upgraded to keep up with the increased traffic loads on the website, caused due to increase in the fleet strength to 97 aircraft now. Or, could it be by design so that the company does not waste resources on a non core function that can be done more efficiently by a third party that has a core business of online reservations. I am not too sure on the philosophy of Indigo on this aspect.

In my opinion a low cost airline survives by cutting costs, and airline owned online booking platforms are one way of keeping costs down, unless Indigo management has now found out a better way to do it.

I am curious to know. Any one who knows this, please share with me on this blog.

Stall Recovery Template issued by FAA in June 2012.

Relevant extracts of FAA Advisory Circular 120 - 109 dated 08 Jun 2012, based on the Colgan Air, Air France and other stall related accidents at high and low altitudes.

TABLE 1. STALL RECOVERY TEMPLATE (WITH ASSOCIATED RATIONALE) 

1. Autopilot and autothrottle………………………………..Disconnect

Rationale: While maintaining the attitude of the airplane, disconnect the autopilot and autothrottle. Ensure the pitch attitude does not increase when disconnecting the autopilot. This may be very important in out-of-trim situations. Manual control is essential to recovery in all situations. Leaving the autopilot or autothrottle connected may result in inadvertent changes or adjustments that may not be easily recognized or appropriate, especially during high workload situations.

2. a) Nose down pitch control…........................................Apply until stall warning is eliminated
 b) Nose down pitch trim…….………………………..….As Needed 

Rationale: a) Reducing the angle of attack is crucial for recovery. This will also address autopilot-induced excessive nose up trim.
b) If the control column does not provide sufficient response, pitch trim may be necessary. However, excessive use of pitch trim may aggravate the condition, or may result in loss of control or high structural loads.

3. Bank…………………………………………………..…….Wings Level 

Rationale: This orients the lift vector for recovery.

4. Thrust …………………………………………….………….As Needed 

Rationale: During a stall recovery, maximum thrust is not always needed. A stall can occur at high thrust or at idle thrust. Therefore, the thrust is to be adjusted accordingly during the recovery. For airplanes with engines installed below the wing, applying maximum thrust may create a strong nose-up pitching moment if airspeed is low. For airplanes with engines mounted above the wings, thrust application creates a helpful pitch-down tendency. For propeller-driven airplanes, thrust application increases the airflow around the wing, assisting in stall recovery.

5. Speed brakes/Spoilers……….…….…………………………..Retract 

Rationale: This will improve lift and stall margin.

6. Return to the desired flightpath.

Rationale: Apply gentle action for recovery to avoid secondary stalls then return to desired flightpath.

A TIMELY GO-AROUND DECISION AND SAFE OPERATIONS

The recent unfortunate accident involving Flight 214, a Boeing-777 aircraft, of Asiana Airlines at San Francisco is a case of a fully serviceable aircraft flying in to the ground in VMC conditions; due to an approach that became increasingly unstabilized with height. Could this accident be averted, had the crew taken a timely decision to go-around? Conditions being VMC, as per the recommendations enumerated below, the approach should have stabilized latest by 500 ft and should have remained so below 500’, to continue with an approach to land. As per reports, the airplane was configured for landing with 30 degrees of flaps and gear down with a target threshold speed of 137 knots. The aircraft descended through an altitude of 1400 ft at 170 kts and slowed down to 149 kts at 1000 feet. The throttles were reportedly at idle and the auto throttle was armed. At 500 feet altitude, 34 seconds prior to impact, the speed dropped to 134 kts, which was just below the target threshold speed. Any speed below the target speed, the approach should have been considered unstabilized, especially below 500 ft in VMC. The situation was allowed to worsen further when the airspeed dropped significantly, reaching 118 knots at 200 feet altitude. Eight seconds prior to impact, the throttles were moved forward. Airspeed reduced further to 112 knots at an altitude of 125 feet. Seven seconds prior to impact, one of the crew members made a call to increase speed. The stick shaker sounded 4 seconds prior to impact. One second later the speed was 103 knots, the lowest recorded by the FDR. One of the crew members made a call for go-around at 1.5 seconds before impact. This was too late to prevent an accident off an approach that was unstabilized. Accidents during the approach and landing (ALA) phase account for a major percentage of all accidents.

Analysis of data collected by a go-around study being conducted by the Flight Safety Foundation’s (FSF) international and European aviation committees has shown that potentially 54 percent of all aircraft accidents in year 2011 could have been prevented by a timely go-around decision by the flight deck crew. Clarifying on the figure of 54%, the FSF director of global programs is quoted to have said that, “this is based on 65 percent of that year’s accidents being in the approach and landing (ALA) phase, and using our analysis that 83 percent of ALAs could be prevented by a go-around decision”. The study has also elaborated that “the majority of accidents over the last 10 years have occurred during the approach, landing and go-around flight phases. The study has also highlighted the fact that the lack of a go-around decision is the leading risk factor in approach and landing accidents and is the primary cause of runway excursions during landing. Yet, less than 5% of unstabilized approaches lead to a go-around.”

Unstabilized approaches have been attributed to various factors, which include company policies, human factors, weather, crew resource management, ATC and automation. The Asiana case can also be attributed to a number of these factors. The crew felt that the auto throttle should have maintained the speed at 137 kts; the PF and PM were not effectively flying and monitoring the flight path and parameters, which permitted the IAS to drop well below the target speed, and the throttles to remain at idle; company culture may have also come into play in this scenario; fatigue after a long flight due to improper work load assignment – there were four pilots on this flight; three of them in the cockpit during the approach. All of these factors that led to the unstabilized approach would have been taken care of, if the crew had made the decision to go around in time. When things are not as planned in aviation, it is always better to have height and speed in hand. In this particular case there were many issues that pointed towards an unstabilized approach. To understand this it is best to study the elements that constitute a stabilized approach.

Stabilized Approach

Stabilized approach concept is all about maintaining a stable speed, descent rate, and vertical/ lateral flight path in the landing configuration. It is felt that a stabilized approach would generally lead to a safe landing, as the crew’s awareness of the horizontal/ vertical flight path; the IAS and the energy-condition of the aircraft would lead to improved overall situational awareness during the approach. Also, flying a stabilized approach permits the crew to devote adequate time and limited human ‘attention resources’ to flying, monitoring, communications, weather conditions, systems check, and most importantly to decision making. As has been brought out earlier, 95% of unstabilized approaches do not lead to a go-around, and this has contributed to 54% of the total accidents in 2011, and the lack of go-around decision is a major risk factor in ALA. It is now an accepted fact that the decision to execute a go-around is no indication of poor performance.

Recommended Elements of a Stabilized Approach

The following recommendations are developed by the Flight Safety Foundation. All approaches should be stabilized by 1,000 feet above airfield elevation (AFE) in instrument meteorological conditions (IMC) and by 500 feet AFE in visual meteorological conditions (VMC). An approach is considered stabilized when all of the following criteria are met:

·                     The airplane is on the correct flight path

·                      Only small changes in heading and pitch are required to maintain the correct flight path

·                     The airplane speed is not more than VREF + 20 knots indicated airspeed and not less than Vref

·                     The airplane is in the correct landing configuration

·                     Sink rate is no greater than 1,000 fpm; if an approach requires a sink rate greater than 1,000 fpm, a special briefing should be conducted

·                     Thrust setting is appropriate for the airplane configuration, and not below the minimum power on approach as defined by the aircraft operating manual.

·                     All briefings and checklists have been conducted.

·                     Specific types of approaches are stabilized if they also fulfill the following:

• ILS approaches should be flown within one dot of the glide slope and localizer
• During a circling approach, wings should be level on finals when the airplane reaches 300 feet AFE.
• Unique approach procedures or abnormal conditions requiring a deviation from the above elements of a stabilized approach require a special briefing.

For safety reasons, an approach that becomes un-stabilized below 1,000 feet AFE in IMC, or below 500 feet AFE in VMC should be discontinued and a go-around executed. Also, stabilized conditions should be maintained throughout the rest of the approach for it to be considered a stabilized approach. If the above criteria cannot be established and maintained at and below 500 feet AFE, initiate a go-around.

Conclusion

Considering the statistics and the facts enumerated above, it is felt that all efforts should be made to fly stabilized approaches, and if due to some reason an approach becomes unstabilized then the decision to go-around should be taken well in time. A well considered, and executed, go-around will go a long way in ensuring safe operations, and enhance safety in aviation.

ASIANA AIR B-777-200 CRASH AT SFO ON 06 JUL 2013

A Boeing 777-200 of Asiana Airlines with 307 people on board crashes while landing on runway 28L at San Francisco, killing 2 people and injuring 180. The accident took place at about 11:28 am local time on 06 Jul 2013. As per initial reports coming through, the ILS Glide slope for the runway was non-operational for runway 28L at SFO. It appears that the aircraft came in low. Watching the debris trail on the runway, it appears that some portion of the aircraft touched well short of the beginning of the runway, let alone the threshold. Why? 

The aircraft has called finals at 7 miles and every thing appears normal. Has any failure taken place after that; the aircraft has encountered wind shear; or is it just a case of an undershooting approach with the tail portion of the aircraft hitting the snow wall - a vertical wall at the edge of the land/ water junction.

Awaiting further news on the cause of the accident - prima facie appears to be human error, with the aircraft making an undershooting approach in the absence of ILS glide slope information. No news about VASI or other visual approach aids. Weather at the time was VFR.

STANDARD OPERATING PROCEDURES AND SAFE OPERATIONS

Introduction      What are Standard Operating Procedures (SOPs)? A letter by the US Federal Aviation Administration (FAA) aptly answered this question where in it was stated that, “SOPs are written, tested procedures that are applied uniformly and consistently within an organization and involve all aspects of flight, both normal and non-normal”. It further stated that “SOPs are widely recognized as a basic element of safe aviation operations”. Safety is one of the pre-requisites for mission accomplishment in aviation, and thus the importance of SOPs can never be under estimated.

Design of SOPs

The aircraft manufacturer provides the initial SOPs for the aircraft based on lessons learned from previous operating experience; analyses performed during design; experience gained during development and certification flight testing; and also experience from the route-proving program. These manufacturer-provided SOPs are adopted without change by an aviation organisation, or these are used as the basis for the development of customized SOPs that promote standardisation across the different aircraft fleets in service at the organisation. Company SOPs so developed reflect the organisation’s operating and training philosophies. Thus, SOPs represent the collective wisdom of the aviation community on how operations could be conducted safely.

To ensure safety, training and operations need to be consistent, implying that training and operations should both be conducted as per the SOPs. This can only happen if everyone in the organisation is convinced of the need to follow SOPs. Bringing about this awareness places a great responsibility on the flying supervisory staff.  Instructors and check airman of the operator are required to ensure that crews are made aware of the reasons for SOPs; are trained as per the SOPs, and are also required to enforce the same during routine line operations.

SOPs published by the operator normally include expected procedures that would be utilised during the flight profiles that are used by the operator, including pre & post flight procedures. SOPs lay down the most effective and efficient procedure to execute any task safely. New procedures need to be added to the SOPs, and redundant ones modified/ deleted based on requirements, and also based on experiences gained by the aviation community. To undertake this task, review of SOPs should be an ongoing task, ideally accomplished with suitable feedback from the end user, the flight crew.

All of this is done with an aim of ensuring safe aviation operations. It is now abundantly clear that safety is not dependant only on the training of the crew, but also on good crew coordination as well as optimum crew performance (or good CRM). This can best be ensured if the crew has a shared mental model of each task that is being undertaken. SOPs provide that vital link that can effectively ensure this shared mental model between crew members, with the least communications, because when every crew member is following SOPs, he/ she is aware of what needs to be done; when it needs to be done; and by whom.

To ensure that every crew member follows the SOPs, these procedures should be clear, comprehensive, and readily available to the flight crew members. In addition the crew members should be aware and convinced of the need to follow the SOPs. All this sounds logical but a study of aircraft incidents and accidents indicates that some of these have been caused due to the crew not following the SOPs.

Operational and Human Factors Involved in Deviations from SOPs

To ensure effective compliance with SOPs, it is important to understand why pilots intentionally or inadvertently deviate from the SOPs. In most cases of deviation from SOPs, the procedure that was followed in place of the published procedure seemed appropriate to the crew, for the prevailing situation, considering the information available in the cockpit at the time. However, it was later found that it was either inappropriate, or at best suboptimal. Experts cite the following factors and conditions as making it more likely that a deviation from SOPs will occur. Awareness of these factors can influence adherence to SOPs and may also be useful in developing corresponding prevention strategies.

• ·         Corporate culture (e.g., the absence of company management’s clear commitment to SOPs and standardization; double standard practices)
• ·         Ineffective or unclear company policies (e.g., regarding schedules, costs, go around, diversion, crew duty time, etc.)
• ·         Inadequate awareness/ knowledge of, or failure to understand the procedure, or action (e.g., quality of wording or phrasing; procedure or action being perceived as inappropriate)
• ·         Insufficient emphasis on strict adherence to SOPs during routine training and checks.
• ·         Insufficient vigilance (e.g., due to fatigue)
• ·       Distractions (e.g., due to cockpit activity)
• ·         Interruptions (e.g., due to ATC communication)
• ·         Task saturation resulting in fixation/ degraded multi-tasking ability or task overload leading to reduced attention.
• ·         Incorrect management of priorities (e.g., lack of or incorrect decision-making model for time-critical situations)
• ·         Incorrect CRM techniques, especially the absence of cross-checking, crew coordination or effective backup
• ·         Personal desires or constraints (e.g., personal schedule, press-on-itis)
• ·         Complacency or Over confidence

An Effective SOP

An effective SOP would need the active collaboration of all stake holders, at the formulation as well as the implementation stages. The following factors should thus be considered for creating effective SOPs: -

•  All crew members should be aware of the reasons for the procedure, and should also be convinced of the need to follow the same. It is a known fact that when flight crew members are so convinced, then they are more likely to follow the procedure, and also offer valuable feedback to improve upon an existing procedure, or  introduce a new relevant procedure.
•   All crew members should hold the belief that the procedure is appropriate to the stated flight situation, and would cover all the likely eventualities. This should be reinforced during effective training sessions conducted by the operator’s flight instructors/ check pilots.
•  The procedure should clearly lay down what needs to be done, by whom (PF/ PM), and when it is to be done. Each crew’s responsibilities would thus be clearly delineated.
•  The senior supervisors should set an example through word, and more importantly through their deeds that SOPs are to be followed. Any shortcomings/ misgivings about the procedure that are pointed out by the line crew should be discussed and remedial action initiated, if considered appropriate; otherwise the crew member should be provided feedback of the reason why the suggestion is not considered worthy of implementation.

 It has been seen that many a times SOPs are not consistently implemented, in that double standards are practiced by the crew and these are also condoned by the instructors/ check pilots/ managers. Flight crews follow the SOPs during training and check rides, but do it their own way during routine line operations. When this kind of a situation exists, it is an indication that the SOP is either not practical or effective for some reason. The reason for the deviation should thus be investigated and remedial action initiated.

Summary

Safety in aviation continues to depend on good crew performance. Good crew performance, in turn, is founded on standard operating procedures that are clear, comprehensive, and readily available to the flight crew. Development of SOPs is most effective when done by collaboration, using the best resources available including the end-users themselves, the flight crew. Once developed, effective SOPs should be consistently enforced during training as well as during line operations and ineffective SOPs should be continually reviewed and renewed. Double standards should not be permitted.