COULD THIS ACCIDENT BE PREVENTED?

Helios' Boeing 737-300 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.

In the morning the 737 was to operate Flight 522 from Larnaca to Prague, Czech Republic with an intermediate stop at Athens, Greece. The flight departed Larnaca at 09:07 for the leg to Athens with a planned flying time of 1 hour and 23 minutes. As the airplane climbed over the Mediterranean the cabin altitude alert horn sounded. This occurred as the 737 passed through an altitude of 10,000 feet. Cabin altitude is usually held around 8,000 feet. The crew possibly thought it was an erroneous takeoff configuration warning because the sound is identical. Then, at 14,000 feet, the oxygen masks automatically deployed and a master caution light illuminated in the cockpit. Because of a lack of cooling air another alarm activated, indicating a temperature warning for the avionics bay.

The German captain and the Cypriot co-pilot tried to solve the problem but encountered some problems communicating with each other. They contacted the Helios´ maintenance base to seek advice. The engineer told that they needed to pull the circuit breaker to turn off the alarm. The radio contact ended as the aircraft climbed through 28 900 ft. The circuit breaker was located in a cabinet behind the captain. The captain got up from his seat to look for the circuit breaker. The crews were 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. Because the plane's autopilot was programmed for FL340 the Boeing continued to climb until leveling out at that altitude some 19 minutes after takeoff. At 09:37 the 737 entered the Athens FIR but no R/T contact was established with the flight. Over Rodos at about 09:52 the airplane entered the UL995 airway. At 10:21 the airplane passed the KEA VOR, which is located about 28 nm south of the Athens airport. The airplane then passed the Athens Airport and subsequently entered the KEA VOR holding pattern at 10:38. All efforts by Greek air traffic controllers to contact the pilots were futile. Around 11:00 two Greek F-16 fighter planes were scrambled from the Néa Anghialos air base. At 11:24, during the sixth holding pattern, the F-16's intercepted the airliner. 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.

At 11:49, 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 11:50, the left engine flamed out due to fuel depletion and the aircraft started descending. At 11:54, two Mayday messages were recorded on the CVR. At 12:00, the right engine also flamed out at an altitude of approximately 7100 feet. The aircraft continued descending rapidly and impacted hilly terrain.

The same Boeing 737 had, suffered a loss of cabin pressure on December 20, 2004 during a flight from Warsaw to Larnaca. Three passengers needed medical treatment after landing in Larnaca. This incident was caused by a leaking door seal of the right hand rear door.

DIRECT CAUSES:

1. Non-recognition that the cabin pressurization mode selector was in the MAN (manual) position during the performance of the:
a) Preflight procedure;
b) Before Start checklist; and
c) After Takeoff checklist.

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.

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.

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.

BASICS OF AN AERODYNAMIC STALL

This is written from a pilot’s point of view with the aim of giving a theoretical aerodynamic background to the actions that one takes in the cockpit. These actions would become instinctive if one understands the basic theory. We are not designers or engineers, but we need to fly the aircraft safely from A to B, under all conditions. Under normal conditions we would never be operating close to stall. The highest AsOA that we encounter in flight are during the take-off and landing phases.  However, when operating under conditions that are not normal we are still required to fly that aircraft safely and thus we need to understand how our aircraft behaves at all times.

• ·         In flight we have four forces that we should be aware of at all times. To maintain steady straight and level flight the Lift has to balance weight and the thrust has to balance the drag, and the sum of the moments has to be zero. This also implies that the Power available is equal to the power required. If the Power available is more than the Power required then the aircraft would have a ROC, and vice versa. Power required = Drag X TAS. Power available is Thrust X TAS.
• ·         A stall is a condition of flight in which the aircraft has exceeded the stalling angle of attack or the critical angle leading to a sharp decrease in co-efficient of lift and a sharp increase in the co-efficient of drag. (Please refer to the AOA vs Cl/ Cd graphs).
• ·         The decrease in Cl leads to loss of lift as L = Cl ½ pv2S. In straight and level flight the lift is now no longer able to balance the weight.
• ·         The increase in co-efficient of drag increases the drag leading to a power deficit, as the power available at the same throttle settings is now less than the power required. On a training aircraft with rectangular wings, propeller slipstream and high thrust line, the wing stalls and the nose pitches down, helping in recovery of the aircraft from the stalled condition.
• ·         This situation changes in aircraft that fly at high altitude, high speed, have sweep back wings and a thrust line below the CG (due to low slung engines). Sweep back wings tend to stall at the tips first causing the nose to pitch up; any addition of thrust from the low slung engines would aggravate the pitch up situation and lead to a stall.
• ·         In a power deficit situation, the aircraft will develop a descent. When the aircraft commences descent, the direction of the relative airflow changes, as the flight path of the aircraft has changed.  The relative airflow comes from further below than earlier leading to an increase in AOA – reducing Cl further and increasing Cd further. We are now entering into a deep stall zone which is more pronounced on sweep back and delta wings. The positioning of the tail also has an effect.  Any other phenomenon like icing could also lead to reduction of Cl and increase in Cd.
• ·         The only way out is to unstall the aircraft by reducing the AOA by aligning the aircraft with the relative airflow coming from below OR in pilot’s parlance by pushing forward on the control column. The throttle is advanced to increase the thrust so that the power available increases to match the power required.
• ·         Once the aircraft unstalls, the aircraft can be eased out. This procedure has to be followed on all aeroplanes – the basic theoretical considerations do not change very much and you can understand the reason why ; the manufacturers give the finer points which would be peculiar to that aircraft type.
• ·         The basic fact is that whether one flies the C-152 or the A-380, the aircraft needs to be supported by the air in which it flies.
• ·         The airflow going around the aerofoil is what generates the lift and the aerofoil (and in turn the wing too) stalls when the airflow ‘separates’ from the aerofoil at a forward position on the chord, leading to sharp loss of lift. (As the AOA increases, the separation point keeps moving forward.)
• ·         Every aerofoil has different aerodynamic characteristics, as can be seen in the books. When icing takes place the aerofoil shape changes, and so do its aerodynamic characteristics – Cl, Cd and separation of airflow too. It would happen every time the aerofoil shape changes – it could be because of dirt, pigeon shit on the wing or any other phenomenon.
• ·         Standard operating Procedures are laid down for all normal operations that a company undertakes, and are a pilot’s life line and should be followed meticulously to go from A to B safely under all conditions – normal or not normal.

An Aircraft Incident - Good CRM

On 25 Oct 2005, Capt. L Marcelo (Brazilian pilot with 8400 hours) and F/O Thomas Abraham (Indian with 939 hours) were scheduled to operate flight BD 201 from Kolkata to Chennai. The crew arrived at flight operations about 0:50 mts before scheduled departure. After a detailed briefing by the FDO, the crew proceeded to the aircraft and spoke with the engineer at the aircraft regarding the snags reported by the previous crew. F/O Abraham was the PF for the first sector from Kolkata to Delhi. There was a slight delay on the part of ground operations and this time was utilized by the crew to discuss various operational aspects connected with the flight. Departure was from R/W 01R. During the take off roll, all callouts were made by Capt. Marcelo. All parameters were normal during the ground roll. After unstick, on selecting gear up, at around 400’ agl a loud bang was heard. This was followed by a yaw to the right, and high vibrations. Capt Marcelo took over control of the aircraft, made a quick scan of the engine parameters and found that there was a rapid rise in the No. 2 engine EGT, which was going beyond limits. Capt Marcelo partially retarded the No. 2 engine thrust lever in order to contain the EGT, while at the same time climbed to the security altitude of 800’. F/O Abraham made a PAN call to the ATC. At security altitude, Capt Marcelo asked for MCT on live engine, engine failure shutdown checklist and after take off checklist, in this order. Both crew members concurred that the No 2 engine was malfunctioning, and the checklist was called out by F/O Abraham. The flaps were left at flap 1 position, as the crew operating the previous flight on this aircraft had reported difficulty/ vibration while deploying flaps. Also, the Capt was not sure if the flap assembly had sustained any damage during this emergency. Capt Marcelo had the field in sight and elected to do a visual circuit to minimise the time in air. On D/W, the one engine inoperative descent approach checklist was carried out by F/O Abraham, followed by the one engine inop landing checklist. An overweight, flap 15 landing was carried out at a Vref of 150 kts. The landing was normal with manual braking, and No. 1 engine reverser deployed. Taxi in and shutdown was as per SOP. The tyres of the right main landing gear deflated on reaching the bay. The cause of the incident has been attributed to internal object damage caused due to fatigue failure of 3 blades of the HP Turbine. The engine sustained extensive damage to the HP and LP turbine section and downstream of the turbine.

Capt Marcelo and F/O Abraham had arrived in Kolkata on 23 Oct 2005 after operating BD 102 from Chennai to Kolkata. This was their first flight together as a crew. The crew utilized the extended stay in the hotel at Kolkata to get acquainted with each other, personally and professionally. During this process, one of the situations put forward by Capt Marcelo was a condition of an engine failure after take off. They discussed the actions in such a situation and agreed that priority should be given to flight path control, followed by the appropriate checklists and a landing back at Kolkata. Overweight landing was discussed, and Capt. Marcelo opined that single aisle aircraft undercarriages were designed to perform overweight landings as the difference in their MTOW and MLW was not very large. Also, that it was preferable to carry out an overweight landing in such a case, as the cause of engine failure would not be known to the crew, and thus such an eventuality should be treated with the same priority as an engine fire.

Crew Resource Management highlights

1. There was a large difference in the flying experience of the crew. In addition to this, there were cultural differences too considering the nationalities of the crew. This was also the crew’s first time together. Capt. Marcelo understood the importance of CRM and thus took advantage of the time available during the extended stay at Kolkata to get to know F/O Abraham better, both personally and professionally.
2. During this interaction, situational emergencies were discussed, including an emergency of engine failure after take-off at Kolkata.
3. The Captain immediately took over controls on encountering the emergency, with the F/O taking over the duties of PNF (PM). The F/O alerted the ATC with a PAN call, and carried out checklists as per the directions of the Captain.
4. The previous discussion of a similar situation helped the decision making process in this case, in terms of overweight landing and the other actions pertaining to the emergency situation.
5. Open cockpit communications helped optimize performance of both crew members.
6. Both crew members concurred on the engine malfunction before taking action.

CREW RESOURCE MANAGEMENT (CRM) AND THE AIRCRAFT COMMANDER

Formal CRM training started sometime in the 70s; the first being KLM that introduced a human factors training programme, based on the Edwards SHEL model and the trans-cockpit authority gradient. Accidents involving fully airworthy aircraft were perplexing the aviation community – the most notable example being the collision of two B-747s in 1977, while on the runway at Tenerife. Accidents like these were pointing towards the breakdown of crew co-ordination and communications between the cockpit crew. It was finally the NASA workshop of 1979 where the role of human factors in aviation accidents came in to sharp focus. Participants at this conference were convinced that formal training in crew co-ordination was required to reduce accidents due to human error. The origin of CRM (initially called Cockpit Resource Management and later changed to Crew Resource Management in recognition of the complex nature of aviation operations - where human errors, anywhere in the chain, can lay dormant for extended periods until an active failure at the hands of pilot leads to an accident) training is now universally traced to this NASA workshop of 1979. As more knowledge was gained on the subject the training has undergone many generational changes, from the first generation CRM to the present day sixth generation CRM, also called Threat and Error Management. CRM training is crucial for flight crew (besides for others too who are connected with aviation) as they are aviation’s last of line of defence to prevent an accident from happening.

 Amongst the flight crew, the Commander of the aircraft has been given the final authority with regards to the safety of the aircraft, and its contents, from the time he/ she assumes command until he/ she relinquishes the command of the flight. This is elaborated in Rule 141 of the Aircraft Rules, which states that “The Pilot-in-command (PIC) shall have final authority as to the disposition of the aircraft while he is in command.” The rule also states that the PIC “shall supervise and direct the other members of the crew in the proper discharge of their duties in the flight operations.” It further clarifies that “In addition to being responsible for the operation and safety of the aircraft during flight time, the Pilot-in-command shall be responsible for the safety of the passengers and cargo carried and for the maintenance of flight discipline and safety of the members of the crew.” This is indeed a very onerous task for any one individual, especially one who is flying above mother earth, in the third dimension. Why?

It is because the PIC is human, and has all the capabilities and limitations like any other human being. These capabilities and limitations have been studied by experts in the respective fields. These are required to be known by pilots to get any aviation licence, and pilots are also being tested for the same, before issue of the licence. ‘Human factors’ is the term designated by the ICAO for this important area of study by pilots (and lately by others like ATCOs, Maintenance too). This article is not going to go into details of the physiological factors like hypoxia, hyperventilation, decompression sickness, fatigue, sleep, etc. or the factors like illusions that most of the pilots are familiar with. The author has participated/ facilitated CRM training and always felt that the training mainly focussed on the ‘What’ and ‘How’ of CRM, after briefly telling the participants about ‘Why’ it is important for the aviation industry to have an even lower accident rate. It is the author’s view that if the CRM training focussed more on convincing the participants of the ‘Why’ it is important for the participants, then the person would be more receptive, and self motivated to listen to the ‘how’ and ‘what’.

This article will attempt to make a strong case for ‘Why’ CRM is important for any crew, and especially so for the Commander because it is the Commander who finally signs on to the task of undertaking a safe flight from A to B, with the help of the crew, of course. It seems simple and every Commander intellectually understands its importance, but this fact needs to be internalised and acted upon if we want to prevent accidents like the one at Mangalore, and others around the world, where in fully serviceable aircraft met with fatal accidents.

 It is a fact that with the new generation of highly reliable aircraft and engines, the major cause of accident is due to factors that are termed as human error. When an accident does[J1]  take place due to human error, it was found that the accident happened due to the active failure in the hands of the pilot, but a number of passive errors had happened at various stages in the life cycle of the aircraft viz., the design, manufacturing, loading, servicing stage, etc. or have been caused due to an error by the regulator, company management, ATC, dispatch or by the meteorologist. The other fact is that in some cases the PIC was the final person who could have prevented the accident from happening. A human error accident in the hands of the pilot is an acceptance by industry professionals that the accident could have been prevented; thus a human error (aircrew) is more appropriately a ‘pilot preventable’ accident. This brings us to larger questions – Firstly, Do human beings like to err? And the answer is ‘No’. Secondly, do humans err?  The answer is ‘Yes’. Think of the number of times one tries to open the lock with the wrong key, or punches in the wrong password. This implies that although no human likes to err, ‘to err is human’. This also implies that PICs, being human, are also prone to errors. Why?

Research in to the human brain has brought out a large number of limitations of the brain. The following are some of the important memory (storage and retrieval of information) problems that most human beings, including pilots, suffer from: -

• Absent mindedness – Forgetting due to lack of attention.
• Blocking – Temporarily forgetting – “did he clear us to land?”
• Transience – Forgetting information with time – “What is the Approach frequency…?
• Misattribution – Forgetting the source of the information.
• Suggestibility – Developing a false memory because of new information received during retrieval.
• Bias – Unconscious reshaping of memory due to personal beliefs or mood.
• Persistence – Negative distortion of a memory of a traumatic event.
• Memory changes – Memory changes from person to person, and also within the same person due to reasons like physical & emotional health, stress, quality and quantity of sleep, diet and age.
• Inattention blindness - Attention resources are very limited and it is a known fact that things to which we are not paying attention to are not perceived; more importantly if we are devoting attention to one task, then we may not have adequate attention resources for other maybe more important primary tasks – fixation – a cause factor in many aviation accidents. Inattention blindness is affected by the following  factors:
• Conspicuity – All warnings in the cockpit are designed keeping this in mind.
• Mental workload and task interference
• Low workload and the effects of automation – Low arousal; low performance.
• Limited processing capability of the brain as compared to large acquiring capability of the five senses. In aviation eyes, ears (hearing and vestibular apparatus) and seat of the pants are the most relevant sense organs. For example in the human visual system, the amount of information coming down the optic nerve is estimated to be in the range of 10 million bits per second. This far exceeds what the brain is capable of fully processing and assimilating; about 16 bits/ second (max 40 bits/ second). Guess why two people looking at the same scene would pick up different images – this is primarily based on what is being paid attention to by each of them.
• Limitations (in terms of time, and capacity) of the working memory (like the RAM in the computer) in humans.

These severe limitations of the human information processing mechanism would convince any human about what he is up to when he/ she is interacting with the outside world and trying to make sense of what is going on, or in aviation parlance when he is trying to get and remain situationally aware.

This already difficult situation becomes even worse when the same set of information is to be processed under time constraints, like in a non-normal or unanticipated situation in the air. Being situationally aware at all times is very important for a crew primarily because without being situationally aware it would not be possible to take the right decisions every time. Poor situational awareness leads to bad decisions; a situation that is detrimental to the task at hand – of ‘flying the aircraft safely and efficiently from one place to another’ – the primary task of the PIC. How do we ensure that we are situationally aware at all times, or regain situational awareness at the earliest, if it is lost due to any reason?

This requires the application of crew resource management – “the effective use of all available resources: human resources, hardware, and information.” The PIC is the final decision maker in the air, but knowing his/ her limitations, he should be the one who makes all efforts to use all available resources to become situationally aware, and there after go on to making the right decision. This sounds simple and logical but a glance through the history of aviation accidents/ incidents would be able to convince any pilot that this is not so. The reasons are many. The reasons could be attributed to the way in which an average human grows up in this world – our formative years in school where we are taught to excel as individuals and compete with each other to stand first in class/ sports etc. The same pattern continues through college, and life there after – our individual successes are celebrated. When we enter aviation, our first solo is the most celebrated event, and solo flights are cherished by ‘real pilots’. ‘The individual is required to be competitive, and is complete’, is the message that life has given us thus far. Even our traditional checks and proficiency testing in aviation are done on an individual basis – testing is of our skills as individual pilot’s (a column for CRM has also been added to the check proforma to assess the pilot’s CRM behaviour). The early pilot’s with the leather jackets, white silk scarves and glasses is the macho image of a pilot, which even today is ingrained in many individual pilot’s minds, some of whom have never been close to a fighter. The author flew single seat fighter aircraft for over two decades and can vouch for the fact that he always felt complete – missed out a few checks here and there; made approaches on the wrong runway; had ‘action total’ on first solo; miscalculated fuel in the air while doing low level navigation, etc. Single seat fighter flying accepted a certain amount of risk due to the nature of the task, but commercial aviation is required to be safe, and risk free. Commercial pilots have to work with a different mindset where the aim safe and efficient flying has to be kept paramount.

Commercial pilot’s need to be convinced about using CRM techniques, if we wish to better aviation’s accident record. The rapid growth in aviation, leading to a larger number of departures, in the coming years would lead to larger number of accidents, if nothing is done to bring down the accident rate/ million departures. The accident rate in commercial aviation has been brought down substantially over the years, from the 1950 – 60s, due to the move from  reciprocating engines to the more reliable jet engines as a means of propulsion,  and due to usage of better technology. However, the accident rate has stagnated at a low figure over the past few decades – it has refused to reduce any further. The major cause of accidents is now human factors. Aviation’s greatest challenge is to tackle this cause factor if we wish to reduce the number of accidents, with the growth of aviation. The most significant contributions to reducing human error accidents can come from internalisation of CRM techniques by the pilot community, because the pilot is the last line of defence of preventing accidents in the aviation system.

Being situationally aware in terms of our location, spatial orientation, environment, aircraft systems, time and fuel requires all inputs that are available to the PIC. It has been found in many accidents that the accident happened in the hands of a situationally unaware PIC, when he was the PF, even though other crew members were situationally aware – the Mangalore accident is our own case in point. What this implies is that the whole crew should be on the same page and there should be no unresolved issues in the cockpit. It is not the PF who causes an accident; it is the entire crew. Accidents happen because either the PIC does not ask for, or permit (through verbal or non verbal communications) free flow of relevant information between the crew, or the crew does not share the relevant information due to reasons that are part of being human. You can be disrespectful/ rude to a machine and it would even then give you the right information if you have pressed the right buttons and controls, but humans are different – we are emotional beings. Emotions are facts as far as humans are concerned. Our life should convince us that emotions always matter. Other reasons could be: a human may feel that the other is aware; knows every-thing; or the other does not need to be told as he is so experienced; or a plain ‘I am not OK, you are OK situation’; or ‘why should I tell him’ he is responsible for his actions. These may be false assumptions, as has been brought to light in a number of aircraft accident/ incident investigations.

Similar to situation awareness, the PIC needs all the inputs to make a correct decision – two heads are always better than one; time permitting though. There may be times when there is no time available and the PIC would then need to take a decision, as he deems fit based on his training and experience. However, when time is available it is best to solicit opinions on the problem; options; pros and cons of each option before taking a decision. Each of these should be weighed in terms of ‘what’ is right, and not ‘who’ is right, under the given set of circumstances. After the decision has been made; and responsibilities assigned to implement the decision, it should be reviewed, and the same process of decision making (DODAR) should continue. This sounds simple but how do we ensure inputs from all sources? This can only happen by empowering the crew.

It is the PIC’s responsibility to empower the crew by facilitating the formation of a team at the earliest opportunity provided. This seems difficult but is actually not so. All crew members on the line are trained, licensed, and proficient to do their jobs well. However, it should be remembered that proficient individuals do not always make competent teams. Our cricket team brings this out clearly. It is the responsibility of the leader, the Commander, to turn these competent individual crew members in to a competent team. The team members are technically qualified, trained and proficient to undertake the flight, and contribute to the task of a safe flight. However, it is the human aspects that need greater attention by each and every PIC before, during, and after the flight to ensure optimum performance from every crew member. A study of past accidents/ incidents points towards a deficiency in this area.

Just thinking of the co-pilot as a ‘Second in Command’, and the cabin crew as additional ‘eyes, ears and brains’ that are available, would help the PIC in finding better ways to making optimum use of all the available human resources within the aircraft itself. In addition, there are other human resources available too via the Radio Telephony. This suggested way of thinking subtly implies that the PIC needs to internalise the fact that each one of his crew in the aircraft, besides others who are outside the aircraft, are making vital contributions to the accomplishment of the common goal of safe flight from A to B, while being assigned seemingly different roles. The contribution of the crew towards the achievement of the common goal should be emphasised, valued, and acknowledged during the first meeting of the crew at the reporting point itself through appropriate behaviours and communicated through words, tone, and body language, so as to create an effective leader/ team relationship.

Research has shown that high performance Captains use three methods to build an effective leader/ team authority relationship. They establish their capability to assume the legitimate authority bestowed on them through law, by establishing competence through a well organised and logical briefing about the specific task at hand – each flight may follow the same routing, but no two flights can ever be the same. Having briefed, they balance the leader/ crew relationship by having the crew members take responsibility for the work of the group as well – this is an important element to empower the other crew members. One Captain is known to have made this statement before an extremely effective crew performance in the simulator: “I just want you guys to understand that they assign seats in this airplane based on seniority, not on the basis of competence. So anything you can see or do which will help out, I’d sure appreciate hearing about it.” Lastly, these Captains interact with humans (emotional beings, unlike robots) who would be filling in different roles on the flight. Crew were encouraged to converse and made to feel comfortable, particularly when conversation was related to the task at hand. Questions and comments were encouraged by all crew members on any aspects of the briefing/ task. By doing this, these Captains had set an authority pattern ranging from the authoritative to consultative, to participative and finally to the democratic. This is what balances the need of a single authority responsible for the safety of the flight with the contributions of all crew members to achieve a safe flight. It is important for the PIC to understand the role of verbal and non verbal communications in the accomplishment of the task. Effective communications before (in the form of a briefing), during (inquiring if something is amiss/ not as planned; advocating one’s own professional opinion, with reasons; etc.), and after the flight (a thorough critique is essential for learning/ team building and growth) is crucial towards effective team work on the aircraft. Effective communications is more likely to result in a situation where the crews are empowered.

The regulator and the company management empower the crew by laying down rules, SOPs and checklists that are required to be followed. The PIC can empower them further by providing them the right leadership, through effective communications, and by communicating, and more importantly by following all laid down SOPs and checklists. As has already been brought out, the leadership style utilised by the PIC would vary from Autocratic (in time critical situations) to Consultative, to Participative, to Democratic. However, it should always be borne in mind that this does not absolve the PIC of any of his responsibilities as laid down by the law. The law gives the PIC the authority, but he needs to earn the respect of his team members by his behaviour. A PIC who respects the others will be respected by the others. The formation of the team starts the moment the individual crew members start assembling at the reporting point.

The Captain must lead by example by following all checklists, laid down procedures and SOPs so that all crew members are on the same page, and know exactly what is being done, and what needs to be done at each stage of the flight. This helps the crew to identify, and point out deviations from the normal, which could be unintentional. Following the Captain’s lead, other crew members would be less tempted to resort to violations or the intentional disregard for laid down procedures. Sterile cockpit procedures are one such procedure that has been violated on a number of flights that have met with accidents or incidents. Sterile cockpit needs to be observed so that our single channel processing brain does not get distracted from the task at hand during crucial phases of flight. The Captain sets the tone for this, and is also responsible to ensure its sanctity by disciplining non conforming crew members.

The workload in the cockpit keeps varying on different crew members during different times/ flights. Workload management is one of the key responsibilities of the Captain. He must ensure that the work load is evenly distributed and that no crew is over or underworked – both situations lead to a drop in the arousal levels and in turn affect the processing capabilities of the brain. High workload leads to stress and fatigue, and its attendant problems, whereas under load leads to boredom, sleepiness, and loss of attention. Low workload situations are encountered during auto-pilot cruise on long flights. The Captain must ensure that the crew continue to monitor the systems for correct functioning. Even when the aircraft is on autopilot, the PF is responsible to ensure that the flight is on the desired trajectory and the systems are functioning as designed. The PM (PNF) must monitor any changes, even when engaged in non critical activities like flight plan, tuning, communications, etc. The standard dictum of flight prioritisation viz., ‘Aviate, Navigate and communicate’ should be followed.

High or low workload, it is a known fact that a highly motivated individual performs better under all conditions. Motivating pilots is relatively simple because most love their job – it is easier to motivate an individual who loves his job, as the motivator is in the job content itself. The Commander should try and provide opportunities for the crew to grow, of course within the laid down regulations. This is very motivating for the crew and the performance of the team improves. Mentoring a relatively inexperienced crew member pays rich dividends in terms of motivation and job satisfaction for both the mentor and the mentee.

Having gone through this paper, one is tempted to ask, “So what is CRM?” It is nothing but understanding that aviation is a complex system; we are human in that our physical, physiological and psychological performance keeps changing and that our information processing system has serious limitations (specially under time critical situations); that humans are emotional beings; that we need all the help possible to fly safely from A to B; that it is humanly not possible to do things by ourselves and that other crew members can be a big help, but would need to be led, motivated, involved to bring out their most optimum performance. Past accidents provide evidence that technical competence is an important requirement, but not the only requirement for safe operations; interpersonal and cognitive (information processing has severe limitations, especially under time critical situations) functions also have to be integrated in to flight operations to achieve a safe flight.

Finally, CRM is a concept that recognises the critical role of human factors in determining the effectiveness of technically proficient crew in both normal and non normal situations and gives one a practical approach which can help in an attitudinal/ behavioural change so that competent individuals can come together to form a competent team.

How does one recognise a competent team from just a technically proficient team? A competent team is one that can operate a safe and efficient flight from A to B, and also terminate the flight with the crews deriving satisfaction from working as valued professional members of the team, and also with a readiness/ willingness to perform together as a crew in the future.

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 [J1]

AERO INDIA 2009

Aero India 2009 is being held at Air Force Station Yelahanka from 11 Feb - 15 Feb 2009. I visited the air show today and had my fill of nostalgia when I watched the powerful fighters defy gravity and create myriad patterns in the sky trying to impress the aviation professionals with a display of their performance. I watched the Eurofighter, the F-16IN, the F-18, the Su 30, the MiG 35 fighters perform with their after burners thrusting them forwards at low, and high speeds through various pre planned manoeuvres. I must also confess that I last flew the Jaguar in Sep 1992, but the sound of the afterburner lighting up and thrusting the aircraft forward gave me goose bumps even today. It is not only the sound of the burner but the sight of the man-machine combination on display that gives one the feeling of how the pilot inside has become one with his machine and the two are performing pure magic for the crowd of spectators below. Wow......enough of this or I will go on and on.

The Sarang helicopter display team in their Advanced Light Helicopters gave a fitting display of their and their helicopters prowess. This was the easiest to capture in my primitive digital camera.... and so there are more photographs of this team. The fighters were too fast and small for me to capture with my camera. Anyways, here are my photographs of Aero India 2009. The two aircraft that I have flown of the aircraft on static display are the Harvard and the Jaguar. The Su 30 with the national flag painted on it just looked superb. Click on the image to get a better view. Happy viewing, though I am not too happy with the results. Next year will be better.....I plan to get a better camera.

CHENNAI TO TORONTO

I do all my air bookings at Makemytrip.com, because I find the site is easy to navigate, user friendly, and reliable. I always find something new everytime I visit the site and it is always something that i had felt would help the person using the site to book tickets. This time too I used the site to book the air tickets for my wife and self for our journey from Chennai to Toronto.

My wife was booked by Air Canada from Chennai to Toronto and back. Just a month before her scheduled departure, I was shocked to see that her itenerary did not exist on the website. I called Makemytrip on the landline and was informed that Air Canada had cancelled their flights to Chennai - maybe because of the economic slowdown and low traffic. I was very upset at first but must now give credit to Makemytrip.com for booking her on Lufthansa on the same ticket, at the same good price that I had got on Air Canada.

I was booked on Emirates from Chennai to London via Dubai and on Air Canada from London to Toronto. I have a frequent flyer card for Emirates and admire the professionalism of this airline everytime i travel by it. Both the flights, from Chennai to Dubai and Dubai to London departed on time. The check in and other formalities were perfect. The service on board was very good and the latest aircraft ensured that we had good inflight entertainment during the journey. Dubai is always a treat to watch. A small sheikdom transforming itself into a major tourist and business destination. Dubai airport puts nearly all Indian airports to shame. Emirates, along with the other Gulf airlines like Qatar, Air Arabia, etc., are slowly but surely eating into the market share of the Indian carriers. Can our government stop this from happening by having market friendly policies?

Air Canada from London to Toronto was professional, but the service was not as good as Emirates. I guess most people working for Emirates are on a work permit that can be cancelled at any time, and that helps the Emirates bosses to keep employees on their toes. This is not to belittle the professionalism of Emirates but to put things in perspective.

ROLE OF CABIN CREW IN CIVIL AVIATION

“One can’t make a career of serving orange juice with a smile. The in-flight crew soon realizes that” is how Ashutosh Upadhyay, a person who runs a placement agency ‘The Headhunters’ sums up the job of cabin crew in today's Times of India (After Pink Slip - 27 Oct 2008). I believe this is not only the perception of Mr. Upadhyay but nearly every one who travels, or thinks, about air travel. The cabin crew’s job is considered to be that of a glorified server. This is misleading, and may only be partly true. The truth is……

The cabin crews are professionally trained flight crew whose carriage is mandated by regulations across the world. The aim of these regulations is to assist the Captain in providing safe transportation to the passengers while they are on board the aircraft. The aircraft is a very sophisticated piece of machinery and is very reliable, but can have problems like any other machine – the only difference being that this machine is in the third dimension and in a very hostile environment too. Sitting in a pressurized cabin gives one a false feeling of security, as the cabin is maintained at settings that are comfortable for people. This can change any minute. Although the probability of this happening is very low, the possibility always exists. Imagine what can happen to a person exposed to the extreme temperatures and pressures at the flight altitudes.

The regulations lay down the minimum number of cabin crews that are needed to be on board based on the number of seats, not the number of passengers. This is to err on the positive side, keeping passenger safety in mind. In case you have not perceived this earlier – it is the cabin crew’s job to apprise all passengers about the safety precautions while on board. Most people ignore these briefings by the cabin crew, although it is vital for the passengers to be familiar with all of them like belt locking/ unlocking, use of emergency oxygen, actions on take-off/ landing, position of emergency exits, actions on crash landing/ ditching etc. Emergencies do not come announced. So it is best to be prepared and listen to the safety briefings by the cabin crew.

The cabin crew’s job does not finish with just the briefing. They have to ensure that the briefings are complied with so that the safety of passengers is not compromised. Have you ever noticed them going around checking that your seats are upright and the table folded during take off and landing and that there is nothing obstructing the pathways. Most mishaps happen during these two phases of flight and thus these are extra precautions that are taken by the cabin crew.

In case there is an in-flight emergency the cabin crews are trained to fight fires, administer emergency oxygen and any other assistance that may be needed. They are also required to check on the health of the cockpit crew, so that the flight can be conducted without problems.

Once these primary functions of the cabin crew are over, they become the more visible part of the customer service process of the company they fly for. Aviation is also a service industry and thus it is this service that gets highlighted with fare paying passengers. These are secondary functions but have a higher visibility, and thus the perception of most people.

So next time when you travel please try and see what the cabin crew do during the flight.

AVIATION INDUSTRY AND THE LOW COST MODEL IN INDIA.

Phufff......... what news about the aviation sector in the last few days???!!!!

Jet Airways laying off 1900 employees. King Fisher will lay off in the near future. Air India asks 15000 employees to opt for voluntary 3 - 5 years unpaid leave. Spice Jet cuts fares for advance bookings by 15%. Paramount is giving half page advertisements in the newspaper about flights to Ahmedabad from all major regional South Indian cities, via Chennai. King Fisher sells off 3 A340s to Nigerian Airways, defers other orders. It is learnt that Spice Jet is handing over only one way tickets to the expat pilots going home, as per terms of contract, having laid off 30 pilots some time back. Praful Patel wants to bale out the private airlines with some sops - Petroleum and Finance Minister not playing ball. Vijay Mallya is looking for a Rs. 5000 crore interest free loan for 2 years for the airlines. Couple of days back Gopinath had volunteered to buy back and run Air Deccan again. He backed off yesterday, after meeting with Dr. Mallya. So, what does all this mean?

Well only one thing: that the aviation sector which did a vertical take-off a few years ago is ready for a crash landing - and also that I do not need to be an astrologer to forecast this. Are there any options in these troubled times for the global economy in general, and the global airline industry in particular - an industry that can only thrive in times of excess discretionary surpluses with businesses and individuals. This seems very distant in the present context. Will the low cost airlines survive or would they be consumed in the Jet-King Fisher tie-up?

As per me, low cost in India can only survive if they cut costs and reduce ticket prices, as we Indians are very value conscious. Revenues will only increase if the Indian traveller sees value in travelling by air. Time is still not a premium resource for most of us, as yet. I believe we would pay about 1.5 times of the AC-2 tier fare to travel by air if it cuts the journey time substantially - like say Chennai - Delhi. Otherwise we would plan to travel by Rajdhani Express. How do the low cost carriers cut costs? Maybe switch to ATRs with seating of 45 - 70 seats and hop across doing Chennai - Delhi, via Hyderabad, Nagpur and Bhopal (depending on market survey, of course). I do believe that Tier 2 and 3 cities can provide number of seats per day to any metro city.

We cannot replicate the North American model in India. India has a very large rail network which is reasonably well served, unlike North America. Indians are very value conscious, unlike the Americans. The low cost airline target customers are the ones travelling by AC-2 tier, and maybe AC-3 tier - stretching things a bit here though. I am a great fan of the low cost model - a model that gave an opportunity to ordinary Indians to travel by air, a model that broke the hierarchical structure of Indian society by selling tickets for ridiculous prices. I want the low cost model to survive this down turn. How???????

Any ideas any one??

'GM' OF INDIAN AVIATION!!

GM (G for Goyal and M for Mallya) - I found this description very amusing. However, this news does not augur well for the low cost airlines and for Air India. In case Jet and King Fisher decide to come together (full details of the tie-up is not yet available) then it would definitely sound a death knell for the low cost carriers, for sure, i.e. if they donot come up with some innovative solution to this latest challenge thrown at them. Air India may survive depending on how long the tax payers can continue to bale them out. Both Goyal and Mallya are businessmen and would find ways to reduce seats to just match demand at the prices that make business sense.

King Fisher has already sold three of its Airbus 340s to Nigerian Airways and has opted to defer its international operations, that were launched with great fanfare. Waiting for more details on the deal.......till then, hope and pray that 'the low cost dream ain't over' yet.

SPICEJET - CHENNAI TO DELHI AND BACK.

SpiceJet B737-900ER in flight

I was on leave for a week, for the week ending 12 Oct 08. I travelled to Chandigarh and back - Chennai to Delhi by Spicejet, and onward by Shatabdi Express. Return followed the same pattern in reverse order.

I was booked to travel by Spicejet on 05 Oct 08 for the Chennai - Delhi sector for a scheduled departure time of 0540 hrs. The baggage X-ray, check-in, and the drop to the aircraft went as per plan and was done very professionally. The door closing was dot on time. The aircraft and the passengers looked well cared for, and the journey was uneventful.

Flare at Delhi

Totally impressed with the service of this low cost carrier. However, the occupancy figures were extremely distressing. I am a great fan of the low cost model and do not want good low cost carriers like Spicejet to fold up, but if the occupancy remains at the distressing 50 - 60 seat occupancy in a B737-900ER, then it is just a matter of time.

Just after touchdown at Delhi

I travelled the return leg from Delhi to Chennai also by Spicejet, departing Delhi dot on schedule at 0615 hrs. Everything from baggage X-ray, to check-in, to the drop at the aircraft were perfect. The occupancy this time was relatively higher. This airline should, and deserves, to survive...I would pray for that.

I would recommend this airline to anyone wanting to travel in a low cost carrier.

BAD NEWS FOR THE AVIATION SECTOR

The state of the global economy, the rise in the price of crude, the dropping profit margins of companies, and the notional drop in the asset prices of individuals has had its negative effects on the aviation sector globally and in India too. Aviation is the first sector to be hit when there is financial insecurity and the notional prices of assets like real estate and equity plunge. All our airlines are bleeding and loosing large sums of money even after the drive to cut flights and get the supply of seats in line with the demand.

The newspapers this morning reported that Kingfisher is cutting jobs, mostly employees of the erstwhile Air Deccan. Kingfisher has also deferred the planned delivery of their aircraft. Jet Airways is also cutting jobs, again mostly employees of erstwhile Air Sahara. Spicejet had already decided to delay induction of new aircraft and have been in the process of leasing out some of their available aircraft. They had laid off 30 pilots sometime back and are now giving a one-way ticket to their expat pilots proceeding to their countries. Go Air had already cut back on flights and aircraft. There is no news on Indigo in the open press and so it is very difficult to fathom what is going on there. However, they could not be in any better state than the others. Air India has had huge losses and has asked the government for a bailout.

Situation looks very fragile. Kingfisher has asked the government for permission to import Aviation Turbine Fuel (ATF) as the prices in India are way too high compared to other countries in the world, due primarily to our tax structure. Hopefully these measures would help the airlines cut some of their losses. Returning to profitability though may take some more time and depends on when companies and individuals feel secure and start to travel by air again, at the new ticket prices that are substantially higher than the ticket prices that had been prevailing for the past few years. Airlines will have to look for newer and more innovative ways to increase revenues and cut costs, just to stay solvent. Any ideas????? Two areas that readily come to mind are, one, the MRO business and secondly, the training business. Instead of laying off surplus staff, some of the airlines have the capability to run these complementary businesses. These are businesses that are evergreen as long as there are aircraft flying around. India can operate these businesses cheaper than the other countries, as our manpower in the present circumstances would come at a much lower cost.

HUMAN LIMITATIONS - CRM AND ERROR MANAGEMENT

Basics about the Cockpit

In aviation, the Captain has been assigned a very important position. He is the designated leader, and is given the legal authority for the flight. He is responsible, along with his crew, for the safe and efficient operation of the flight. His decision under most normal conditions of flight is final. However, he may take the help of all available resources to arrive at the final decision, as he may not have the full picture, at all times. He is also responsible for crew performance, directing actions of the crew and can ask for assistance of any crew member. The First Officer (F/O) is a qualified crew member who has the education, training, and skills and as some one rightly put it ‘he is like a second in command’ who can take over as Captain in the event of incapacitation of the Captain. This is an important point. However, depending on his experience and personality, the F/O may not be able to handle all situations like the Captain but would be competent to handle all probable situations in flight. With these basics, let us analyse the worst case.

Human Limitations
It must be understood that both the Captain and the F/O are human beings and that their performance is susceptible to all human limitations. These include being prone to loss of situational awareness, stress and fatigue; having an attitude and perceptual problems. Other problems may include limitations in the application of knowledge, exercise of judgment, short term memory (working memory, which is akin to the RAM in a computer) overload, and finally incapacitation. Also, we are all familiar with the saying that ‘to err is human’. This saying will continue to be true as long as we human beings have limitations. However, in aviation – a profession that is very constrained by time; is highly stressful; has complex processes; and which is closely scrutinized the media, regulator and public, we can ill afford to have human errors, as these errors can be fatal, and have been so in the past. Human errors are defined as ‘the unintentional act of performing a task incorrectly which can potentially degrade the system’. Errors can include problems in practice, procedures, and systems. Human error has been a major contributor to incidents/ accidents in the past. Here it also needs to be emphasized that accidents do not generally happen due to a single factor. They are a culmination of a ‘chain of events’ of small factors. The aircrew is the last link in this chain that can prevent these errors from turning into incidents/ accidents. To prevent these incidents/ accidents, the crews need to be aware of error management.

Error Management
Error management can be best accomplished by ‘Error Avoidance’. In case this is not possible then the next step would be ‘Early detection’. Finally, in case the error has been detected late or not detected, then steps have to be taken to ‘minimise the consequences’ as a result of these residual errors. Let’s take an example to understand this process. We have been cleared for a radar vectored ILS approach for R/W 28 at Delhi. The local QNH is 983 hpa and the weather is Rain/ Thundershowers with low clouds at 300ft. We are descending through transition level, and about to change the altimeter setting when the TCAS warning goes off. You are put off for a while, and forget to change your altimeter setting to local QNH with the result that you are now flying 900 ft. below the required altitude. An error has been made. This could have been prevented if the crew had remembered to call out the QNH changeover, after the excitement about the TCAS had been resolved. Once this error has been made, the next option is to detect it at the earliest. This can happen when the PF calls for the completion of the approach checklist. The next checkpoint would be when the radio altimeter is called out and altimeter cross checked. The next stage would be the callout at the Outer Marker, followed lastly by the Landing checklist. In case this error goes undetected then it would be vital to mitigate the consequences of this error by initiating go around at the Decision Altitude, if there are no visual references to land. This is a very mild example of an error and the three step process to prevent incident/ accident. The PNF (PM) by just doing his job of giving the callouts at the correct time would help in neutralizing the error. In an actual case the error could have been introduced by any component of the aviation system involved with the preparation, launch, execution and recovery of the flight. In such cases it may be very difficult, at times, to prevent the error and equally so to detect the error. A 2-crew operation can help in such cases. Our checks, callouts, and procedures have been designed with an aim of detecting and neutralizing errors before they can become problematic. The 2-crew cockpit has the inherent advantage of built in redundancy. It also helps in workload sharing and in ensuring constant crosschecking and monitoring of all actions (by both crew members); monitoring of aircraft trajectory; automation systems and mode status; and aircraft systems and components. To ensure all of this, it is vital to practice CRM. The major rationale for CRM is to enhance crew co-ordination and through this ‘to reduce the frequency and severity of errors’, or error management. Error management can be further enhanced by optimizing human performance in the here and now. What is CRM? NTSB defines CRM as ‘using all available resources – information, equipment and people to achieve safe and efficient flight operations’

GARUDA INDONESIA ACCIDENT ON 07 MAR 2007 - FACTS AND CAUSE

Relevant Facts leading to the accident
On 07 Mar 2007, Garuda Indonesia flight 200 was being operated on a domestic flight from Jakarta to Yogyakarta (Indonesia). The PIC was also the PF. The PIC intended to carry out an ILS approach to R/W 09 at Yogyakarta, and had briefed for the same. ATC cleared the aircraft for a visual approach, with a requirement to proceed to long final and report runway in sight. Although the crew acknowledged the visual approach clearance, they continued with the ILS approach, without informing the controller. Descent and approach were carried out in VMC. At 10.1 miles (initial fix) from the R/W, the aircraft was at 3927 feet (against an altitude of 2500’, as published in the approach chart) at a speed of 283 kts. The PIC intended to make the FAF (6.6 DME) at the correct altitude and thus carried out a steep descent. This did not permit the speed to wash off at the anticipated rate (a tail wind at this altitude also added to the problem). Speed brakes were not selected. He was aware that it was difficult to make the FAF correctly. Flap 1 was selected and thereafter gear was selected down. The PIC called ‘Check speed, flaps 15’. The copilot called ‘Flaps 5’, as the speed was beyond the flap 15 speed of 205 kts. Flaps 5 were selected. The PIC called for ‘flap 15’ twice but the copilot did not select flap 15 as the speeds were beyond the limits. The PIC called ‘Check speed, flaps 15’ again but the copilot did not select flaps as the speed was beyond 240 kts. Also, he did not apprise the PIC of this fact. During the approach the GPWS alerts and warnings sounded 15 times, and the co-pilot also called for a go-around. The PIC continued the approach with flaps 5, and the aircraft attained glide slope close to R/W 09 threshold. The PIC asked the copilot if the landing checklist had been completed, to which he received no response from the copilot. The aircraft crossed threshold at 232 kts (98 kts faster than the flaps 40 landing speed). Ground speed was 235 kts. The aircraft touched down at 221 kts, bounced twice before settling on the runway. Shortly after touchdown, the copilot called for a go around. The PIC selected thrust reverser and continued with the landing. The aircraft overran the R/W, to the right of the centerline at 110 kts. The aircraft crossed a road, and impacted an embankment before stopping in a paddy field 252 metres from R/W 27 threshold. The aircraft was destroyed by the impact forces and post impact fire. 119 of the total 140 occupants survived the accident.

Causes
1. Flight crew communication and co-ordination was less than effective after the aircraft passed 2336’ on descent after flap 1 was selected.
2. The PIC flew the aircraft at an excessively high airspeed and steep descent during the approach. The PIC did not go around when stabilized approach criteria were not met.
3. The PIC did not act on the GPWS warnings, and the two call outs by the copilot to go around. (The PIC was 'fixated' on landing the aircraft - was responding to only one stimuli when there were a host of other stimuli seeking his attention. Happens under stress)
4. The copilot did not follow company instructions to take over control of the aircraft when he saw that the PIC repeatedly ignored warnings to go around.
5. Garuda did not provide simulator training to its B737 flight crews covering vital actions and required responses to GPWS alerts and warnings.

ADAM AIR ACCIDENT ON 01 JAN 2007 - FACTS AND CAUSE

Relevant Facts leading to the accident
On 01 Jan 2007, a B737-400 of Adam Air with 102 occupants on board went missing while on a domestic flight from Surubaya to Manado (Indonesia). Last contact with the aircraft was at 14:07, with the flight at FL350. Reports indicate that the flight changed course twice as a result of severe (70 kts) cross wind. The aircraft crashed into the sea killing all occupants. The FDR and CVR were finally recovered from the sea on 27/ 28 Aug, 2007.

Analysis revealed that the autopilot was engaged and was holding 5 deg. left aileron wheel to maintain wings level. Inertial Reference System (IRS) had malfunctioned. Both pilots had become engrossed with trouble shooting the IRS for at least the last 13 minutes of the flight, with minimal regard to other flight requirements. The pilots could not trouble shoot the problem and finally selected the IRS to Attitude. This action disengaged the autopilot, as per design. The auto pilot disengage warning was silenced after 4 seconds but it appears that no pilot was flying the aircraft. After the autopilot disengaged, the control wheel centred and the aircraft began a slow roll to the right. The aural alert, Bank Angle, sounded as the aircraft exceeded 35 deg. bank. The roll rate was momentarily arrested several times, but there was only one significant attempt to arrest the roll. Positive and sustained roll attitude recovery was not achieved. Even after the aircraft had reached a bank angle of 100 deg, with the pitch attitude approaching 60 deg nose down, the pilot did not roll the aircraft to wings level before attempting pitch recovery. The pilots appeared to have become spatially disoriented. Control was thereafter lost; the aircraft had a significant structural failure, and crashed into the sea. The aircraft had recorded a max of 3.5g/ 0.926M/ 490 kts.

Causes as per the Investigation

1. Flight crew co-ordination was less than effective. The PIC, who was also the PF for this segment, did not manage the task sharing; crew resource management practices were not followed.
2. The crew focused their attention on trouble shooting the IRS failure with neither pilot flying the aircraft.
3. After the autopilot disengaged and the aircraft exceeded 30 deg. right bank, the pilots appeared to have become spatially disoriented.
4. The company’s syllabus did not cover complete or partial IRS failure.
5. The pilots had not received training in aircraft upset recovery, including spatial disorientation.

Other Causal Factors

1. 154 recurring defects directly or indirectly related to the IRS between Oct and Dec 2006.
2. Poor Maintenance engineering supervision and oversight.