ANALYSIS OF SERIOUS INCIDENT- B 737-800 AT COCHIN ON 18/08/2015

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

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

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

Situational Awareness and Decision Making.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CRM.

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

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

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

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

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

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

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

Lessons Learnt.

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

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