Analysis of Serious Incident B 737-800 at Cochin, Trivandrum on 18 Aug 15
On 17/08/2015, Boeing B737-800 aircraft was scheduled to operate sector Doha-Cochin. Both the operating crew were duly qualified on type B737 aircraft to operate the flight. There were 142 passengers and 08 crew members on board the aircraft. The flight departed Doha at 1940 UTC and was uneventful until top of descent into Cochin. At the time of departure from Doha, weather of Cochin, Bangalore, time 0900 UTC only was available with the crew.
Sequence of Events.
The aircraft came in contact with Cochin ATC at time 2300 UTC and the weather reported by ATC was visibility 3500 meter haze, few clouds at 1500 ft and scattered clouds at 8000 ft.
The aircraft arrived overhead Cochin at time 2348 UTC with 4844 Kgs of fuel on board. ATC cleared the aircraft for ILS approach Runway (Rwy) 27.
The visibility requirement was RVR 650m and the DA was 320 feet. During approach, the flight crew was not able to make visual contact with the runway due to low clouds and initiated a go-around at 256 feet by pressing TOGA at around 2358 UTC.
After the 1st go around, fuel on board was 4699 Kgs and the Minimum Diversion Fuel (MDF) for designated alternate destination Bangalore was 3306 Kgs.
Thereafter the PIC followed the missed approach procedure and joined the holding 3 pattern overhead Cochin. ATC cleared the aircraft to proceed outbound for the second approach ILS Rwy 27 during which the crew discussed the alternate fuel requirements for Coimbatore and Trivandrum also.
The F/O advised the Captain that at Trivandrum, only VOR Approach is available as ILS is not available. The Captain responded that Trivandrum reported visibility is 3000 meter and is adequate to carry out the VOR Approach in Trivandrum.
While the aircraft (555) was heading overhead Cochin to proceed outbound on the second approach, Air India Express B737 aircraft operating flight 474 which was ahead of 555 executed a go-around and had reported low clouds at 600 feet and broadcasted that the visibility has dropped to 2500 meters.
555 continued for 2nd approach and again on reaching DA did not sight the Runway and executed the 2nd go-around at 0017 UTC.
The fuel on board after 2nd go-around was 3919 Kgs, and the MDF for Bangalore was 3306 Kgs.
After following the missed approach procedure, 555 joined the holding pattern overhead Cochin again and the crew discussed to re-designate Trivandrum as the alternate destination in order to gain more holding time over Cochin.
The F/O expressed concern about the possibility of visibility dropping further due Haze. The Captain responded that in case of emergency they can ask for Coimbatore as it is a closer airport to Cochin. However the Coimbatore weather details was not obtained by the crew of 555.
ATC was advised by 555 about re-designating of Trivandrum as the alternate destination Aerodrome.
Thereafter ATC instructed 555 to join the holding pattern over Cochin. As 555 entered holding pattern, another aircraft, Kuwait 329 executed a go-around on ILS approach Rwy 27 Cochin due being unable to sight the runway.
Subsequent to Kuwait 329 go-around, ATC broadcasted latest visibility of 2000 m, with low clouds reported scattered at 400 feet.
Air India Express flight 474 informed ATC that reported visibility at Trivandrum is 3000 m and requested Cochin ATC to confirm with Trivandrum ATC if there were any reports of low mist, haze, or go-arounds at Trivandrum.
Thereafter Cochin ATC broadcasted to all stations “Trivandrum visibility is 3000 m and clouds at 1500 feet”.
Cochin ATC informed 555 that trend is reducing visibility and requested for their intentions. 555 intimated ATC that they would like to make another attempt and if unsuccessful, they will divert to Trivandrum.
ATC gave 555 the option of trying an approach for R/W 09, the PIC asked for the visibility or RVR value for R/W 09. ATC intimated them that no RVR was available for R/W 09, so the PIC decided to continue for an ILS Approach R/W 27.
Further ATC gave a weather updates to 555 that “tempo visibility reducing to 1500 m in mist and low clouds now at 400 feet” and advised 555 that in case of missed approach “turn left to intercept 180 radial Cochin and climb to 4000 feet”.
After 33 minutes of 2nd go around, 555 made third approach on Rwy 27, as the Runway was not sighted at DA, the 3rd go-around was initiated by PIC at 0050 UTC. The fuel after the 3rd go-around was 2644 Kgs and the MDF for Trivandrum was 2614 Kgs.
After the third go around, the crew set course and diverted to Trivandrum. While diverting from Cochin to Trivandrum 555 climbed to FL 210.
At 0102 UTC aircraft came in contact with Trivandrum ATC. The weather reported by Trivandrum ATC at 0100 UTC was visibility 1500 meter haze, winds 290/3 kts, and scattered cloud at 1500 ft and at 2500 ft.
Around 25 nm short of Trivandrum VOR, the PIC realised he was high and requested ATC for a right 360 orbit to reduce the height.
ATC cleared the aircraft 555 for VOR approach and landing on Rwy 14. The crew of 555 contacted Trivandrum ATC to check for the availability of high intensity lighting system (HILS) on runway 14 as they would like to use CMV to land on runway 14.
ATC Trivandrum informed that HILS is not available on runway 14 and only Simple intensity lighting system with high intensity is available for runway 14. The Visibility requirement was RVR 2100 m for runway 14.
The crew had informed ATC about minimum fuel conditions. ATC cleared 555 for landing on runway 14 with visibility 2000 m. During approach and landing, the crew was unable to sight the runway and initiated the 1st go – around at Trivandrum (4th go-round of the flight) at 0119 UTC.
The fuel on board after the 4th go-around was 1324 Kgs.
About 40 seconds after the Go-Around, as the fuel on board was below 1300 Kgs, 555 Declared “MAY DAY due Fuel”.
Thereafter Captain informed ATC of his intention for right hand visual circuit for Rwy 14.
As the crew of 555 had declared fuel emergency, the ATC cleared 555 for visual approach runway 14.
On the 2nd visual approach circuit the crew was not in visual contact with the runway and sighted the runway very late and at time 0126 UTC crew initiated the 2nd go-around at Trivandrum (5th go-around of the flight) as the crew also realized that aircraft was not aligned with the runway. The fuel on board after go-around was 898 Kgs.
The PIC again requested ATC for circling visual approach for Rwy 14, however he was not in visual contact with the runway and once again crew was late in sighting the runway, too high on approach and was not able to align the aircraft on the runway and carried the 3rd go around (6th go round of the flight) at 0132 UTC. The fuel on board after the go-around was 662 Kgs.
After carrying out the 6th go-around at 700 feet AGL, the PIC requested ATC to take left 180° turn and self-position for landing for inbound runway 32. This manoeuvre activated EGPWS caution “TERRAIN TERRAIN” followed by EGPWS warning “TERRAIN TERRAIN PULL UP”.
The First officer selected Ground proximity Terrain Inhibit switch to TERR INHIBIT and at around 50 feet radio altitude, the EGPWS bank angle alert also got activated. The first officer asked PIC at time 1:38:06 UTC “do you know where it is” and PIC mentions that “just going blindly”, thereafter autopilot disconnect noise is recorded and the bank angle alert is also heard.
The PIC continued the approach with all warnings and with no visual contact with the runway and finally landed on runway 32 on the 7th attempt at 0139 UTC.