Indian incident report highlights aircraft evacuation procedures and decision making

September 19, 2011

The investigation into an evacuation of a Boeing 737-800 on a taxiway at Mumbai Airport, India revealed poor decision making and highlights the importance of aircraft evacuation procedures.

On August 27, 2010 Jet Airways Boeing 737-800 aircraft, VT-JGM, was operating flight 9W-2302 from Mumbai to Chennai. There were 139 passengers 3 flight crew members, 4 cabin crew members and 8 ACM (Additional Crew Member) cabin crew onboard.
While taxying to the runway an additional cabin crew (ACM) seated at row 35A apparently observed some fire from left engine and informed another ACM on seat 35B who also claimed to have confirmed the fire from the left engine. Immediately the ACM seated on 35B got up from his seat and went to the rear galley and informed the captain about the fire. In turn the captain asked the cabin crew in charge-CCIC (L1 Position) to confirm the fire. She also confirmed fire to the Captain. But all the indications in the cockpit were normal and there was no fire warning.

However based on the confirmation given by the CCIC he ordered for precautionary evacuation. A precautionary emergency was declared and Engines and APU were shut down. For the purpose of evacuation L2,R1 and R2 slide chutes were deployed and inflated. Also Left side aft over wing exit door and right side both over-wing exit door were opened.
During the evacuation time airport fire and rescue services were also deployed. However no foams were discharged as there was no fire/smoke. At the time of incident the taxi track was wet due drizzling of previous hours. Weather was fine. In the process of evacuation 25 passengers were injured and four of them were seriously injured with multiple fractures on the legs. There was neither smoke nor actual fire in the incident.

Investigators concluded that wrong decision of the captain to carry out evacuation for non-real emergency situation of imaginative fire from the left engine, leading to the serious injuries to passengers is the most probable cause for the incident.

Contributory factors were:

  1. Non-awareness of the effect of anti-collision light by the ACMs, cabin crew and CCIC
  2. Over reacted ACMs and absence of company policy on ACM role in the flight
  3. Failure of CCIC to play her role in evacuation
  4. Incorrect usage of non-required exit for evacuation
  5. Lack of training on over-wing exit evacuation
  6. Wrong door guarding procedure
  7. Lack of situational awareness and crew coordination of the cockpit crew.
More info:

Report: Poor CRM factor in cargo plane takeoff incident (India)

February 28, 2011

Indian investigators concluded that inadequate CRM and a lack of assertion on the part of the first officer were factors in a takeoff incident at Mumbai Airport in June 2010. A Boeing 757 was lined up right of the centreline and k knocked down 15 runway edge lights during the takeoff before the captain was able to steer to the runway centreline.

Blue Dart Aviation Flight No BD-201, a Boeing 757-200F, operated on a cargo flight from Kolkata to Delhi, Mumbai and Bangalore. The flight departed on schedule from Kolkata at 22:25 hrs and was uneventful till Mumbai.

At Mumbai, the aircraft taxied out from Bay No G-4 via Papa, Echo, and was cleared to proceed to holding point N1 for runway 27. The flight was cleared to line up after an arrival of Kuwait Airways Boeing 777 aircraft.

The Captain was PF and the FO was Pilot Monitoring for the departure. While lining up, the Captain lined up on the right of centerline of the runway. The FO promptly drew the attention of the Captain by stating that the centerline was on the left. This was acknowledged by the Captain. On being cleared for take off the thrust levers were opened by the Captain and the aircraft commenced its roll. The FO at this stage called out to the Captain that he was on the right, twice in quick succession. The Captain carried out a correction to the left to return to the centerline. The take off was continued with and the aircraft took off at 05:15 hours at the correct speed and carried out a standard departure. The flight to Bangalore i.e climb, cruise, decent and approach were normal. The aircraft carried out an uneventful landing with FO as PF. The aircraft taxied to the bay at 06:45 hours.

On arrival at the bay, the Engineer observed that there were damages to the right hand wheels. No. 3 main wheel tyre was deflated. There were deep incisions on No.3, 4 & 8 main wheel tyres and reverted rubber on No. 7 tyre. No. 3 brake assembly had signs of FOD and grease nipple was deformed.

At 08:30 hours information was received from Mumbai that a runway inspection was carried out and runway edge lights were damaged. A subsequent report indicated that a total of 15 runway edge lights of runway 27/09 were damaged, nine towards the north side between N1 and N4 and six on the southern side between taxiway E1 and intersection.

The investigators concluded:

The cause for the incident is incorrect lineup by the Captain on the right side of the RW instead of the Center even after being informed by the FO.

Contributory factors: An error in judgement / assessment in determining the extent of displacement to the right of centerline while lining up. Inadequate CRM practices both by the Captain and FO. Lack of assertion on the part of the FO in emphasizing the displacement of the aircraft to the Captain. Inadequate attention on the part of the Captain towards inputs from the FO.

More information:


Report: ATR-72 runway excursion accident following unstabilized approach (India)

January 13, 2011

Investigators from the Indian DGCA concluded that an ATR-72 runway excursion at Mumbai was caused by the failure of the crew to execute a go around during an unstabilized approach.

An ATR-72 passenger plane, operated by Kingfisher Airlines, was substantially damaged when it aquaplaned off the runway on landing at Mumbai-Chhatrapati Shivaji International Airport (BOM), India on November 10, 2009.

Flight IT4124 operated on a scheduled domestic flight from Bhavnagar Airport (BHU) to Mumbai. There were 36 passengers, 2 Infants and four crew members on board the aircraft.

Maintenance on runway runway 14/32 and runway 27 at Mumbai effected operations at the airport between certain times. There were several NOTAM’s in effect relating to runway 27:

GP RWY27 NOT AVBL DUE SHORTENED RWY27. BTN 0730-1130 ON EVERY TUE, 03 NOV 07:30 2009 UNTIL 23 MAR 11:30 2010
RWY27 CL LGT NOT AVBL. 27 OCT 12:30 2009 UNTIL 31 MAR 23:59 2010.
RWY27 TDZ LGT NOT AVBL. 27 OCT 12:30 2009 UNTIL 31 MAR 23:59 2010.
RWY27 SHALL BE USED FOR LDG AND TKOF FM A POINT 1262M FM THR OF RWY27
1.THE SHORTENED RWY SHALL BE DESIGNATED AS RWY 27A. RADAR VECTORED VISUAL APP WILL BE PROVIDED SUBJ TO VIS 2800M OR MORE.DECLARED DIST OF RWY27A-
RWY TORA TODA LDA ASDA
27A 1703M 1703M 1703M 1703M
2.THR MARKING PROVIDED ON BOTH SIDES OF RWY27A ON RWY SHOULDER AREA AT A DIST OF 180M
3.PAPI RWY27A PROVIDED
4.AIMING POINT MARKING PROVIDED ON SHOULDER OF RWY27A OPPOSITE PAPI
5.DIST INDICATION SIGN PROVIDED EV 300M FM RWY27A END.
6.TORA SIGN PROVIDED AT TWY Q HLDG POINT.
7.TEMP WING BAR LGT PROVIDED FOR THR.
8.RWY EDGE LGT,RWY CL AND RWY END LGT PROVIDED FOR RWY27A. BTN 0730-1130 UTC ON EV TUE ON [...],10,17,24 NOV 2009 [...]

Runway 27 thus was available only after runway intersection as runway 27A. To carry out operations on this reduced runway 27 a NOTAM was issued and designated runway 27A for visual approach only. The weather conditions prevailing at the time of accident was winds 070/07 knots visibility 2800 m with feeble rain. Prior to Kingfisher aircraft, Air India flight IC-164, an Airbus 319 had landed and reported to ATC that it had aquaplaned and broken two runway edge lights. The ATC acknowledged it and sent runway inspection vehicle to inspect the runway.

The ATC person was not familiar with the terminology of ‘aquaplaning’ and not realizing the seriousness of it, cleared the Kingfisher flight for landing. At the time of accident there were water patches on the runway. ATC also did not transmit to the Kingfisher aircraft the information regarding aquaplaning reported by the previous aircraft.

The ATR-72 approached high and fast. The aircraft landed late on the runway and the runway length available was around 1000 m from the touchdown point. In the prevailing weather conditions this runway length was just sufficient to stop the aircraft on the runway. During landing the aircraft aquaplaned and did not decelerate even though reversers and full manual braking was applied by both the cockpit crew. The aircraft started skidding toward the left of center line. On nearing the runway end, the pilot initiated a 45° right turn, after crossing Taxiway N10, the aircraft rolled into an unpaved wet area. It rolled over drainage pipes and finally came to a stop near open drain. There was no fire.

PROBABLE CAUSE OF THE ACCIDENT:

The accident occurred due to unstabilized approach and decision of crew not to carry out a ‘Go-around’.

Contributory Factors:

  1. Water patches on the R/w 27A
  2. Inability of the ATCO to communicate the aircraft about aquaplaning of the previous aircraft
  3. Lack of input from the co-pilot.

More information:

VT-KAC final report


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