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Category: <span>inadequate training</span>

Pilot Taking a Nap, Co-pilot Busy on Tablet; Jet Airways Boeing 777 Drops 5,000 Feet over Turkey

Jet AirwaysAn inquiry has been launched after the Indian Directorate General of Civil Aviation (DGCA) found out that a Jet Airways flight abruptly descended 5,000 feet over Turkish airspace, on August 8.

The Indian media reports that the incident first came to light on August 12 when the Director General of DGCA, Lalit Gupta, received an anonymous SMS, informing him about the incident.

It was discovered that the captain of the flight 9W-228, on its way from Mumbai to Brussels, was taking a controlled nap at the time while his co-pilot was supposed to sit on the controls. However, the co-pilot claimed that she did not notice that the aircraft is descending below the assigned level since she was busy with her electronic flight bag (EFB) – a tablet containing aircraft documents. She realized the situation only after getting a call from the air traffic controller in Ankara, Turkey, and immediately woke up the captain, who then brought the Boeing 777-300 back to its level.

The DGCA has suspended the pilots and launched an investigation to find out whether the sudden drop was caused intentionally or accidentally by the co-pilot. The DGCA has also decided to audit the airline’s training procedures for the pilot.

According to Jet Airways, “The airline is also extending all co-operation in the matter to the DGCA by providing all necessary assistance for the inquiry. Safety is of paramount importance to Jet Airways as is also the welfare of our guests and crew and the airline will always take appropriate steps to ensure the same.”


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Airblue Crash Heirs Case Hits Immobile Object

If you’re wondering about the Airblue 202 case, it has run into the politics of Pakistan. The situation has been piled high with difficulty. Even though I am an optimist and see opportunity in every difficulty, even though I have a great team of attorneys in Pakistan, and a great team here in the states coordinating on this case, there comes a time when we must realize where we stand. Despite our efforts, with the present laws and political situation, helping the families is like patching shattered glass with paste. It has been a very difficult to make things stick. Or to change metaphors, it has been an uphill climb.

The Flight: 28 July 2010, Airbus A321, Air Blue Fight 202, en route from Karachi to Islamabad

146 passengers and 6 crew members flew into a mountain near the airport. Witnesses wondered why it seemed as if “the plane had lost balance, and then we saw it going down.”

Why it was flying so low? Why did it strike the mountain? Audio and a report were released that seemed to answer those question—lack of coordination in the flight crew.

Our study of the audio indicates the pilots are served tea early on, then…

  • Confusion ensues in the cockpit, caused by some unknown reason.
  • Wrong settings introduced into the settings that were already abnormal.
  • A tower operator who had gone for coffee was complacent.
  • Aircraft flew lower than normal.
  • Abnormal personality traits/interaction reflecting mistakes in the cockpit.
  • Weather and apprehension and strange out of norm complacency by the FO when he realizes they are going to die

When the audio was released and studied, it became clear there was no teamwork between the pilot Perve Iqbal Chaudhary and the first officer Muntajib Ahmed.

The pilot had 35 years and more than 25,000 hours of flying experience but made inexplicable mistakes and demeaned the co-pilot. The first officer was aware of the danger and tried to amend the situation but he had been so disheartened beforehand by sharp questions putting the first officer “in his place.”

He was unaccountably meek for a former F-16 Pakistan Air Force fighter pilot. The pilot did not properly respond to Air Traffic Control directives and automated cabin warning systems and flew the plane into a mountain. Air Traffic Control responses were less than professional. The first officer appeared helpless and ineffective.

On January 17,2013, two and a half years after the accident, the Peshawar High Court closed proceedings for the Airblue compensation case.

Counsel was directed to withdraw the client’s petition from the Islamabad High Court or the the Peshawar High Court. The client refused to do so on the basis that the cases were different. The court closed the case because the heirs of the victims had had filed an independent lawsuit at Islamabad High Court.

We believed the Airblue compensation case had merit. The pilot committed the error. The first officer was ineffective. They were Airblue employees.

Yes, there was pilot error, but the airline is doubly responsible, because the flight crew did not have adequate CRM training. (COCKPIT Resource Management/Crew Resource Management) Absolutely what happened in the case was the result of the airline failing to establish a working protocol.

It’s like children at school practicing a fire drill so they know what to do when a crisis occurs. Fire drills save lives. They prevent missteps in the face of danger. They give the people in trouble a set of directions to follow that will get them out of the jam they are in. A drill answers questions ahead of time, so precious time is not wasted figuring out what to do. Without the drill, what happens when disaster strikes? Chaos. Loss of life.

I feel bad for the people. First they lose their families. Then they don’t get all the compensation available to them.

Take a look at the safety recommendations from the report (pasted below).

See how 3.1-3.5 and 3.7 all duplicate the same working environment issue? Investigators recognize the troubled working environment. Today’s flight crews are taught CRM which means they have safe practices in place in case the captain is incapacitated and starts to fly into mountains like the captain of Air Blue 202.

But realistically, will recommendations change AirBlue? Will Air Blue be able to implement non-traditional interpersonal relations on the job? And if they can not, how will they ever fly safely with a first officer culturally unable to do his job?

The first officer was ineffective in securing the plane; and sadly, the court appears to be equally as ineffective in getting justice for some of the heirs of the victims.

Re: Investigation Report -AB-202 CHAPTER – 13 :

SAFETY RECOMMENDATIONS

13.1 All aircrew be re-briefed on CFIT avoidance and Circling Approach procedures
and a strict implementation of this procedure be ensured through an intensive
monitoring system.

13.2 Aircrew scheduling and pairing being a critical subject be preferably handled /
supervised by Flight Operations.

13.3 The implementation of an effective CRM program be ensured and the syllabus of
CRM training be reviewed in line with international standards.

13.4 Existing aircrew training methodology be catered for standardization and
harmonization of procedures.

13.5 Human factor / personality profiling program for aircrew be introduced to predict
their behaviour under crises.

13.6 Instrument landing procedure for RWY-12 be established, if possible.

13.7 Safety Management System be implemented in ATS as per the spirit of the ICAO
document (doc. 4444).

13.8 New Islamabad International Airport (NIIA) be completed and made functional on
priority

13.9 Visual augment system (Approach Radar Scope) be installed in control tower to
monitor the positions and progress of aircraft flying in the circuit.

13.10 Review of the existing Regulations for the compensation and their expeditious
award to the legal heirs of the victims be ensured.

13.11 Adequacy of SIB resources comprising qualified human resource and equipment
be reviewed.

13.12 Information to public on the progress of the investigation process through the
media by trained / qualified investigators of SIB be ensured on regular intervals.

13.13 NDMA be tasked to acquire in-country airlift capability for removal of wreckage
from difficult terrain like Margalla etc. As an interim arrangement, some foreign
sources be earmarked for making such an arrangements on as and when
required basis.

13.14 Civil Police Department be tasked to work out and ensure effective cordoning and
onsite security arrangements of crashed aircraft wreckage at all the places
specially remote / difficult hilly locations.

13.15 Environment Control Department be directed to recover the ill effects of
deterioration / damages caused to Marghalla hill due to the crash.

Family Charges Bombardier with Negligence

The National Transportation Safety Board’s decision on the Colgan Air Flight 407 crash is that the pilot responded inappropriately to the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. The stick shaker only comes into play when the plane is already slow enough to stall. The plane fell 800 feet before crashing pointing northeast, away from the airport

The family of Ellyce Kausner has filed a lawsuit against Bombardier. Bombardier is the manufacturer of the plane involved in the crash. The suit charges that Bombardier was “negligent and careless” in the design of the plane by not providing more efficient internal mechanical warning systems.

Kausner was a 24 year old Jacksonville law student traveling to NY to visit family.

At least 19 other families have filed suits.

At the time of the crash, the automated “stick-pusher,” pushes the control column down in order to send the aircraft into a temporary dive so it can regain speed and recover from a stall but Capt. Renslow yanked back on the controls while adding thrust, manually overriding the stick-pusher.

Colgan Air, Clarence Center, NY, Accident Dockets

George’s Point of View

Time for Bombardier to step up to the plate. Although this has little to do with the pilot, who had flunked numerous flight tests during his career and was never adequately taught how to respond to the emergency that led to the airplane’s fatal descent. Maybe Ellyce would still be here if the warning systems on the Bombardier were simply better.

When the plane slowed down to a dangerous level, it set off the stall-prevention system, and the pilot performed the opposite of the proper procedure. So there were hiring and training issues involved too. And Captain Renslow had about 109 hours of experience, hardly enough to be pilot.

Even if procedures seem counter-intuitive, shouldn’t the pilot be aware of them?

Barring the inefficiency of an ill-prepared pilot, shouldn’t Bombardier have some kind of way to limit ineffective pilot responses?

When the hiring and training fails, and when the pilot fails, shouldn’t there be some kind of fail-safe within the plane? Even a copy of the Complete Idiot’s Guide to Not Crashing your Bombardier for pilots who flunked their last check write 16 months before and who apparently didn’t read the real manual?


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Korean Air Crash at Nimitz Hill, Guam


Click to view full size photo at Airliners.net
Contact photographer Michel Gilliand

What: Korean Air Boeing 747-3B5B (747-300) en route from Seoul, Korea to Agana, Guam.
Where: Nimitz Hill, Guam
When: August 6, 1997
Who: 2 pilots, 1 flight engineer, 14 flight attendants, and 237 passengers
Why: On August 6, 1997, about 0142:26 Guam local time, Korean Air flight 801, a Boeing 747-3B5B (747-300), crashed at Nimitz Hill, Guam. Flight 801 departed from Kimpo International Airport, Seoul, Korea, with 2 pilots, 1 flight engineer, 14 flight attendants, and 237 passengers on board. The airplane had been cleared to land on runway 6 Left at A.B. Won Guam International Airport, Agana, Guam, and crashed into high terrain about 3 miles SW of the airport. 228 were killed, and 23 passengers and 3 flight attendants survived the accident with serious injuries. The airplane was destroyed by impact forces and post crash fire. Flight 801 was operating in U.S. airspace as a regularly scheduled international passenger service flight. The National Transportation Safety Board determines the probable cause to be the captain’s failure to adequately brief and execute the nonprecision approach and the first officer’s and flight engineer’s failure to effectively monitor and cross-check the captain’s execution of the approach. Contributing to these failures were the captain’s fatigue and Korean Air’s inadequate flight crew training.


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Tam Crash on Take-off Pilot Error


Click to view full size photo at Airliners.net
Contact photographer Normando Carvalho Jr.

What: Tam Fokker 100 en route from Sao Paulo to Rio
Where: residential area 1 mile from Sao Paulo
When: October 31 1996
Who: 89 passengers,6 crew and 2 on the ground died.
Why: Summary: On October 31 1996, about 0545 UTC a Fokker 100, registration PT-MRK, operating as TAM Airlines flight. 402, a shuttle between Sao Paulo and Rio de Janeiro, Brazil, crashed shortly after takeoff from the Congonhas Airport, Sao Paulo, Brazil. The aircraft was destroyed; 89 passengers,6 crew and 2 on the ground died. 3 passengers were Americans .Witnesses reported the aircraft failed to gain altitude after take-off, collided with a tall building and crashed into residential area 1 mile from the end of the departure runway. Pilot error, unfamiliarity with the craft was judged to be partially responsible.

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