Jet Airways B738 at Trivandrum on Aug 18th 2015, landed below required final fuel reserve on 7th approach

Last Update: February 24, 2017 / 17:53:19 GMT/Zulu time

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Incident Facts

Date of incident
Aug 18, 2015

Classification
Incident

Flight number
9W-555

Departure
Doha, Qatar

Destination
Cochin, India

Aircraft Registration
VT-JFA

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

A Jet Airways Boeing 737-800, registration VT-JFA performing flight 9W-555 (dep Aug 17th) from Doha (Qatar) to Cochin (India) with 142 passengers and 8 crew, was on approach to Cochin and went around three times due to weather. Following the third go-around the crew declared fuel emergency and diverted to Thiruvananthapuram (in India often also referred to as short "Trivandrum"), located about 95nm south of Cochin, where the aircraft again needed to go around three times before managing a safe landing on the fourth approach.

On Aug 21st 2015 India's Directorate General of Civil Aviation (DGCA) reported the aircraft landed with just 270kg/600lbs of fuel left, where the required minimum fuel reserve would have been around 1500kg/3300lbs. The aircraft had gone around 3 times in Cochin due to bad weather, the crew then decided to divert to Trivandrum, which had poor weather conditions, too, and managed a landing there only on the 4th attempt. Both pilots have been suspended pending investigation. The DGCA reported they are looking into the airline's fueling policy as well as into the weather reports and why the crew diverted to Trivandrum.

On Oct 13th 2015 the French BEA reported in their weekly bulletin, that the aircraft attempted three approaches to Cochin but needed to go around three times due to bad weather. The crew subsequently diverted to Trivandrum declaring Mayday due to low fuel. The aircraft needed to go around two times due to low cloud which prevented the runway to become visible at minimum descent altitude. The third time the aircraft flew the approach for runway 32, received a GPWS terrain warning, went around again and managed to land on the fourth approach. The occurrence was rated a serious incident and is being investigated by India's DGCA.

On Feb 24th 2017 India's Aircraft Accident Investigation Bureau (IAAIB) released their final report concluding the probable causes of the serious incident were:

- The absence of a company policy pertaining to the number of approaches/missed approaches in inclement weather led to the crew of 9W-555 attempting total of 07 approaches/missed approaches at Cochin and Trivandrum. The crew also attempted 03 visual approaches at Trivandrum in below minima conditions, below circuit altitude and ignored several EGPWS cautions/warnings, thereby jeopardising the safety of the passengers and the aircraft.

- The absence of a company policy pertaining to the re-designation of destination alternate during the flight in inclement weather led to the flight crew choosing an alternate, which was probably not the best decision given the available information and the prevailing weather conditions.

The IAAIB reported that the aircraft arrived at Cochin with 4844 kg of fuel before commencing the first approach. The crew performed an ILS approach to Cochin's runway 27 but went around from 256 feet AGL due to low cloud preventing visual contact with the runway. Fuel remaining was 4699kg (diversion fuel to Bangalore was 3306kg). The aircraft followed the missed approach procedure and joined the hold. The aircraft performed another approach to runway 27 and again went around from decision height after being unable to obtain visual contact with the runway. Fuel remaining was now 3919kg.

The crew discussed the options, the first officer commented that Trivandrum featured only VOR approaches, the captain commented that 3000 meters of visibility were sufficient for the VOR approach.

Two other aircraft had gone around in the meantime, the first inquired with ATC to check out Trivandrum weather, ATC confirmed the weather at Trivandrum was reported with 3000 meters of visibility and clouds at 1500 feet.

The crew decided to make another approach and if unsuccessful divert to Trivandrum. The crew positioned for another approach to runway 27 and went around again due to lack of visual contact with the runway at decision height. Fuel remaining was 2644 kg with the minimum diversion fuel to Trivandrum at 2614kg.

The crew set course to Trivandrum, climbed to FL210 and were descending towards Trivandrum, but were high and needed to fly an orbit. The crew advised they were low on fuel and was subsequently cleared for the VOR approach to runway 14, however were unable to establish visual contact with the runway at Minimum Descent Altitude and went around. Fuel remaining was now 1324kg.

The crew declared Mayday as the fuel dropped below 1300 kg, the captain decided to fly a right hand visual circuit to runway 14, due to the Mayday ATC cleared the flight for a visual approach to runway 14. The crew performed the visual circuit without having visual contact with the runway, sighted the runway very late and initiated another go-around as the aircraft was not aligned with the runway, fuel remaining 898 kg. The captain attempted another visual circuit to runway 14, however, again sighted the runway too late and went around another time, fuel remaining 662 kg.

Following this 6th go around the crew requested to turn around and self position for an approach to runway 32, ignored a number of EGPWS alerts including "Terrain! Terrain!" and "Terrain! Terrain! Pull Up!". At 50 feet AGL the EGPWS bank angle alert activated. The IAAIB wrote:

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. After landing, the total fuel on board was 349 Kgs. There was no damage to the aircraft. There were no fire and no injury to any of the occupants on board the aircraft.

With respect to fuel planning the IAAIB analysed:

Considering the fuel policy the minimum legally required fuel for the flight was 15295Kg however 9W-555 was dispatched with a total of 16100Kg with the advisory hold fuel was 00:19 minutes (750 Kgs).
From the above it is inferred that the fuel planning for the flight was not a factor to the incident.

With respect to weather the IAAIB analysed: "From the above it is inferred that weather was the contributory factor affecting the PIC decision which eventually resulted into fuel emergency at Trivandrum."

The IAAIB analysed that flight crew situation awareness and decision making were factors to the serious incident on following factors:

- The PIC carried out a total of 07 approaches for the sector flight

- PIC decision of Re-designating the alternate destination to have more holding fuel in order to carry out another approach at Cochin when the ATC had broadcasted that visibility had reduced and with reducing trends.

- All the three visual approaches at Trivandrum were in below minima conditions and below circuit altitude. The PIC also ignored several EGPWS cautions/warnings on the last approach in a manner that jeopardised the safety of the passengers and the aircraft.

- The decision of PIC to choose Trivandrum over Bangalore as alternate destination as Bangalore had better prevailing weather conditions and had ILS available for landing.

With respect to ATC coordination the IAAIB analysed:

It appears that there was a lag in flow of information regarding the downward trend of visibility from Trivandrum ATC to the diverting aircrafts that were under control of Cochin ATC. The timely and accurate transmission of information may have had an effect on the decision made by the diverting aircraft to Trivandrum which was under Cochin ATC control.

Metars Cochin:
VOCI 180230Z 09004KT 2000 BR BKN006 SCT015 24/22 Q1009 BECMG 2500 BR
VOCI 180200Z 09003KT 1800 BR BKN004 SCT015 24/22 Q1009 BECMG 2000 BR
VOCI 180130Z 00000KT 1800 BR BKN004 SCT015 24/22 Q1008 TEMPO 1000 FG
VOCI 180100Z 00000KT 1800 BR BKN004 SCT015 24/22 Q1008 NOSIG
VOCI 180030Z 00000KT 2000 BR SCT006 SCT015 24/22 Q1007 TEMPO VIS 1500 BR
VOCI 180000Z 00000KT 3000 BR SCT006 SCT015 24/22 Q1007 TEMPO VIS 2000 BR
VOCI 172300Z 00000KT 3500 HZ FEW015 SCT080 25/22 Q1007 BECMG 3000 BR
VOCI 172230Z 00000KT 3500 HZ FEW015 SCT080 25/22 Q1007 NOSIG
VOCI 172130Z 00000KT 3500 HZ FEW015 SCT080 25/22 Q1007 NOSIG
VOCI 172100Z 00000KT 3500 HZ FEW015 SCT080 25/23 Q1007 NOSIG
VOCI 171930Z VRB03KT 3500 HZ SCT015 BKN080 26/23 Q1008 NOSIG

Metars Trivandrum:
VOTV 180440Z 27005KT 5000 HZ FEW020 29/24 Q1009 NOSIG
VOTV 180410Z 27005KT 4000 HZ FEW015 SCT090 28/24 Q1009 BECMG 5000
VOTV 180340Z 27005KT 4000 HZ FEW015 SCT090 29/24 Q1009 NOSIG
VOTV 180310Z 25006KT 3000 HZ FEW015 SCT090 27/23 Q1009 NOSIG
VOTV 180140Z 23004KT 2000 BR FEW015 SCT090 26/23 Q1008 NOSIG
VOTV 180040Z 29003KT 3000 HZ FEW015 SCT090 25/23 Q1007 NOSIG
VOTV 180010Z 28004KT 3000 HZ FEW015 SCT090 25/23 Q1007 NOSIG
VOTV 172310Z 30003KT 3500 HZ FEW015 SCT090 25/23 Q1007 NOSIG
VOTV 172210Z 27003KT 3500 HZ FEW015 SCT080 25/23 Q1006 NO
Incident Facts

Date of incident
Aug 18, 2015

Classification
Incident

Flight number
9W-555

Departure
Doha, Qatar

Destination
Cochin, India

Aircraft Registration
VT-JFA

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

This article is published under license from Avherald.com. © of text by Avherald.com.
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