Indigo A320 at Male on Feb 3rd 2019, approached runway under construction

Last Update: June 9, 2020 / 15:50:42 GMT/Zulu time

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Incident Facts

Date of incident
Feb 3, 2019

Classification
Report

Airline
Indigo Airlines

Flight number
6E-1783

Departure
Mumbai, India

Destination
Male, Maldives

Aircraft Registration
VT-INY

Aircraft Type
Airbus A320

ICAO Type Designator
A320

An Indigo Airbus A320-200, registration VT-INY performing flight 6E-1783 from Mumbai (India) to Male (Maldives) with 106 people on board, was on approach to Male's runway 36 when the crew was informed the ILS had become inoperative. The crew therefore performed a VOR/DME approach to runway 36. The crew was aware that a runway under construction was running parallel to the active runway. Unsure whether they were approaching the active runway the captain decided to go around at 12 feet AGL. The aircraft descended to 8 feet AGL above the runway under construction and then climbed out. The aircraft positioned for another approach and landed safely on runway 36.

A similiar approach followed by a landing had occurred in 2018, see Incident: India A20N at Male on Sep 7th 2018, landed on runway under construction.

India's DGCA released their final report concluding the probable causes of the approach to wrong runway were:

The inability of the operating crew to positively identify the runway to which the aircraft was cleared to land during final approach was the cause of the incident.

Contributory factors included the following:

- Inadequate flight planning/review by the operating crew despite operating for the first time to MALE(VRMM).

- Lack of assertiveness of the PIC.

- In-complete information supplied to the flight crew by dispatch (of M/s IndiGo) and lack of clarity of the information contained in the Operations Manual-Part C.

- Inappropriate scheduling of PIC to operate the flight without factoring for the time allowances required for transport between different terminals.

The DGCA analysed:

The PIC was on stand-by duty on the date of incident. He was informed at 0140UTC about the flight duty assigned for the day. He first operated a flight from Bengaluru to Mumbai (VTITL, 6E-346), the aircraft was parked on stand 84 of Apron ‘D’ of domestic apron at 0651UTC against an expected time of arrival of 0640UTC. He then proceeded by a vehicle to the international terminal from the city side. At the international terminal he reached the dispatch of M/s InterGlobe Aviation Ltd. and performed the pre-flight medical examination at 0738UTC. The flight crew did not discuss the destination NOTAM’s prior to departure from Mumbai. The approximate time to reach the stand V17R from the IndiGo dispatch is estimated at 15 minutes. The departure time (Chocks OFF) from Mumbai to MALE was 0823UTC. The above translates to a total transit time (Chocks ON time of Bengaluru-Mumbai flight to Chocks OFF time of Mumbai-MALE flight) of 01hour and 33 minutes at Mumbai.

The PIC reported at M/s IndiGo dispatch/airline office at Terminal-2, 12 minutes prior to the ETD of flight to MALE(VRMM). Whereas, as per the Operations Manual of M/s IndiGo, operating crew are required to report 01 hour and 15 minutes prior to departure at airline’s dispatch office. In-addition, as per the Operations Manual part-A, a standard allowance of 30 minutes is required to be added at the end of flight time to allow for the completion of checks and records.

Hence, it would have been evident at the stage of crew scheduling itself, that the time interval between the arrival (from Bengaluru, ETA: 0640UTC) and departure (to MALE, ETD: 0750UTC) flights was not sufficient to comply with the requirements stated in the Operations Manual-Part A.

Instead of the expected RWY18, RWY36 was in use at the time of clearance to approach for MALE. The Operations Manual guideline regarding, new runway being to the left of the existing runway (guideline for RWY18 approach) was being recollected by the First Officer during approach to RWY36.

Though the crew members successfully sighted the two runways during approach, their discussion in the cockpit did not indicate that they had positively identified the runway, which they were instructed to use by the ATC. The ‘X’ markings on the under-construction runway to identify the non-availability of the runway, was identified by crew members, neither did the crew raise any clarifications with the ATC nor did the ATC advise the crew that the approach path did-not align with the runway in use. The operating crew appeared to have remained unsure of their position relative to the active runway until the go-around, which occurred 12ft above the under-construction runway. The aircraft had descended to 08ft above the runway underconstruction prior to climb.

After the go-around the crew clarified with the ATC tower whether they made approach to the wrong runway. ATC Tower controller responded that the aircraft had in-fact aligned to the wrong runway, which signifies that the ATCO was also aware that 6E-1783 was not aligned for the runway to which the aircraft was cleared to land.

The DGCA analysed the crew cooperation:

During planning for approach to MALE (in cruise phase) an approach on RWY18 was expected by the crew, the First Officer informed the PIC that as per the company Operations Manual-Part ‘C’ among the two parallel runways at MALE the one on the LEFT was the under-construction runway. Whereas, at the time of descend of the subject aircraft to MALE, RWY36 was in use, the ILS navigational aid became un-serviceable and the crew was advised to perform a RNAV approach RWY36, however since they were not approved for RNAV approach, the crew made a VOR-DME approach for RWY36 followed by transition to visual approach.

From the CVR it is noted that, the First Officer had his presumptions regarding the runway configuration at MALE based on discussions with other cockpit crew members who had previously operated to MALE. The reference to company Operations Manual-Part C, also did not give any clarity to the crew, as it states that during approach to RWY36 the runway on the RIGHT is the ‘parallel runway’. The First Officer did not consider clarifying with the ATC regarding the active runway, despite a request from the PIC.

Neither of the operating crew identified the visual glide path of the available Precision Approach Path Indicator (PAPI), during first approach, which would have not only indicated the glide path indications but also the relative location to the runway to which they intended to land.

The PIC was not confident of the runway to which approach was being made, even below minimums, as he noticed the ‘X’ marks made on the ‘under-construction’ runway. However, the First Officer kept advising the PIC to continue the approach. The First Officer continued to be assertive regarding visual identification of the under-construction runway as the actual runway during approach. The PIC did not make an assertive command to confirm the runway from ATC, even though there was no consensus between the operating crew on the runway identification, as they continued the final approach below minimums unaware of the runway to which the approach was being made. A go-around was not considered at this point.

Neither of the operating crew appropriately assess the destination aerodrome- MALE(VRMM) peculiar characteristics prior to departure, nor did they ask for any additional guidance from the dispatch office, even-though they were operating to MALE for the first time.

Instead of the expected RWY18, RWY36 was in use at the time of clearance to approach for MALE, however the Operations Manual guideline regarding, new runway being to the left of the existing runway (guideline for RWY18 approach) was being recollected by the First Officer.

The First Officer identified the under-construction runway as the actual runway and was assertive in advising the PIC on the same.

The result was that the aircraft descended to 12ft radio altitude above the runway underconstruction; however PIC still unable to confirm the active runway performed a go-round. The aircraft had descended to 08ft above the runway under-construction, prior to climb.

The DGCA analysed the operation manuals:

The MALE- AIC 04/17 specifically states that, the runway being constructed is to the “East of the present runway staggered northwards approximately 500m”; the operational guidelines in the Operations manual of M/s IndiGo on the other hand, makes use of relative direction (i.e., left and right) to define the runway configuration. It is stated that, while carrying out ILS approach for RWY 36 flight crew to brief ‘parallel runway’ is to the RIGHT and hence will fly the instrument approach till minimums. But this does not clarify which runway is to the RIGHT, whether the ‘actual runway’ or ‘under-construction runway’.

The above factors created confusion for the operating crew, who were operating for the first time to MALE (VRMM) in differentiating the actual/active runway from the underconstruction runway.

With respect to the flight preparation the DGCA analysed:

During review of flight folder of the subject flight, it was observed that the supporting document (AIC 04/17-MALDIVES) of NOTAM-VRMM A0360/18 02DEC0453-02MAR1859 2019EST, was not included in the flight folder presented to the operating crew.

The flight crew failed to adequately analyse the flight documents and did not notice the absence of the supporting document (AIC 04/17-MALDIVES). The cockpit crew members did not perform a proper review/ discussion of Notices to Airmen (NOTAMS) even though they were operating to MALE for the first time.
Incident Facts

Date of incident
Feb 3, 2019

Classification
Report

Airline
Indigo Airlines

Flight number
6E-1783

Departure
Mumbai, India

Destination
Male, Maldives

Aircraft Registration
VT-INY

Aircraft Type
Airbus A320

ICAO Type Designator
A320

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