Jet Airways B738 enroute on Oct 14th 2011, unqualified pilot monitoring

Last Update: August 18, 2020 / 18:03:44 GMT/Zulu time

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Incident Facts

Date of incident
Oct 14, 2011

Classification
Report

Flight number
9W-481

Departure
Mumbai, India

Destination
Chennai, India

Aircraft Registration
VT-JGK

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

A Jet Airways Boeing 737-800, registration VT-JGK performing flight 9W-481 from Mumbai to Chennai (India), had been dispatched with a captain (35, ATPL, 8,372 hours total, 8,372 hours on type thereof 3551 hours in command), first officer (FO, 31, CPL, 302 hours total, 99 hours on type) and a supernumerary trainee first officer (TrFO, 22, CPL, 222 hours total, 190 hours as supernumerary on type) occupying the observer seat. After departure while climbing through FL200 the captain instructed FO and TrFO to swap seats, the TrFO occupied the right hand seat afterwards and continued to act as pilot monitoring until after landing in Chennai.

On Aug 18th 2020 India's DGCA released their final report concluding the probable cause of the serious incident was:

The incident occurred due to PIC instructing trainee first officer to occupy right hand seat in the cockpit and permitting the trainee F/O to be there till landing.

Contributory factor is the lack in the monitoring of the training specially Supernumery flying.

The DGCA analysed:

The Trainee F/O underwent type training course on Boeing 737-800 type aircraft from R.J. Flight Academy, Sweden at their training center/Simulator at Dubai as per JAA Approved type rating course. Accordingly CPL license of the trainee F/O has been endorsed with B-737-800 type aircraft as Co-Pilot.

Para 2.5 of the Training Manual of Jet Airways lists the training course/Syllabus for Initial Endorsement Course B737-400/700/800/900. During the type training course, the trainee First officer had completed the ground training & assessment and Simulator Training & assessment. As per the syllabus the trainee F/O had to undergo:

- 50 hrs of Supernumerary flying
- Familiarization flight of 45 minutes duration, consisting of at least 3 landings [1 instrument approach mandatory]
- Line training consisting of Initial route check with TRE/TRI with Safety Pilot on board. SLF with Check Pilot /TRI/TRE for 50 hrs. First 4 sectors with Safety Pilot and a minimum of 5 sectors by night.
- Finally release route check with Instructor/Examiner.

Against the above requirements the trainee F/O had undergone 190:16 hrs of Supernumery flying which is much in excess of the requirements of the 50 hrs. However she had yet to undergo Familiarization flight, line training and the release route check.

Thus from above it is concluded that the trainee F/O qualification was not complete to perform the functions of first officer (Pilot Monitoring).

After takeoff while passing through 20,000 ft. the Tr. F/O switched the seat with the first officer and continue to occupy that seat till touchdown. During the flight the PIC and the F/O helped the trainee to do the FMC procedures. During the cruise The RT conversation was handled by the First Officer/Trainee First Officer. The Tr. F/O did the pilot monitoring procedures such as callouts, checklist and monitoring of the aircraft parameters. The same was also being monitored by the First officer. The descent briefing was done by the PIC before commencement of the descent in which he briefed the first officer and the trainee F/O. He also discussed the emergencies. The descent checklist callouts were made by the trainee F/O.

During approach and landing, the first officer handled radio conversation and checklist items were called by him while occupying the jump seat and PIC carried out the action and replied back in confirmation for Pilot Flying actions. PIC is the in charge of the aircraft during the flight. The first officer was also a newly released First Officer. The authority gradient in the Cockpit was steep. Therefore this switching of the seats and permitting the Trainee First Officer to carryout pilot monitoring functions cannot happen without the expressed permission of the PIC or his instructions.

Thus it can be safety concluded the Trainee F/o occupied the right hand seat in the Cockpit at the instructions of the PIC although there may have been desire on the part of the trainee F/O also in view of long waiting for remaining procedure for the release as First officer.

The DGCA reported the airline conducted an internal investigation confirming the facts as analysed above. As result the captain and TrFO were taken off flying duties for three months effective Oct 22nd 2011 in concurrence with the Chief Operating Officer of the company.

The 737 fleet captain however reduced the grounding time on Jan 4th 2012 and instructed the rostering office to roster both captain and TrFO for flights subject to training requirements. The DGCA analysed:

Though the Company Operations manual is not emphatic on the issue; however, this being a serious issue, where the safety of the passengers was jeopardized, the matter should have been placed before the COO before reducing the grounding period.

Thus the decision of the B737 fleet captain to reduce the grounding period of PIC and the trainee First Officer is inappropriate.

The DGCA analysed:

M/s Jet Airways has its own training establishment for the pilots and other operations personnel. In case of the abinitio pilots, after completing the ground training, they have to undergo 50 hrs of Supernumery flying. During the Supernumery flying they have to get the progress report signed from each pilot they fly with, however during investigation it was observed that that document is not being signed by the pilots. After completing 50 hrs of Supernumery flying they may continue to fly as Supernumery depending upon the backlog in the training after personally contacting roistering and the PIC concerned. However this process is not monitored either by the training department or by the Fleet office. This may lead to trainee getting inordinately delayed in getting in the remaining phase of the training and their performance not being monitored. This makes the situation ripe for the trainee first officer seeking up gradation to the pilot monitoring function.

Thus M/s Jet Airways should ensure that each phase of the training is coordinated and monitored by a particular department.
Incident Facts

Date of incident
Oct 14, 2011

Classification
Report

Flight number
9W-481

Departure
Mumbai, India

Destination
Chennai, India

Aircraft Registration
VT-JGK

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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