Air India A320 at Jaipur on Jan 5th 2014, runway excursion on emergency landing

Last Update: February 24, 2017 / 17:23:13 GMT/Zulu time

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Incident Facts

Date of incident
Jan 5, 2014

Classification
Accident

Airline
Air India

Aircraft Registration
VT-ESH

Aircraft Type
Airbus A320

ICAO Type Designator
A320

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

The cause below has been given considering events as a combination of organizational factors and human error.

- The flight crew made an erroneous decision of diverting & continuing to an airfield with reducing visibility.

- The flight crew attempted a manual landing in below minima conditions.

- Lack of operational supervision and desired ground support to flight.

- Internal quality assurance not capturing the hazards which slipped through due complacency

- Lack of oversight of the flight operations

The IAAIB reported the crew had been rostered to fly AI-899 from Deli to Guwahati and further on to Imphal (India) and the return flight AI-890 from Imphal to Guwahati and Delhi. Aircraft VT-ESL had been assigned to the flight, all flight plans had been prepared for VT-ESL. However, it was later decided to assign VT-ESH to the flight, the commander accepted the aircraft and the VT-ESL flight plans considering that both aircraft had bogie type of landing gear and the performance factor for both aircraft was the same.

The captain (43, ATPL, 8,322 hours total, 5,502 hours on type) was qualitifed for Category III ILS approaches, the first officer (46, ATPL, 2,798 hours total, 2,610 hours on type) was qualified for Category I ILS approaches.

The aircraft did not feature ACARS.

Prior to the sector from Guwahati to Delhi 12,7 tons of fuel were uplifted (the report does not mention what amount of fuel was still on board), the crew filed Lucknow and Jaipur as alternates. At that time Delhi reported a RVR of 500 meters for runway 29 and 150 meters visibility in general, both temperature and dew point were at 12 degrees C. Jaipur was reported at 3000 meters vibility, winds of about 4 knots, no significant cloud, temperature at 18 degrees C and dew point at 13 degrees C, Lucknow reported a visibility of 3000 meters, temperature at 18 degrees C and dew point at 13 degrees C.

The crew computed 12.2 tons of fuel for the flight, the captain instructed an additional 500 kgs of fuel to be taken on board due to weather at Delhi and possible congestion at Delhi Airport.

Enroute the crew checked the fuel burn, which was marginally higher than planned. There was no mention of traffic congestion at Delhi enroute.

When overflying Lucknow the crew took notes of the ATIS, later noted down Delhi ATIS.

When the aircraft contacted Delhi ATC the crew was instructed to enter a hold and was informed, that they were #12 in sequence. Runway 28 RVR had dropped to lower end of CAT I visibility, runway 29 RVR had dropped below minima. The aircraft entered the hold for about 20-25 minutes. No attempt was made by the flight crew to request the Lucknow or Jaipur weather, nor did dispatch provide any updates of the weather situation at the alternates.

The RVR for runway 28 also dropped below minima for CAT I ILS, due to the first officer's qualification the aircraft therefore was unable to use any of Delhi's runways. The crew therefore discontinued the approach and, being closer to Jaipur than to Lucknow after the discontinued approach, decided to divert to Jaipur, where according to information provided by dispatch earlier a visibility of 2000 meters was available. Again, the crew did not seek an update of the weather information for Jaipur.

The diversion fuel to Jaipur was 2.9 tons, 3.1 tons of "Fuel on Board" were remaining.

The aircraft contacted Jaipur ATC while 68nm out of Jaipur and learned of the actual weather for the first time: visibility 900 meters, temperature 13 degrees C, dew point 13 degrees C, RVR 1000 meters.

While descending through FL083 Jaipur ATC announced visibility was down to 400 meters with RVR at 1000 meters.

At DME 25nm from Jaipur ATC announced that visibility was rapidly deteriorating and visibility was 400 meters. The crew advised they were committed to land in Jaipur due to fuel.

When the aircraft intercepted the localizer runway 27, ATC transmitted the visibility at 50 meters with RVR at 200 meters, trend reducing.

While on final approach, the aircraft reaching the MDA of 1480 feet, ATC announced the RVR at 50 meters and cleared the flight to land subject to Minima.

The crew had used dual autopilot for the ILS approach until MDA at 200 feet AGL. After descending below MDA, both flight crew maintaining there were visual with the runway lights, the captain disconnected the autopilot and flew the remainder of the approach manually, however drifted left of the runway center line and touched down on soft ground left of the runway. The IAAIB wrote: "During touchdown and landing roll, the visibility was zero and crew were unable to see any of the reference cues. The crew had heard rumbling sound during landing roll. The aircraft continued to roll/ skid on the unpaved surface and during this period the left wing impacted trees causing damage to the left wing. Thereafter aircraft turned right and entered the runway finally coming to a halt on the LH side of runway. There was no fire."

The IAAIB further wrote: "As per the commander, he did the manual landing as he was not sure if he could do auto-land on a ground facility which is CAT I certified airfield in actual zero visibility."

After landing 2400kg of fuel were still on board of the aircraft, that had sustained damage to its left wing (including fracture and separation of wing tip, aileron damage, slat damage), blue hydraulic failure and left main gear and was disabled on the runway. The passengers disembarked onto the runway and were taken to the terminal, the passenger luggage was unloaded onto the runway and taken to the terminal, too. The aircraft was towed to the apron the following day.

With respect to the operator's dispatch the IAAIB analysed:

As brought out earlier in the report PIC rated pilot of the organisation with more than 500 hrs PIC experience (license/medical need not be current) can be nominated by General Manager (Ops.), as Designated Operations Controller, to exercise the functions of Operations Control. Operations Controller is required to be available at Flight Dispatch and he shall furnish the PIC, while in flight, with appropriate information that may be necessary for the safe conduct of the flight. However, the Investigation team observed that on the date of accident, no Operations Controller was available at Flight Dispatch, Delhi.

From the documentation and discussions with the flight dispatch personnel, it could not be established that who had dispatched the flight from Delhi to Guwahati. There were three personnel in the morning shift and the individual who had prepared the FWz Operational Flight Plan could be identified but Committee could not find any record indicating who finally dispatched the aircraft. No signatures of flight dispatcher were available in the dispatch register in the column provided.

Further, there is no systematic process of hand over and takeover of the shift and the briefings are all verbal and not documented. The Flight Dispatchers & Flight Crew was not aware of the requirement of PLANNING MINIMA REQUIRED FOR EN-ROUTE/ DESTINATION ALTERNATE nor was it followed. Keeping the weather trend of Jaipur under watch, flight dispatch proactively should not have filed Jaipur as an alternate.

The Flight Dispatch did not make any effort to update the flight crew with latest destination & alternate weather especially after the issue of 0900 UTC Delhi TAF which clearly mentioned that by time 1500-1600 UTC of 5th of January, the visibility would have dropped to 0200 meters, when this is read in conjunction with the METARS (1130 UTC onwards) which indicate outside air temperature & Dew point merging, the visibility/ RVR was bound to drop rapidly after sunset.

During the course of interview with the Flight Dispatchers committee was given to understand that the existing Narrow Body HF sets were unserviceable and the aircraft could only contact Delhi dispatch while in VHF range between (100-150 nms) from Delhi.

...

During the course of investigation and discussions with flight dispatchers, it came to light that most flight dispatchers had not undergone any specific training for preparation of the Flight Plans.

With respect to weather updates the IAAIB analysed:

The flight crew therefore was duty bound to seek weather update from ATC units and plan well in advance a course of action in case the weather goes below minima. As per the company SOP‘s, the flight crew is supposed to keep themselves updated with latest destination & alternate weather.

With respect to training the IAAIB analysed:

As per the PIC, he has not carried out any Cat-II or Cat-III ILS practice approach during last 6 months. He has undergone last simulator check in September 2011 wherein only one Low Visibility approach was carried out. Jaipur was below CAT I minima and the PIC has used his emergency authority, to make an approach below minima. He also informed that he has not undergone any training on Safety Management System (SMS). The flight crew was not aware of a safety policy of the company.

With respect to the sequence of events the IAAIB analysed:

During departure from Delhi the flight crew was not CAT II/III compliant to operate the last leg of the series of flight i.e. Guwahati-Delhi. Jaipur could not have been filed as an alternate due weather (temp/dew point) and weather trend from the TAFs available at that time. Before dispatching the aircraft from Delhi, the Flight Dispatch has not given additional fuel for the purpose of anticipated delay due ATC requirements for the return leg i.e. Guwahati to Delhi as per the regulations. Though the flight was dispatched from Delhi and the remaining sectors were self dispatch sectors, there is no procedure laid down for self dispatch.

Weather trend of Jaipur, Delhi & Lucknow should have been reviewed by the flight crew while departing from Guwahati for Delhi. Though 500 kgs of extra fuel was uplifted by the Captain but there was no feedback from the flight dispatch or ATC to captain on the anticipated delay. While crossing Varanasi Control neither the VHF VOLMET was available nor crew has asked Delhi Jaipur and Lucknow weather. Lucknow was the first designated alternate and had serviceable CAT II ILS facility available. Crew has not utilised updated Lucknow weather with the help of Lucknow ATIS to decide further course of flight.

In view of the fact that crew compliment was not CAT II/ III compliant, and the weather minima deteriorating below CAT I, the flight crew on the first instance should have diverted to Lucknow for which they had adequate fuel on board. Approach should not have been initiated into Delhi with RVR fluctuating toward the lower end of CAT I conditions for runway 28. Runway 29 was already below minima. Crew has not asked Delhi ATC for Jaipur and Lucknow weather.

Flight dispatch of the airline relayed to the aircraft Jaipur METAR which was 2 hours old indicating that visibility at Jaipur is 2000 m which prompted the flight crew to have false picture of Jaipur weather.

At the time of diversion to Jaipur, the aircraft had 3.1 tonnes of fuel on board which was adequate to divert to Lucknow which was the 1st alternate. The aircraft after commencing missed approach at Delhi was around 40 Nm west of Delhi. The incorrect weather information provided to flight crew prompted them to continue towards Jaipur which at that point of time was closer than Lucknow, however flight crew had not made any effort to check the weather with ATC Jaipur.

Once the crew was made aware of the rapidly deteriorating weather conditions (visibility/ RVR) at Jaipur, no discussions were held between the flight crew regarding diverting to Udaipur, Jodhpur or Ahmedabad.

No discussions were held between the crew to conduct an auto land once ATC advised them regarding visibility/ RVR going below CAT I minima when the flight crew committed themselves to land at Jaipur.

Flight crew continued to use the landing lights, which in such low visibility conditions impairs the forward vision. This probably contributed to the late sighting of the approach and runway lights by the flight crew, though there exists instructions in the organisation to keep the landing lights OFF for landing in low visibility conditions.

The PIC disengaged the auto-pilot at 200 feet. At 75 feet RA on the longitudinal axis, the Captain applied two successive back stick inputs (5.5° and 7°). The pitch increased up to 5.5°. On the lateral axis, aircraft was aligned with runway axis, left roll was commanded on captain stick leading left roll to increase. In the meantime, a progressive right rudder pedal input was applied.

The decision of PIC to disengage the autopilot was the last inappropriate act which caused the aircraft to deviate to left from localiser resulting in the aircraft landing (with both landing gears) on the soft ground.

The increase of pitch led to a slight decrease of the aircraft speed. The A/THR, which was still active, commanded an increase of the thrust to maintain the target speed. On lateral axis, the Captain applied successive right and left side stick inputs (high activity on the stick) with predominance on the left (up to full left order), increasing the left roll (up to 10° at 7ft RALT). In the mean time the right rudder pedal input was accentuated (up to 27° right order). These inputs led the aircraft to deviate to the left of the runway with a drift angle of 8° just before touchdown. TLA were progressively retarded and reached IDLE just after touchdown.
Incident Facts

Date of incident
Jan 5, 2014

Classification
Accident

Airline
Air India

Aircraft Registration
VT-ESH

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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