India A319 at Mumbai on Apr 12th 2013, landed without clearance and despite go-around instruction

Last Update: July 28, 2017 / 15:37:11 GMT/Zulu time

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Incident Facts

Date of incident
Apr 12, 2013

Classification
Report

Airline
Air India

Flight number
AI-944

Departure
Abu Dhabi, United Arab Emirates

Destination
Mumbai, India

Aircraft Type
Airbus A319

ICAO Type Designator
A319

An Air India Airbus A319-100, registration VT–SCL performing flight AI-944 from Abu Dhabi (United Arab Emirates) to Mumbai (India) with 81 passengers and 7 crew, was on approach to Mumbai's runway 27 when after being handed off to tower the crew did not report on tower frequency. There were two ground vehicles on the runway performing a runway inspection after a previous departure had reported a possible bird strike. one of the vehicle drivers noticed the aircraft on final approach and instructed the other vehicle driver to vacate the runway, both cars sped off the runway. Tower instructed the aircraft to go around, the aircraft however continued the approach and landed, after both cars had vacated the runway, safely on runway 27.

India's DGCA released their final report into the serious incident concluding the probable causes were:

- After being handed over to tower, the flight crew did not communicate with the ATC on any of the frequencies and continued to land whereas it was instructed to go around by the tower due ongoing runway inspection.

- Fatigue on the part of flight crew contributed to the error.

The DGCA complained that the CVR had not been retained after landing due to late reporting of the occurrence.

The DGCA reported the first officer (ATPL, about 2800 hours of total flying experience) was pilot flying, the captain (ATPL, about 8000 hours total) was pilot monitoring and operating the radio.

There had been no communication problem prior to be handed off to Mumbai tower. Once being handed off to tower the aircraft did not report on tower. The DGCA summarized the testimonies by both crew, that after tower frequency was selected there were disturbances and garbled transmissions on that frequency, multiple attempts to contact tower failed. They did not set the transponder code for loss of radio contact as they believed the radio was working however the frequency blocked by noise. They then became distracted observing the two cars on the runway, the captain briefed that they would go around if the cars had not vacated the runway at decision height. As the cars were off the runway at decision height, they continued the landing, at about that time they realized their radio wasn't working but again had no time to set the transponder code.

After landing, upon contacting ground the crew restored normal communication and explained the situation to ground control. The captain stated that after facing the communication failure they used VHF-1 only and did not use VHF-2.

The DGCA analysed:

The SSFDR data of flight AI-994 of 12-04-2013 indicated that the crew was in contact with ATC (Approach) till an altitude of 3000 ft. which corresponds to approximately 10 miles from touchdown. At this point the flight was changed from approach radar to tower frequency. From this point onwards crew have not made any transmission to the tower. (The next transmission was made after the Aircraft landed at Mumbai on ground frequency)

The crew at about 900 feet spotted two jeeps near N5 and as per them decided that in case the jeeps do not clear the runway they will abort approach by the decision altitude of 230 feet and carry out go around. Since when the aircraft was at 500 feet AGL, the jeeps had cleared the runway by N5, the aircraft landed on RWY 27. There was no visual warning signal from the ATC to carry out a go around.

The approach radar controller had cleared AI-944 for ILS approach and as per the “SOP for Mumbai airport (Jeppesen chart) in case of communication failure if Aircraft is cleared for approach it is expected to continue and land, if visual or -------”.

It was likely that air traffic controller assumed that a loss of communications would probably result in a go-around while pilots were expecting that they will land if they were able. These disparities probably lead to conflict between the thought process of controller and the pilot, thereby resulting in the incident.
Incident Facts

Date of incident
Apr 12, 2013

Classification
Report

Airline
Air India

Flight number
AI-944

Departure
Abu Dhabi, United Arab Emirates

Destination
Mumbai, India

Aircraft Type
Airbus A319

ICAO Type Designator
A319

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