REPORT ON ACCIDENT TO AIR INDIA EXPRESS BOEING 737-800 AIRCRAFT VT-AXV ON 22nd MAY 2010 AT MANGALORE BY THE COURT AIR MARSHAL BN GOKHALE, PVSM, AVSM, VM (Retd) FORMER VICE CHIEF OF AIR STAFF, INDIAN AIR FORCE GOVERNMENT OF INDIA MINISTRY OF CIVIL AVIATION THIS PAGE IS LEFT BLANK INTENTIONALLY REPORT ON ACCIDENT TO AIR INDIA EXPRESS BOEING 737-800 AIRCRAFT VT-AXV ON 22ND MAY 2010 AT MANGALORE BY THE COURT AIR MARSHAL BN GOKHALE, PVSM, AVSM, VM (Retd) FORMER VICE CHIEF OF AIR STAFF, INDIAN AIR FORCE GOVERNMENT OF INDIA MINISTRY OF CIVIL AVIATION REPORT ON ACCIDENT TO AIR INDIA EXPRESS BOEING 737- 800 AIRCRAFT VT - AXV ON 22nd MAY 2010 AT MANGALORE BY THE COURT AIR MARSHAL BN GOKHALE, PVSM, AVSM, VM (Retd) FORMER VICE CHIEF OF AIR STAFF, INDIAN AIR FORCE ASSESSORS: 1. Capt. Ron Nagar, Senior Vice President (Ops & Trg), Kingfisher Airlines, Mumbai 2. Shri Babu Peter, Executive Vice President (Engg), Go Airlines (India) Pvt Ltd, Mumbai 3. Shri SS Nat, Deputy DGCA (Retd), Club One Air, New Delhi 4. Shri Gurcharan Bhatura, Executive Director (Ops) (Retd), Airports Authority of India, New Delhi 5. Group Captain Deepak Gaur, Director Medical Services (Aviation Medicine), Air Headquarters, New Delhi SECRETARY Shri S N Dwivedi, Director of Airworthiness, O/o DGCA, New Delhi NEW DELHI st 31 OCTOBER, 2010 Contents Aircraft Accident Report, Mangalore Contents Serial No Subject Page No Executive Summary .......................................viii Abbreviations Used .......................................x Photographs, Diagrams and Tables..............xiii 1. Factual Information ........................................1 1.1 History of Flight ............................................................1 1.2 Injuries to Persons..........................................................7 1.3 Damage to Aircraft..........................................................8 1.4 Other Damages...............................................................8 1.5 Personnel Information.....................................................8 1.5.1 Pilot in Command - Capt Zlatko Glusica 1.5.2 First Officer - HS Ahluwalia 1.5.3 Cabin Crew 1.6 Aircraft Information.........................................................13 1.6.1 Aircraft Particulars 1.6.2 Airframe Particulars 1.6.3 Engine Particulars 1.6.4 APU Particulars 1.6.5 Maintenance Arrangements 1.6.6 Maintenance Records 1.6.7 Incidents 1.6.8 Snags Reported 1.6.9 Minimum Equipment List 1.6.10 Weight and Balance Information 1.6.11 Record of Previous Flight on VT-AXV Prior to The Accident 1.6.12 Landing Distance Specified by M/s Boeing Company 1.6.13 Aircraft Systems 1.7 Meteorological Information..............................................31 1.7.1 Area Weather Information 1.7.2 Mangalore Airport Weather Information 1.8 Aids to Navigation and Landing......................................33 1.8.1 Multi Mode Secondary Surveillance Radar (MSSR) 1.8.2 Non Directional Beacon (NDB) 1.8.3 Doppler Very High Frequency Omni Range (DVOR) 1.8.4 Distance Measuring Equipment (DME) 1.8.5 Instrument Landing System (ILS) 1.8.6 State of Navigation and Landing Aids on 22nd May 10 1.9 Communication...............................................................35 (iii) Contents Aircraft Accident Report, Mangalore 1.10 Mangalore Airport Information.........................................35 1.10.1 Licensing of Mangalore Airport 1.10.2 Runway 24/06 Safety Areas 1.10.3 Runway 24/06 Lighting Information 1.10.4 Runway 24 I L S System 1.10.5 Location of Air Traffic Control Tower 1.10.6 Facilities in the ATC Tower 1.10.7 ATC Watch Hours 1.10.8 Manning of ATC Controllers and Training 1.10.9 ATC Tape Recorder 1.10.10 Runway Marking and Friction 1.10.11 Rescue and Fire Fighting Capability at Mangalore Airport 1.10.12 Rescue and Fire Fighting Carried out on 22nd May 2010 1.11 Flight Recorders..............................................................40 1.11.1 Downloading of DFDR Data of the Accident Aircraft 1.11.2 Downloading of CVR Data of the Accident Aircraft 1.12 Wreckage and Impact Information..................................43 1.12.1 General Wreckage Distribution 1.12.2 Cockpit Switches and Gauges 1.13 Medical and Pathological Information.............................49 1.13.1 Post Mortem Report of PIC Captain Z Glusica 1.13.2 Post Mortem Report of First Officer H S Ahluwalia 1.14 Fire ................................................................................49 1.14.1 Fire in the Air 1.14.2 Post Impact Fire 1.14.3 Emergency Response 1.15 Survival Aspects ...........................................................50 1.15.1 General Description 1.15.2 Evacuation of Passengers and the Crew Members 1.15.3 Survivors 1.15.4 Assistance to Injured and Family Members 1.16 Examination and Testing of Components ....................53 1.16.1 Flight Compartment Controls and Indicators 1.16.2 Testing of Components 1.17 Organisational and Management Information ..............68 1.17.1 Brief History of Air India Express 1.17.2 Organisational Structure 1.17.3 Flight Operations 1.17.4 Employment of Foreign Pilots: Captain Z Glusica 1.17.5 Flight Crew Training 1.17.6 Flight Safety Organisation and Supervision 1.17.7 Computerisation for Efficient Functioning 1.17.8 Working Environment 1.18 Additional Information ...................................................77 1.18.1 Use of Mobile Phones and PED 1.18.2 Table Top Airport at Mangalore 1.18.3 Critical Airfields 1.18.4 Distance to Go Markers (DTGM) 1.18.5 Pilot Fatigue: FDTL Regulations 28 of 1992 1.18.6 Controlled Rest in Seat (iv) Contents Aircraft Accident Report, Mangalore 1.18.7 Submission by the Participants to the Court 1.18.8 Brief on Airports Authority of India (AAI) 1.18.9 Brief on DGCA 1.18.10 Setting up of Indian Aviation Safety Board 2. Analysis ............................................................83 2.1 General............................................................................83 2.2 Sequence of Events ……………………………………....83 2.2.1 Pre-departure Check by AME 2.2.2 Pre-flight check by Pilot 2.2.3 Take off 2.2.4 Climb 2.2.5 Cruise 2.2.6 Descent 2.2.7 Interception of DME Arc 2.2.8 Capture of Localiser 2.2.9 Initial Approach 2.2.10 Selection of Speed Brakes During Approach 2.2.11 High on Approach 2.2.12 Disengagement of Auto-Pilot 2.2.13 Unstabilised Approach 2.2.14 Landing 2.2.15 Braking 2.2.16 Accident 2.2.17 Pilot Incapacitation 2.2.18 Aspects of Hard Landing and Going Around 2.2.19 Incorrect Procedure to Ascertain False ILS Glide Slope 2.3 Flight Crew Performance ……………………………......92 2.3.1 Crew Resource Management 2.3.2 Trans-Cockpit Authority Gradient (TAG) 2.3.3 Analysis of Crew Conversation 2.3.4 Monitoring of Training and Evaluation 2.4 Cabin Crew Performance …………………….…...94 2.5 Airworthiness of Accident Aircraft …………………......94 2.6 Bird Strike …………………………………………......95 2.7 Portable Electronic Devices ………………………....…95 2.8 Analysis of Safety Factors at Mangalore Airport ….......95 2.8.1 Runway Surface and Friction 2.8.2 Downward Slope in Overshoot Area 2.8.3 Maintenance of RESA 2.8.4 Soft Ground Arrestor 2.8.5 Non-frangible ILS Mounting Structure 2.8.6 Strip Width 2.8.7 Narrow Roads outside the Perimeter 2.9 Analysis of Area Radar Availability …………………... 97 2.10 Additional Area Radar in the Region ……………….....98 2.11 Weather Conditions …………………………………......98 2.12 Sabotage Aspects …………………………………........98 (v) Contents Aircraft Accident Report, Mangalore 2.13 Fire ………………………………………………….........98 2.13.1 Fire in Air 2.13.2 Fire on Ground 2.13.3 Crowd Control 2.14 Aero Medical Aspects ………………………………..…99 2.14.1 Medical History of Pilot-in-Command: Capt Z Glusica 2.14.2 Medical History of First Officer: HS Ahluwalia 2.14.3 Pre-Flight Medical Examination 2.14.4 Evidence and Possible Consequences of Fatigue 2.14.5 The Survivors 2.14.6 Requirement for Post-Mortem Examination 2.14.7 Post-Mortem Findings 2.15 Analysis of ATC and Flight Recorders ………….…...107 2.15.1 ATC Recorder Analysis 2.15.2 DFDR Analysis 2.15.3 CVR Analysis 2.15.4 Co-relation of Data of Recorders 2.16 Circumstances Leading to the Crash of the Aircraft ...111 2.17 Why did the Accident Take Place? …………………...112 3. Conclusion ..................................................113 3.1 Findings ……………………………………………….......113 3.2 Cause of the accident ........................................…...115 3.2.1 Direct causes 3.2.2 Contributing factors to the accident 4. Recommendations .......................................116 4.1 For the Parent Company Air India and the Operator Air India Express …………………………….………...116 4.1.1 Air India Express Should Operate as a Separate Entity 4.1.2 Need for Calibrated Growth of Air India Express 4.1.3 Post Holders in Air India Express 4.1.4 Computerised Network for all Activities 4.1.5 Flight Safety Management 4.1.6 Training 4.1.7 Training on Simulator 4.1.8 Co-ordination Meetings 4.1.9 Crew Resource Management (CRM) 4.1.10 Employment of Foreign Pilots 4.1.11 Crew Scheduling 4.1.12 Pre-flight Medical Check 4.1.13 Aviation Medicine Specialist 4.2 For Airports Authority of India (AAI) …………………...122 4.2.1 SOP on Watch Hours 4.2.2 Avoidance of Downward Slope in the Overshoot Area Particularly on Table Top Runways 4.2.3 Need for Frangible Structures on the Overshoot Area 4.2.4 Maintenance of RESA 4.2.5 EMAS and Soft Ground Arrestor Barrier 4.2.6 Installation of Distance to Go Markers (DTGM) (vi) Contents Aircraft Accident Report, Mangalore 4.2.7 Location of Air Traffic Control Tower at Mangalore 4.2.8 Approach Radar/Area Radar Repeater in the ATC Tower 4.2.9 Preventing Erosion of Strip