Air India, Mangalore 22 May 2010, Mishap

All: Does it appear that this operator and the regulator are “coming to the safety party too late? Are they trying to close the corral gate after the horses have already escaped from the barnyard?”

Is this “investigation” going to relearn of all of the lessons already learned by others? Would this investigation be categorized as a “safety investigation,” or more of a futile exercise of re-examing the same mishap over and over again?

Possibly shooting from the hip, but here is what pops out at first blush:

1. No stabilized approach criteria, training or performance
2. No crowned and grooved runway, nor a national policy by the country regulator
3. No wind field data available or provided to the flight crew during convective weather
4. No back up of flight crew with real time metro data from their own flight dispatch office
5. No convective weather wind shear evaluation escape procedures trained, checked or used by the flight crew
6. CRM training appears to be ineffective.
7. Reject landing procedures, training and performance appears to be ineffective.
8. No coordination of convective weather arrival avoidance and holding procedures in effect by ATC

This is Just My Humble Opinion of course. But it seems to me when all this process is completed, nothing will be learned that could not have already been determined ahead of time, before the mishap occurred. This mishap appears to have been preventable. Why are so many organizations around the world unwilling, unable and unprepared to operate with safe standards?

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Pilot Error Seen Likely in Fatal India Landing (WSJ, June 21)

Investigators are becoming increasingly convinced that last month’s fatal Air India Express crash was caused by pilots landing too far down a hilltop runway, and belatedly trying to get the Boeing 737 airborne again, according to people familiar with the probe.
Preliminary conclusions about the May 22 accident in India’s southern city of Mangalore, these people said, indicate failures by the pilots to follow basic safety rules during the final approach, compounded by apparent cockpit confusion after touchdown. Only eight of the 166 people aboard survived the early morning crash, in which the twin-engine jet plummeted down a cliff at the end of the strip, broke apart and then caught fire. It was India’s worst aviation disaster in more than a decade, and has prompted a barrage of criticism.
Regulators and international air-safety experts are now focusing on ways to fix persistent shortcomings in India’s pilot-training programs. Indian officials already have proposed tightening rules ranging from acceptable landing procedures to fatigue-prevention schedules for crews. Broader mandates are likely.
Other areas under scrutiny include safeguards when pilots temporarily leave the cockpit for breaks. There also are stricter requirements that all aviators-particularly expatriate pilots-speak good English and are well-versed in air-traffic-control terminology. The captain of the accident plane was a British citizen of Serbian descent, and the co-pilot was an Indian national.
Indian regulators also are considering ways to ensure that pilots are trained and assigned so they fully understand the particular handling characteristics of a designated aircraft model.
“A lot of new and revised safety proposals…will be disclosed next month,” an official with India’s regulator, the Directorate General of Civil Aviation, said Friday. The DGCA official wouldn’t discuss details of the probe except to say that “the possibility of pilot error” on the flight “cannot be ruled out.”
The moves come amid increased domestic and international criticism of alleged gaps in India’s commercial-aviation safety net. A U.S. Federal Aviation Administration team plans to visit the country later this year to make an informal assessment of progress in enhancing safety, according to people familiar with the issue.

About Paul Miller

Captain Paul Miller has developed a unique approach to aviation safety by forecasting safety hazards. Yes, that is right, forecasting safety hazards. Most people think of safety as a study of what has already gone wrong. But SafetyForecast looks forward in time at factors that will negatively impact your business in the future. Then using this unique and very powerful forecasting tool, you will be able to develop a unique Safety Plan. That is right, a Safety Plan. Your tailored Safety Plan will reduce losses of personnel and property to well below your most extraordinary expectations. That is our guarantee. No other safety consultant uses this method and no method has ever achieved the superior results by driving the mishap rate towards zero in such a short time. SafetyForecast modest consulting fees will be recovered by your business in a short time by the reduction of just the financial and legal losses alone, losses that you do not often think about due to mishaps. No other consultant will provide a unique Safety Plan that will make your company prosper by saving lives and injuries. Additionally your company will prosper by reducing the damage and destruction of property. Try SafetyForecast and you will see for yourself how well the Safety Plan works.
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One Response to Air India, Mangalore 22 May 2010, Mishap

  1. Paul Miller says:

    Would a safety program based on prevention rather than mishap investigations help?

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