Indian Airlines Flight 605
| Indian Airlines Flight 605 | |
|---|---|
 A similar Airbus A320-231 from Indian Airlines |
|
| Accident summary | |
| Accident type | Controlled flight into terrain |
| place | Challaghatta Valley, near HAL Bangalore International Airport , India
|
| date | February 14, 1990 |
| Fatalities | 92 |
| Survivors | 54 |
| Injured | 54 (including 22 difficult) |
| Aircraft | |
| Aircraft type |
 Airbus A320-231
|
| operator |
Indian Airlines
|
| Mark |
VT-EPN
|
| Departure airport |
Bombay Airport , India
|
| Destination airport |
HAL Bangalore International Airport , India
|
| Passengers | 139 |
| crew | 7th |
| Lists of aviation accidents | |
The Indian Airlines Flight 605 (flight number IC605 ) was a domestic flight of the airline Indian Airlines from Bombay airport for HAL Bangalore International Airport . On February 14, 1990, an Airbus A320-231 with the registration number VT-EPN crashed shortly before landing. 92 people were killed in the accident and 54 survived.
It was the first fatal incident involving an Airbus A320-200 , the first of which had been delivered in May 1989. For more than ten years it was the worst accident with this type of aircraft. As a result of the investigation, the accident was attributed to pilot errors, but the Indian pilots union India Commercial Pilot Association (ICPA) contradicted the accident report and blamed design errors on the aircraft, especially the layout of the controls and the fly-by-wire controls. The captain's high level of flight experience was offset by a comparatively low level of experience with the modern Airbus and its computer control.
plane
The aircraft involved in the accident was an Airbus A320-200 that was five months old at the time of the accident. The aircraft had undergone final assembly at the Airbus Clément-Ader plant in Toulouse- Saint-Martin-du-Touch, France and completed its maiden flight on September 15, 1989 with the test registration number F-WWIV . On December 23, 1989 the delivery to Indian Airlines with the aircraft registration VT-EPN followed . It was the 79th Airbus A320 produced, of which the first 21 aircraft were still in the A320-100 version. The twin - engine, narrow -body aircraft was equipped with two IAE V2500-A1 engines. The Airbus had the main landing gear specially designed by Airbus for Indian Airlines and the ten-wheeled main landing gear that was only delivered to them. By the time of the accident, the machine had completed a total of 370 operating hours, with 302 take-offs and landings.
Passengers and crew
There were 139 passengers, including four children on board. The crew consisted of the master, the first officer and five flight attendants.
The machine was controlled by the 46-year-old Indian citizen Cyril A. Fernandez in the left pilot's seat. As a qualified first officer, he should complete the first of ten test flights for certification as a captain on the A320. He worked for Indian Airlines from 1977, first as first officer on the Hawker Siddeley HS 748 , then as captain on this type. Fernandez became first mate on the Boeing 737 in 1983, and captain on this machine a year later. In 1989 Fernandez became first officer for the Airbus A320. He had 9,307 hours of flight experience, 68 of which with the Airbus A320.
The examiner overseeing Fernandez was Satish S. Gopujkar, a 44-year-old Indian national. He was employed by Indian Airlines from 1969, first from 1971 to 1981 as first officer on the Hawker Siddeley HS 748. He later flew machines of this type as a captain. In 1981 he obtained a type rating as first officer on the Boeing 737, and in 1983 as captain. In 1989 he became first officer on the Airbus A320. Captain Gopujkar had 10,340 hours of flight experience, including 255 on the Airbus A320. During the flight he carried out both the duties of a first officer and a test captain.
Flight history
Indian Airlines Flight 605 was a domestic flight from Bombay (now Mumbai) to Bangalore |
The plane took off from Bombay Airport ( Mumbai since 1995 ) at 11:58 a.m. local time, one hour late . At 12:53 p.m., the machine appeared on the radar system of flight control in Bangalore . The air traffic control instructed the crew to make a right turn and approach runway 09 according to visual flight rules. The pilots later switched off the autopilot and contacted the control tower in Bangalore. The weather at the destination airport was slightly hazy with scattered clouds at a height of about 600 meters. The wind speed was five knots , the air temperature was 27 ° C and the visibility was 10 kilometers.
On its final approach, the aircraft touched down about 850 meters from the airport on the grounds of the Karnataka Golf Club . Most of the occupants of the machine, including the surviving crew members, thought at the time that the machine had landed because that was how it felt when it touched down. After the machine had risen slightly again, the landing gear and both engines were correctly sheared off due to the design when it touched down again on the golf course on a three-and-a-half meter high dam . Several passengers had previously opened their seatbelts, which threw them to the ground. The machine shot across a road behind the embankment and came to rest on a site outside the airport's walls.
Rescue operation
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After the accident, the fuselage caught fire from the front right part, presumably near the wing root. A member of the cabin crew opened the rear left emergency exit and initiated the evacuation. Some passengers managed to leave the machine through a hole in the fuselage that had been made during the accident, others through the wing emergency exits. Most of the survivors were among the passengers on the plane on the left. A total of 92 people, including 86 passengers and four crew members including both pilots, died at the scene of the accident. Two passengers later died of their injuries in the hospital. One crew member and 21 passengers were seriously injured. Two other crew members and 30 passengers suffered no or only minor injuries.
The first designated rescue workers at the airport were at the end of the runway within two minutes, but could not reach the scene of the accident because they did not have a key to open an exit gate in the airport fence and because the area was a bit swampy. The gate was still locked around 15 minutes after the accident. Personnel arriving later finally sawed open the lock. Two fire engines did not reach the source of the fire adequately with their extinguishing agent from within the premises and also had no possibility of refilling their own tanks in the vicinity. The first rescuers reached the aircraft on foot when cries for help came from the fuselage behind the left wing. Three or four people were saved there. During this time, other fire engines, including those from the Hindustan Aeronautics fire brigade , arrived and supported the fire fighting work.
Victim
According to official reports, at least 20 people suffered head injuries and 32 people injured their lower limbs . Seven people suffered chest injuries.
The report showed that many victims had survived the impact themselves, but were too badly injured to leave the wreck on their own, so that they were at the mercy of the fire that broke out. The accident report noted that most of the passengers who survived the accident sat near the emergency exits and evacuation slides.
Since most of the passengers suffered head and leg injuries, the investigation assumed that this was due to poorly constructed footwells. In addition, many seats were moved forward in the event of an impact, which is why passengers hit the seats in front of them with their heads. The reason why the numerous seat belts jumped open on landing was that the passengers had not properly tightened them for landing.
Accident investigation
In addition to the accident investigations by the Indian Aircraft Accident Investigation Authority AAIB, the Transportation Safety Board of Canada analyzed the data from the digital flight data recorder at the request of the Indian government . The accident investigators visited the site of the accident on February 19, 1990 and examined the debris of the machine. They found that the front part of the machine had been destroyed by the impact with the embankment. In a subsequent fire, the machine was then completely burned out. After recovery of the flight data recorder and the voice recorder , investigators in the evaluation of the data found that the machine at the time of the accident in the mode of a "idle descent" (open descent) were. The engines are idling and the autopilot restricts itself to keeping the speed in the required range with the help of the angle of attack (pitch around the transverse axis ).
the accident
The investigation revealed that the cockpit crew switched off the autopilot after sighting the runway at Hindustan Bangalore Airport. The pilots then contacted air traffic control in Bangalore. At 13:01 local time, the cockpit displays showed the pilot that the aircraft was at almost 5,000 ft (1,524 m ), which meant that its approach path was 600 ft (183 m ) above the normal glide path .
Captain Fernandez noticed this and suggested a go - around to ascend to 6,000 ft (1,829 m ), fly a traffic pattern , and then make a more aligned approach along the normal glide path. Inspector Gopujkar replied to his request: “Do you want a go-around? Or do you want a higher rate of descent? ” (13:01:40 Check Pilot:“ Go around you want? ”, 13:01:48 Check Pilot:“ Or you want vertical speed. ”) Captain Fernandez finally decided to reduce the rate of descent ( vertical speed) . The investigation committee later came to the conclusion that the following accident could have been avoided if the pilots had agreed on a missed approach at this point in time .
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Since the machine was flying above the normal glide path, Captain Fernandez asked for a higher rate of descent of 1,000 ft (305 m ) per minute instead of the usual 700 ft (213 m ). As a result of this faster descent, the flight speed of the machine increased to 275 km / h and thus to more than the recommended 240 km / h - but this allowed the machine to return to the intended glide path. The machine was also in a correct control mode for landing with a high but defined rate of descent.
Inspector Gopujkar then went through the landing checklist and then asked the cabin crew to sit in their seats. After realizing that the machine had returned to the intended glide path, he informed Captain Fernandez at 13:02:42 that he had set a rate of descent of 700 ft (213 m ) per minute again. Instead of using the descent speed switch, he accidentally operated the altitude switch. So instead of re- entering a more moderate rate of descent of 700 ft (213 m ) per minute, he instructed the machine to descend to an altitude of 700 ft (213 m ). The descent speed and altitude switches are arranged side by side and designed similarly, which may have confused the pilot. However, the threshold height of the runway at HAL Bangalore International Airport is 2,912 ft (888 m ). In this case, this means that the automatic control system did not have any orders to independently cancel the descent at some point over the terrain.
As a result of the inputs from Inspector Gopujkar, the aircraft went into an “idle descent” mode, so that the engines were idling. Due to the lack of engine thrust, the machine's speed decreased and the Airbus quickly lost altitude. Although the disaster was imminent, the crew seemed unaware of it. The report found that the pilots did nothing during the 25 seconds when they should have acted.
After the voice output of the altimeter had warned the pilots of a remaining height of 400 ft (122 m ), test captain Gopujkar remarked: “You are sinking all the time in an idle descent!” (13:02:53 Check pilot: “You are descending on idle open descend ha, all this time. ") . According to the accident report, this was 14 seconds before the last possible time to intercept the machine. When 300 ft (91 m ) was announced, Inspector Gopujkar asked if Fernandez would like to turn off the flight director . This replied that his was switched off. Inspection Captain Gopujkar's flight director, on the other hand, remained active, although he himself remarked: " But you didn't turn mine off" (13:03:00 Pilot Flying: "But you did not put off mine.") And according to the investigation it was his job would be to disable both. Had both been turned off at this point, the machine would have activated its speed mode and enough thrust would have developed even at this late point to prevent it from hitting the ground.
Three seconds later came the altimeter announcement for 200 ft (61 m ) and another two seconds later the computer control activated a protection program (Alpha Protection Speed) because the speed was too low in relation to the angle of attack (Alpha) of the aircraft.
The machine continued to fly towards the ground. When she was only 135 ft (41 m ) above the ground, Captain Fernandez suddenly became aware of the seriousness of the situation and shouted: “Hey, we're going to crash!” (13:03:10 Pilot Flying: “Hey, we are going down. ") . The stunned test captain Gopujka only replied with: "Oh, shit!" (13:03:11 Check pilot: "O shit.") These were the last words recorded by the voice recorder. Meanwhile, Captain Fernandez gave control orders for an immediate go- around , for which it was already too late. Investigators said the serve could have been prevented if the go-around had been initiated two seconds earlier. Incidentally, due to the protection program activated four seconds earlier, the control computer had ahead of the pilot by one second when starting up the engines: the pilot had pulled the control stick moderately before the final decision to go around, and the aircraft was now in the Alpha Floor state, which is decisive for the computer reached, at which he ordered full thrust. Although the machine made a hop five seconds after the first contact with the ground, which was estimated to be around three meters high due to the fallen trees, it came back to the slightly rising ground and moved with it to the 3.5 meter high embankment at the end of Karnataka Golf club too.
Final recommendations
The recommendations of the investigation included the construction of additional driveways on the airport side for the rescue vehicles as well as equipping all rescue vehicles with keys for the outside gates of the airport fence. Furthermore, Airbus was asked to change the design of the control button for the descent speed so that it could no longer be confused with the switch for the flight altitude. In addition, an improvement in the evacuation slides was suggested, as some had not been triggered during the evacuation. In connection with the leg injuries suffered by many of the victims, it was recommended that the seat structure be provided with foam padding wherever such injuries are likely to occur.
Reactions to the aircraft accident
Indian Authorities and Pilots Union
In addition to initiating accident investigations, the Indian authorities ordered a flight ban on all fourteen Airbus A320s in operation in India until the causes of the accident had been clarified. In Indian aviation history, this was the most drastic measure taken after an aircraft accident to date.
The Indian aviation accident investigators later came to the conclusion that the accident had been caused by pilot errors. The Indian pilots union India Commercial Pilot Association (ICPA) contradicted the report and took the view that a design flaw on the Airbus A320 was the cause of the accident. The ICPA found that an experienced pilot like Captain Gopujkar could not have made such an extensive series of mistakes.
However, the captain's extensive general flight experience was offset by a comparatively low level of experience with the modern Airbus A320 and its fly-by-wire technology. The captain could not have made the mistake despite his experience, but rather because of it. The ICPA nevertheless stressed that there was no evidence that he made the wrong entry, as the flight data recorder did not record such errors. In contrast to what the investigators said, the ICPA was of the opinion that the engines had gone into idle due to a serious system defect. When Gopujkar tried to switch off his flight director, according to the thesis of the ICPA, he did not react.
At the time of the accident, the Airbus A320 was relatively new to the market as it was only introduced in 1988. It differed significantly from earlier aircraft models in the fly-by-wire technology used. In conventional aircraft, pilots regulate the thrust of a machine through direct control commands. In the Airbus A320, the pilots' control commands are implemented by the on-board computer: Control commands are only carried out as far as they pose no danger to the aircraft and the thrust is also activated with a delay of up to half a second. In this case, however, the on-board computer had given full thrust one second before the pilot, purely because of the flight position, not because of the approach to the ground. At most, it played a role that fly-by-wire decouples the pilot from the flight physics and the forces that occur on the rudders and flaps, or that the pilots cannot tell which control commands the other pilot is sending to the aircraft, as there is no mechanical coupling between the two pilots as in conventional aircraft. Correct communication between the pilots is all the more important. When the check pilot made the first control input in this case, however, it was ineffective because the flying commander had already pulled the steering wheel to the stop. More modern developments in fly-by-wire control provide artificial feedback by using actuators to simulate the forces on control sticks or pedals.
Changes to the A320 by Airbus
As a result of the aircraft accident, Airbus made changes to the flight director and the early warning system for insufficient airspeed and improved the display of the idle status of the engines (IDLE) and the airspeed on the PFD (Primary Flight Display) .
Less than two years after the accident in Bangalore there was the third time in a row to a fatal accident of the type Controlled flight into terrain of an Airbus A320, as a machine on the Air Inter Flight 148 landing at Strasbourg against the Odilienberg bounced. After this accident, the final report of the investigative commission explicitly criticized the cockpit design of the Airbus, which caused the pilots to set an incorrect rate of descent. As a result, the cockpit design of the Airbus A320 was changed.
See also
- List of Airbus A320 Family Incidents
- Turkish Airlines flight 1951 on February 25, 2009, on which a Boeing 737-800 was put into idle shortly before Amsterdam Airport by control commands from the autopilot and the crew intervened too late
literature
- K. Shivashankar Bhat (Karnataka High Court): Report on the Accident to Indian Airlines Airbus A320 Aircraft VT-EPN on February 14th, 1990 at Bangalore. Government of India, Ministry of Civil Aviation, 1990 ( PDF with different page numbers than the original document).
Web links
- Cover of India Today magazine with a picture of the burning machine shortly after the impact
- Simulation of the course of the accident by the Canadian Transportation Safety Board , YouTube
Individual evidence
- ↑ Production list Airbus A320. on Airfleets.net, accessed December 5, 2019.
- ↑ VT-EPN Indian Airlines Airbus A320-200. on planespotters.net, accessed November 30, 2019.
- ↑ Accident report A320-231 VT-EPN. on the Aviation Safety Network , accessed November 30, 2019.
- ↑ K. Shivashankar Bhat: Report on the Accident to Indian Airlines Airbus A320 Aircraft VT-EPN. 1990, p. 31 f. (Pages in PDF ).
- ↑ K. Shivashankar Bhat: Report on the Accident to Indian Airlines Airbus A320 Aircraft VT-EPN. 1990, p. 31 (pages in PDF ).
- ↑ a b K. Shivashankar Bhat: Report on the Accident to Indian Airlines Airbus A320 Aircraft VT-EPN. 1990, pp. 27–29 (pages in PDF ).
- ↑ a b c d e f Indian Airlines Flight 605, Airbus A320-231, VT-EPN Location: Bangalore, India Date: February 14, 1990 , Lessons learned from civil aviation accidents, Federal Aviation Administration , accessed on November 30, 2019.
- ↑ K. Shivashankar Bhat: Report on the Accident to Indian Airlines Airbus A320 Aircraft VT-EPN. 1990, p. 30 and 72 (pages in PDF ).
- ↑ K. Shivashankar Bhat: Report on the Accident to Indian Airlines Airbus A320 Aircraft VT-EPN. 1990, p. 30 f. (Pages in PDF ).
- ↑ K. Shivashankar Bhat: Report on the Accident to Indian Airlines Airbus A320 Aircraft VT-EPN. 1990, pp. 130-132 (pages in PDF ).
- ↑ K. Shivashankar Bhat: Report on the Accident to Indian Airlines Airbus A320 Aircraft VT-EPN. 1990, pp. 121–132 (pages in PDF ).
- ↑ K. Shivashankar Bhat: Report on the Accident to Indian Airlines Airbus A320 Aircraft VT-EPN. 1990, p. 128 (pages in PDF ).
- ↑ K. Shivashankar Bhat: Report on the Accident to Indian Airlines Airbus A320 Aircraft VT-EPN. 1990, p. 44 (pages in PDF ).
- ↑ K. Shivashankar Bhat: Report on the Accident to Indian Airlines Airbus A320 Aircraft VT-EPN. 1990, p. 46 (pages in PDF ).
- ↑ K. Shivashankar Bhat: Report on the Accident to Indian Airlines Airbus A320 Aircraft VT-EPN. 1990, p. 45 (pages in PDF ).
- ↑ K. Shivashankar Bhat: Report on the Accident to Indian Airlines Airbus A320 Aircraft VT-EPN. 1990, p. 24 and 41–43 (pages in PDF ).
- ↑ a b c d e f g h 14 February 1990 - Indian Airlines 605. Cockpit Voice Recorder Database, tailstrike.com (transcription of the Cockpit Voice Recorder), accessed on November 30, 2019.
- ↑ K. Shivashankar Bhat: Report on the Accident to Indian Airlines Airbus A320 Aircraft VT-EPN. 1990, p. 152 (pages in PDF ).
- ↑ K. Shivashankar Bhat: Report on the Accident to Indian Airlines Airbus A320 Aircraft VT-EPN. 1990, p. 2 (pages in PDF ).
- ↑ a b K. Shivashankar Bhat: Report on the Accident to Indian Airlines Airbus A320 Aircraft VT-EPN. 1990, p. 152 (pages in PDF ).
- ↑ K. Shivashankar Bhat: Report on the Accident to Indian Airlines Airbus A320 Aircraft VT-EPN. 1990, p. 13 (pages in PDF ).
- ↑ K. Shivashankar Bhat: Report on the Accident to Indian Airlines Airbus A320 Aircraft VT-EPN. 1990, p. 15 (pages in PDF ).
- ↑ K. Shivashankar Bhat: Report on the Accident to Indian Airlines Airbus A320 Aircraft VT-EPN. 1990, p. 14 (pages in PDF ).
- ↑ Prabhu Chawla: Rs 2,400-crore Airbus A 320 deal smacks of undue haste and arbitrariness. In: India Today . March 15, 1990, Retrieved December 3, 2019.
- ↑ a b c Raj Chengappa: Dispute over findings. In: India Today . June 15, 1990, Retrieved November 30, 2019 .
- ↑ a b Airbus Briefing: Airbus Industrie Flight Safety: A320 Accident - Bangalore 14 February 1990. Chapter: Safety Enhancements , pp. 27-36, accessed on December 3, 2019.
- ↑ Accident report A320-111 F-GGED. on the Aviation Safety Network , accessed December 3, 2019.
Coordinates: 12 ° 56 '53.2 " N , 77 ° 38' 52.1" E
