1.
Aircraft Type :
Aircraft
Model : ATR 72-212 A.
Nationality : Indian.
Registration : VT-KAC.
Engine Type : Turbo-prop.
Model : PW 127 F
2.
Owner : M/s KF Aero, Paris, France.
3.
Operator : M/s Kingfisher Airlines, Mumbai
4.
Date of Incident : 10th November, 2009.
5.
Time of Incident : 16:40 IST.
6.
Last point of departure : Bhavnagar
7.
Point of intended landing : Mumbai
8.
Geographical location of : Lat. N 190519.5
the site of Incident : Long E 0725056.9
9.
Type of Operation : Scheduled Flight.
10.
Phase of Operation : During landing.
11.
Type of Incident : Aircraft Skidded off R/W 27 A after landing.
(All timing in IST)
3. CONCLUSIONS:
3.1
FINDINGS:
3.1.1 The Certificate of Airworthiness of the aircraft was valid on the date of incident.
3.1.2 All maintenance schedules for the aircraft were found to be complete.
3.1.3 All mandatory modification status have found to be complied with.
3.1.4 There was no major defect/snag pending on the aircraft prior to this incident flight.
3.1.5 The license for both the crew was valid to operate the flight.
3.1.6 As per DGCA circular for operation on 27A, the Pilot in command should have been a Training Captain & the first Officer should have a minimum 300 hrs on type. The commander however was not meeting this laid down conditions.
The AAI had issued a special NOTAM one day prior to operation restricting the operation on 27A. The Final Approach Fix was made at 9.5 DME instead of 10 DME. Only VOR-Localizer approach was permitted on 27A since the runway length was restricted to 1703M.
Prior to Kingfisher aircraft, Air India flight IC-164 operated with A319 aircraft landed and aquaplaned during landing. Same was reported to the ATC. The ATC controller did not understand the terminology ‘aquaplaning’ and its seriousness cleared the Kingfisher aircraft for landing which also aquaplaned after landing and resulted into serious incident.
The ATC while giving the landing clearance to the kingfisher aircraft did not mention that the earlier aircraft had aquaplaned during landing and also that runway had water patched on the runway.
Kingfisher aircraft during approach was not on profile and was high and fast, the ATC advised them that they were not profile and report when runway in sight.
The commander disconnected autopilot early and carried out a very steep descent with high rate of descent generating sink rate warning in the cockpit to come on profile.
The decision of the crew to continue a unstablized approach was not in accordance with requirements of the company’s operations manual and regulatory instructions.
There was a failure of crew resource management principles on part of the pilot for not carrying out adequate briefing regarding the approach procedure and R/w conditions of R/W 27A and on Part of Co pilot in not intervening to abort the unstablized approach and make a “Go Around”.
The aircraft floated a bit and landed late on the runway. The runway length available after touchdown was around 1000m which was just enough for the aircraft to stop on the runway.
After touch down the pilot applied reversers but felt that the aircraft was not decelerating and the aircraft was skidding to the left. Both the pilots applied maximum foot pedal brakes but the aircraft kept on skidding realizing that the aircraft will not stop on the runway the pilot initiated a right turn and entered into unpaved surface and finally came to rest in the soft ground.
Neither the ATC nor the operating Crew of the kingfisher were aware that the operation was to be suspended under wet runway conditions.
3.1.16
3.1.17
Both the cockpit crew and the all the passengers evacuated the aircraft safely without any major injury.
No.2 engine did not shut down even after pulling the fire handle.
PROBABLE CAUSE OF THE SERIOUS INCIDENT:
The incident occurred due to unstabilized approach and decision of crew not to carry out a ‘Go-around’.
Contributory Factors:
i) Water patches on the R/w 27A
ii) Inability of the ATCO to communicate the aircraft about aquaplaning of the previous aircraft
iii) Lack of input from the co-pilot.
4. SAFETY RECOMMENDATIONS:
4.1 Corrective training may be imparted to the involved crew in view of the lapses brought out on their part in the report.
4.2 AAI may bring it to the notice of all concerned that while giving the landing clearance to the aircraft the characteristics of aquaplaning or water patches on the runway, if any, should be mentioned.
4.3 Kingfisher should evolve a system of disseminating the information affecting the safety of aircraft operation to all concerned immediately.
4.4 Non shutting-off, the engine even after pulling down the fire handle may be referred to Aircraft Manufacturer for analysis.
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