Indian King Air Take Off Accident: Organisational & Training Weaknesses
Beechcraft King Air 200 VT-BSA of the Indian Border Security Force (BSF) Air Wing crashed on 22 December 2015 after a Loss of Control – Inflight (LOC-I) shortly after take off on a flight from New Delhi to Ranchi. There were ten persons on board, all of whom were fatally injured.
The Accident Flight
Shortly after take-off and attaining a height of approximately 400 feet AGL, the aircraft progressively turned left with simultaneous loss of height. It had taken a turn of approximately 180º and impacted some trees before hitting the outside perimeter road of the airport in a left bank attitude.
Thereafter, it impacted ‘head on’ with the outside boundary wall of the airport. After breaking the outside boundary wall, the wings impacted two trees and the aircraft hit the holding tank of the water treatment plant. The tail portion and part of the fuselage overturned and went into the water tank.
There was post impact fire and the portion of the aircraft outside the water tank was destroyed by fire.
The weather at the time of accident at Delhi was foggy with visibility reported as 800 meters and winds of 3 knots. The previous METAR which was available with the flight crew mentioned visibility of 600 meters. The visibility was marginal and it is inferred that the marginal visibility was a contributory factor to the accident.
The safety investigators explain that:
As per the Pilot Operating Handbook procedure…the autopilot should be engaged only after attaining the height of 500 feet AGL…
…however conversation recorded on the CVR indicates that…
…the Autopilot was engaged just after the aircraft had lifted off (even the landing gear had not been retracted).
This hurried and non-standard action by the flight crew…reveals their eagerness to let the aircraft be flown by the autopilot…
Engagement of the autopilot without engaging the Heading Mode resulted in the aircraft turning left probably due to the existing left bank or inadvertent manual input by the flight crew at the time of engagement of the autopilot.
The bank angle increased progressively and beyond 45º , a situation the flight crew could not decipher because of their disorientation.
Organisational Factors and Culture
The safety investigators make the point that:
An Organisation may look compliant vis-a-vis the mandatory requirements but may still be seriously deficient in discharging its duties safely and efficiently.
We would add, that they may even be compliant but effectiveness may be weak. The investigators elaborate:
Therefore deeper analysis of the Organizational Structure & Procedures (if existing), and those practised is required to find out the answer to the circumstances leading to the accident.
The safety investigators then note that:
Civil Aviation Requirement Section 3 – Air Transport Series C Part X Issue I, gives the minimum procedural requirements for the issue of permission to undertake aircraft operations by State Governments or Public Sector Undertakings of the Central/ State Governments.
Unlike in some other nations, this requires a Safety Management System (SMS) for such operations. However they determined that the Safety Department and SMS “was practically non-existent” (similar to a prior 2015 Indian offshore helicopter accident):
From the discussions with the Officers who were designated as the Chief of Flight Safety in the present and past, it was noted that as and when any regulatory requirement arose, an Officer was nominated for the purpose. At times Officers have conveyed their unwillingness to the Accountable Manager & Alternate Accountable Manager on the work load grounds and not being trained on Flight Safety.
In this case the current Chief of Flight Safety was under-qualified for the position and had only been accepted on 6 months probation.
A Flight Safety Manual and the SMS Manuals had been prepared, and the Safety Policy had been signed by the Accountable Manager. However these where what we like to term ‘shelfware‘:
It appears, however that these documents were prepared for fulfilling the regulatory requirements [for manuals / policies] only.
The safety investigators further point to a series of occurrences that had not been formally recorded during the previous 6 months.
In this case the safety investigators say:
The Organisation seems to suffer from Complacency…
The PF was released as PIC after 620:35 hours of co-pilot experience on Type, while the PM was released as PIC after 183 hours of co-pilot experience on Type.
Most of the on Type experience of these two flight crew was gained while flying amongst themselves.
There [was] no laid down procedure in the Organisation regarding ‘Flying under Supervision‘.
Despite written instructions of the Accountable Manager that an experienced pilot should be on board as the second pilot whenever the PF or PM were flying as PIC, these low experienced pilots did not fly under supervision of an experienced pilot while building their respective PIC experience.
Though the numbers of flying hours flown by these flight crew members was increasing the investigators query if thus “added to qualitative improvement in their flying skills” as:
…there was no opportunity available to this flight crew to identify their deficiencies in flying techniques, operational procedures, correct interpretation of the effects of weather, airmanship, etc. All this while, the highly experienced Examiner was meagrely rostered for the flights.
The safety investigation also determined the aircraft was overloaded. The flight was carry personnel and equipment to conduct a check on a BSF Mil Mi-172 helicopter. The CVR recorded conversations that suggested big equipment, such as aircraft jacks, were stowed below the seats and in the aisle. Among the cargo was a Mi-172 battery:
The DGAC highlight a further habitual weakness in weight and balance calculations:
The weight and load data sheets for B200 aircraft since April 2015 were perused. In all data sheets, the weight of baggage in the aft cabin compartment is calculated as 20 Kgs, irrespective of the number of passengers or sector [or indeed the individual crew].
Five safety recommendations were raised.
LOC-I Departure: AAIB Report on King Air 200 Accident We look at three aspects from the investigation into a fatal air accident in the UK: Recording of aircraft defects, TAWS and the carriage of non-crew members on the flight deck.
UPDATE 7 April 2018: Investigators Criticise Cargo Carrier’s Culture & FAA Regulation After Fatal Somatogravic LOC-I. A Shorts 360 N380MQ, operated by SkyWay Enterprises as a Part 135 flight on contract to FedEx crashed in the Caribbean after the crew likely suffered a Somatogravic Illusion raising the flaps on a dark night in 2014. The lack of an FAA SMS regulation for Part 135, the operator’s poor safety culture and implications for the wider industry culture stand out in a thoughtful accident report.
UPDATE 17 November 2018: Investigation into F-22A Take Off Accident Highlights a Cultural Issue
UPDATE 6 January 2020: Runway Excursion Exposes Safety Management Issues
Aerossurance is pleased to sponsor the 9th European Society of Air Safety Investigators (ESASI) Regional Seminar in Riga, Latvia 23 and 24 May 2018.