Diving to disaster - lessons from the Air India incident

O   On 26.5.10, Air India express flight (Boeing 737-800 NG aircraft) from Dubai to Pune, when on normal flight, suddenly plunged from 37000 feet to 30200 feet. The commander of the flight had over 6000 hours of flying with 870 hours on similar type of aircraft while the copilot had total of 1310 hours with 968 hours on similar type of aircraft. The commander was 39 years old and the copilot was 26 years old. The commander went out of the cockpit to the washroom after the plane was on autopilot. He was only out for a few seconds when the plane started diving down. The copilot was not responding to open the cockpit door. Finally the commander opened the door with an emergency access code and entered. The flight was then stabilised and landed safely later. The reasons for the incident was that the copilot, while adjusting his seat, inadvertently pushed the control column, resulting in the plane diving down. He then reportedly panicked and could not open the cockpit door for the commander to enter. The investigation report has great parallels to process safety. On reading the report the following facts emerge:

1. The commander when asked why he left the cockpit to the washroom without asking the cabin steward to be in the cockpit (as is standard practice in the aviation industry – not to leave any pilot alone in the cockpit) reported that it was not in the SOP.
2. The co pilot has reportedly told investigators that he panicked when the dive occurred and the overspeed alarm was blaring.
3. The simulator training given to qualify the pilots does not include the scenario of autopilot engaged and control column pushed inadvertently.
4. The position of chief of training for Air India has been lying vacant since June 2008.

Lessons to be learnt:

1. Make sure your SOP’s are current
2. The age of the copilot was 26 years old. He panicked when the situation occurred as he was not trained to handle the situation.Make sure your control room operators are properly trained in all scenarios. Use simulator training to educate them
3. Make sure critical positions like process safety, training and HR (other than operations) are filled up with competent personnel.

Read the full report in this link. Kudos to the DGCA for putting the report up on their website!! The transparency of the government may, I hope, slowly result in the formation of an investigating agency like the CSB for investigating chemical incidents in India!